Foundations Exam 2

The nurse notes that a patient's albumin is low and is concerned about the patient's ability to fight infection related to antibodies being made from what? a. Protein b. Carbohydrates c. Fats d. Vitamins

A Adequate nutrition is important in the body's defense against infection. Antibodies are made of protein. Carbohydrates store energy, fats store energy and provide energy, and vitamins are a nutrient.

In determining patient goals, the nurse should: a. allow patients to identify what is most important to them. b. take the lead and determine what is best for the patient. c. should focus on health promotion and staying healthy. d. explain the importance of avoiding complications.

A As health care educators, nurses should allow patients to identify what is most important to them. If a newly diagnosed diabetic patient is interested in learning techniques of care that will allow discharge to home rather than to an extended care facility, the patient is more likely to be receptive to learning about self-monitoring blood sugar levels. After the learning goals related to the issues that the patient feels are a priority have been met, the patient may then be able to focus on health promotion and avoiding complications.

The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if: a. the nurse asks the UAP to assess the wound. b. the nurse asks the UAP to report increased wound drainage. c. the nurse asks the UAP to observe changes in dietary intake. d. the nurse asks the UAP to change the dressing.

A Assessment and evaluation of a patient's skin and wounds, and the effectiveness of the treatment plan, are a nurse's responsibility and cannot be delegated to unlicensed assistive personnel (UAP). UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary intake. Some dressing changes can be performed by UAP in some situations.

Regarding denture care, what action by the nurse is inappropriate? a. Carrying the dentures to the sink wrapped in a paper towel. b. Placing a towel in the sink and brushing the dentures over the towel. c. Brushing the dentures as the nurse would the teeth of a conscious patient. d. Applying adhesive, then inserting upper and then lower dentures.

A Dentures should not be wrapped in a paper towel; they should be placed in the denture cup to carry them to the sink. The towel prevents the dentures from being damaged if the teeth are dropped. The nurse can brush the dentures as she would the teeth of a conscious patient. Apply denture adhesive (if used) and insert the dentures, inserting first the upper and then the lower plates, using 4- × 4-inch gauze.

The patient has pertussis. What isolation precaution is correctly implemented? a. Droplet b. Airborne c. Contact d. Protective

A Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods.

The nurse is ambulating her patient back from the bath when the patient begins to have a seizure. Which of the following actions should the nurse do first? a. Lower the patient to the floor if standing. b. Move sharp or hard objects away from the patient. c. Turn the patient to his/her side to prevent aspiration. d. Attempt to place a tongue blade to prevent choking.

A During a seizure, a patient should be protected from injury by first lowering the patient to the ground if he/she is standing. The nurse should then place the head on a soft surface and turn it to the side to prevent aspiration and move sharp or hard objects out of the way. You should never attempt to force any object into a seizing patient's mouth.

The nurse has established a teaching plan including goals. This type of education is termed: a. formal teaching. b. informal teaching. c. psychomotor teaching. d. affective teaching.

A Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The antigen-antibody reaction is an example of what type of immunity? a. Humoral b. Cellular c. Innate d. Passive

A Humoral immunity is a defense system that involves antibodies and white blood cells that are produced to fight antigens. Cellular immunity involves defense by white blood cells against any microorganisms that the body does not recognize as its own. The innate (nonspecific) immune system provides immediate defense against foreign antigens. Passive immunity occurs when a person receives an antibody produced in another body.

The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next? a. Moisten the finger with lens solution and gently touch it to pick it up. b. Moisten the contact lens with tap water and pick it up. c. Pick it up and insert the contact lens. d. Discard the contact lens.

A If a lens is dropped, do the following: (1) moisten a finger with the lens solution, and then gently touch the lens with the moistened finger to pick it up. (2) Clean, rinse, and disinfect the lens to avoid a potential eye infection from any microorganisms that might have adhered to the lens. The contact lens does not need to be discarded.

The nurse knows the following wound would be classified as a closed wound: a. A large bruise on the side of the face b. A surgical incision that is sutured closed c. A puncture wound that is healing d. An abrasion on the leg

A In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin's surface. For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when she tries to exercise. The nurse is concerned that her decrease in activity may lead to: a. orthostatic hypotension. b. increase risk of heart disease. c. loss of short-term memory. d. worsening shortness of breath.

A Inactivity in patients with cardiopulmonary disease can lead to an unsafe drop in blood pressure with position changes, or orthostatic hypotension. The patient already has heart disease so there is no further risk. Loss of short-term memory is not related to the shortness of breath. The lack of activity is not likely to worsen the shortness of breath; improving activity level may help things eventually.

A disease-causing organism is known as: a. a pathogen. b. normal flora. c. a germ. d. a microorganism.

A Infectious agents include any disease-causing agent and are called pathogens. They include bacteria, fungi, viruses, and parasites. Normal flora is a group of non-disease-causing microorganisms that live in or on the body. A microorganism is bacteria, fungi, or protozoa.

The nurse knows that which of the following skills does not require the use of sterile technique? a. NG tube insertion b. Foley catheterization c. Tracheostomy care d. PICC line insertion

A NG tube insertion requires a clean, not sterile, technique. Use strict aseptic technique when inserting an intravenous (IV) or Foley catheter and when performing suctioning of the lower airway.

The nurse manager is developing a training guide. Which is the best organization to help her develop guidelines she can use to help her to prevent exposure to hazardous situations and decrease the risk of injury in the work place? a. OSHA b. CDC c. QSEN d. NIOSH

A Occupational Safety and Health Administration (OSHA) was established in 1970 to provide employers with guidelines for preventing exposure to hazardous chemicals and hazardous situations and reducing the risk of injury in the workplace. The CDC is the Centers for Disease Control and Prevention and provides information to address exposure to infectious diseases. QSEN, or the Quality and Safety Education for Nurses, was funded by the RWJ to focus on preparing nurses of the future with the knowledge, skills, and attitudes to advance quality and safety on the job. NIOSH, or the National Institute for Occupational Safety and Health, is a federal agency within the CDC that was established to conduct research and recommend interventions for the prevention of work-related injury and illness.

Ongoing evaluation of patient education occurs by: a. each member of the health care team who provides teaching. b. the nurse who evaluates the patient's physical abilities. c. the patient stating that he understands the instruction. d. not allowing review so the focus remains forward.

A Ongoing evaluation of patient education occurs by each member of the health care team who provides teaching according to the patient's teaching plan. Having the learner repeat what has been learned can help the nurse evaluate the teaching plan and adjust the plan for future patient education sessions. Future sessions should review what was learned previously and continue to add to what has been taught. Health care team members can view documentation on the electronic health record (EHR) before beginning an education session to determine the patient's progress in meeting educational goals.

The nurse is preparing to teach a 5-year-old child postoperative care that will be anticipated after a tonsillectomy. The nurse should: a. use pictures and simple words to describe care to the patient. b. teach the parents alone to reduce fear in the patient. c. exclude the parents to reduce parental anxiety. d. use clear simple explanations to convey information.

A Patient education provided for children should be age specific. Use pictures and simple words for young children. Use clear, simple explanations for school-age children. The patient's age directly affects the instructional methods and materials used. Effective patient education involving a child requires the presence of a parent or caregiver, who is likely the target of teaching. Children should not be excluded from the learning session unless exclusion is deemed appropriate by the parent or caregiver; a presentation using an age-appropriate strategy may complement the instructions reviewed with the adult. The stages of development should be explored as the foundation for the choice of educational materials.

The nurse is preparing to provide preoperative teaching to a patient who is deaf. To ensure proper learning, the nurse may: a. use printed materials. b. provide unamplified recorded materials. c. use a family member to interpret. d. place an interpreter behind the patient.

A Patients with hearing loss may not be able to hear and understand verbal instructions. Nurses should use other methods such as printed material, demonstration, recorded materials amplified through headsets, interpretation provided by a professional interpreter face-to-face with patients and families or by phone or video medical interpretation (VMI), and/or simulations, photos, drawings, or video to enhance understanding.

Many health care facilities use the fire emergency response defined by the acronym: a. RACE. b. PASS. c. PACE. d. QSEN.

A RACE stands for rescue, alarm, contain, and extinguish. QSEN is the Quality and Safety Education for Nurses. PASS is pull, aim, squeeze, and sweep for fire extinguishers.

The nurse knows that which of the following patients has a teaching need based on statements by the patient or the patient's parents? a. "My 6-month-old daughter only sleeps with me when she's ill." b. "I do not put pillows in the bed with my 3-month-old son." c. "I do not feed popcorn to my 2-year-old." d. "I have discussed the risks of the 'choking game' with my 16-year-old."

A Small children should never sleep in the bed with others because of the risk of suffocation. The rest of the statements are appropriate. Pillows do present a hazard to a 3-month-old, and popcorn is a choking risk for a 2-year-old. The choking game is a risk to any adolescent.

The nurse correctly identifies which patient as having the greatest risk for infection? a. An 80-year-old male with an enlarged prostate b. A 24-year-old female long-distance runner c. A 50-year-old obese male d. A 40-year-old sexually active female

A The 80-year-old has more risk factors because he is elderly and has increased risk of urinary tract infection related to prostate enlargement, so he has two risk factors. A 24-year-old runner is likely healthy with no additional risk factors. The 50-year-old obese male has one additional risk factor. The 40-year-old sexually active female may not have additional risk factors because she is using protection and does not have multiple

Which tool is used to determine risk for impaired skin integrity? a. Braden scale b. Glasgow scale c. Vanderbilt scale d. MMSE scale

A The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.

The nurse knows that which of the following is not used to assess fall risk? a. Glasgow Falls Scale b. Johns Hopkins Hospital Fall Assessment Tool c. Morse Fall Scale d. Hendrich II Fall Risk Model

A The Glasgow is a coma scale used to measure level of consciousness, not falls. The rest are scales used to assess the risk for falls in patients.

The nurse knows that which of the following statements is true regarding the importance of hygiene? a. The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath. b. UAPs perform hygiene because there is no benefit of nurses doing it. c. The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene. d. The main purpose of bathing is to decrease odor.

A The bath is an excellent opportunity for the nurse to assess multiple body systems. Although the UAP can perform hygiene, there is benefit to the nurse doing it because of the ability to assess the patient. The mucous membranes are a part of the integumentary system, and bathing cleanses the skin, provides comfort, and contributes to the patient's health and well-being.

The unique ability of the patient to understand and integrate health-related knowledge is known as: a. health literacy. b. formal patient education. c. informal patient education. d. primary education.

A The unique ability of a patient to understand and integrate health-related knowledge is known as health literacy. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. Many health care consumers begin receiving information as children through their primary education. Handwashing, proper dental care, and nutrition are examples of early instructions.

The nurse is preparing to teach a patient for the first time and needs to evaluate the health literacy of the patient. She uses the VARK assessment to: a. assess the learning styles of the patient. b. find the one method that the patient uses to learn. c. be sure that the patient is a unimodal learner. d. reduce the need for creating a collaborative learning plan.

A Tools have been developed to help health care workers evaluate the health literacy of their patients. One such tool is the VARK (verbal, aural, read/write, kinesthetic) assessment of learning styles of people who are having difficulty learning. Individuals typically learn through more than one method. For example, a patient's VARK assessment may indicate learning through VAR or ARK. When the use of more than one style facilitates learning, the individual is considered a multimodal learner, meaning that the person does best when more than one teaching strategy is used or that the person is able to adapt to a variety of teaching strategies on the basis of what is being presented. Understanding how patients learn best makes collaborative learning plans most effective. It is good practice to provide multiple means of learning, because most individuals learn through more than one style and repetition enhances learning.

The nurse is teaching a group of patient about diseases such as Rocky Mountain Spotted Fever that are transmitted by ticks. The nurse's explanation would be correct if she states that the tick functions as: a. vectors. b. bacteria. c. viruses. d. fungi.

A Vectors carry pathogens from one host to another. Bacteria are single-cell organisms. Viruses are the smallest organisms. Fungi are single-cell organisms that can cause infection.

The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate? a. To promote circulation b. To maintain asepsis c. To maintain comfort d. To maintain tradition

A Washing from distal to proximal promotes circulation and blood return. Asepsis is the state of being free from disease-causing contaminates. There is no difference in comfort. Tradition is a custom.

Which statement by the patient indicates a teaching need? a. "I use bobby pins to remove excessive ear wax." b. "I use soap and a warm cloth to clean the outside of my ear." c. "My doctor sometimes gives me oil drops for my ears." d. "I never use Q-Tips."

A Washing the ear with a washcloth and soap is sufficient in most patients. If the patient has a buildup of wax, or cerumen, the health care provider may order special oil drops to soften the wax before irrigating the ear canal. Do not try to remove the wax using a cotton-tipped applicator because this can push the wax farther into the ear canal. Caution patients to never insert anything sharp into the ear, such as bobby pins. Sharp objects can rupture the tympanic membrane.

The nurse recognizes the correct order to remove PPE as: a. gloves, eyewear, gown, mask. b. mask, eyewear, gown, gloves. c. gown, mask, eyewear, gloves. d. gloves, gown, mask, eyewear.

A When removing PPE, gloves, which are contaminated, are removed first to prevent contamination of the face and eyes during removal of the mask and to prevent spread of microorganisms. Eyewear should then be removed, followed by the gown and finally the mask.

The nurse is to teach an 84-year-old Spanish-speaking patient newly diagnosed with diabetes how to self-administer insulin. The patient has hearing and visual impairments. In order to be effective as a teacher, the nurse should: (Select all that apply.) a. assess reading level and learning style. b. determine readiness to learn. c. use family members as interpreters. d. provide written instruction in English. e. place the patient in group classes.

A, B Before health care teaching sessions for adults, assess reading level, learning styles, and readiness to learn. Family members should not be used as interpreters of specific medical information to maintain the patient's right to privacy and to avoid possible misinterpretation of medical terminology. Access to interpretation or translation for deaf and limited English proficiency (LEP) patients is required by Title VI of the Civil Rights Act of 1964, which mandates equal rights for people regardless of race, color, or national origin. Use photos, drawings, or video to enhance understanding. A patient whose cultural beliefs and values are considered is more likely to demonstrate compliance. Patients with learning disabilities or cognitive alterations need individualized instruction geared to their special needs.

The nurse is teaching a patient about ways to decrease her risk of bone fractures. The following statements by the patient indicate a good understanding. (Select all that apply.) a. "I should do weight-bearing exercises." b. "I should get adequate intake of calcium and vitamin D." c. "I should exercise regularly." d. "I need to do yoga exercises."

A, B, C Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures. Decreased physical exercise and lack of weight-bearing exercise also contribute to bone fragility, deterioration, and loss of strength. Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

The nurse is providing some education to a community group on environmental safety. Which of the following safety measures are effective in improving their environmental safety? (Select all that apply.) a. Use of night lights throughout the home b. Illumination of stairwells and pathways c. Installation of motion-activated lighting on the exterior of the home d. Application of wax to all floor to increase shine

A, B, C Inadequate lighting presents safety concerns in home, work, community, and health care environments. For an individual to safely and successfully navigate pathways and perform various activities while avoiding potential obstacles and hazards, the environment must be well illuminated. Well-lit, glare-free halls, stairways, rooms, and work spaces help to reduce the risk of tripping, slipping, and falling. Night lights reduce the risk of injuries to children, guests, and older adults.

On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. Diagnoses specifically related to patient education include: (Select all that apply.) a. deficient knowledge. b. readiness for enhanced knowledge. c. noncompliance. d. pain. e. alteration in elimination.

A, B, C On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. Diagnoses specifically related to patient education include deficient knowledge, readiness for enhanced knowledge, and noncompliance.

The nurse should avoid soaking the feet of which patient population? (Select all that apply.) a. Patients with peripheral vascular disease b. Patients with a stroke c. Patients with diabetes d. Patients with arthritis

A, B, C Soaking the feet of patients with peripheral vascular disease, cardiovascular disease such as strokes and diabetes are contraindicated because it may cause skin breakdown or infection. Patient with arthritis have no contraindications to having their feet soaked.

Regarding perineal care, which nursing action is appropriate? (Select all that apply.) a. The nurse applies gloves prior to performing perineal care b. The nurse ignores the erection of a male patient during perineal care c. The nurse documents the perineal care. d. The nurse only completes perineal care with daily bathing

A, B, C The nurse uses standard precautions (gloves) whenever contact with body fluids is expected. A male patient may have an erection during care, which is a normal response with tactile stimulation. The care provider can ignore the erection and continue with the procedure or return later to complete the care, depending on the comfort level and the situation. Documentation is part of hygienic care. Note any redness, drainage, odor, edema, or skin changes. Perineal care is provided during a bath or shower but may be necessary more frequently, especially in incontinent patients.

Which statement regarding handwashing indicates a need for further education? (Select all that apply.) a. Wash hands first, then wrists. b. Rinse from fingertips to wrists. c. Dry using a scrubbing motion. d. Turn off faucet with clean, dry paper towel.

A, B, C When washing hands, first wet the wrists and hands; with fingers pointing downward, first wash the wrists and then the hands below the wrists. Then apply soap, lather, and rub using a circular motion for 15 to 20 seconds. When rinsing, rinse from wrist to fingertips, keeping hands with fingers pointing downward. Using clean paper towels, dry thoroughly in the same order (from wrists to fingers) using a patting motion. Turn off the faucet with a clean, dry paper towel.

In addressing patient education, the nurse recognizes that patient education is a process involving: (Select all that apply.) a. assessment. b. diagnosis. c. planning. d. implementation and evaluation. e. reliance on evidence-based practice (EBP).

A, B, C, D Assessment of health literacy occurs with each patient encounter. On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. After working with the patient or caregiver to determine the appropriate nursing diagnosis, the next step is developing the patient education plan. In all patient education situations, a return demonstration by the patient (i.e., repeating what has been taught) helps the nurse to assess the level of learning that has taken place. Although evidence-based practice is important, it is sometimes insufficient when making patient care decisions.

The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.) a. A patient who has diabetes b. A patient with COPD on long-term steroid therapy c. A patient with on bed rest who is repositioned d. A patient who is obese and sweats excessively

A, B, C, D Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal antiinflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

The nurse is using the Braden scale to assess the patient's risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.) a. Activity b. Friction and shear c. Moisture d. Sensory perception e. Cognition

A, B, C, D The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

The nurse knows that standard precautions are indicated for: (Select all that apply.) a. all patients. b. patients with HIV. c. patients with MRSA. d. patients with tuberculosis.

A, B, C, D The nurse can take steps at any link in the chain to halt the spread of infection. Standard precautions are used with all patients to limit direct exposure to blood and body fluids. Additional precautions such as airborne precautions are used with patients who have diseases such as tuberculosis and contact precautions with patients who have MRSA.

The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.) a. Intensity of the pressure b. Duration of the pressure c. The tissue's ability to tolerate the pressure d. The person's age

A, B, C, D The primary cause of pressure ulcers is, as the name suggests, pressure. However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue's ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

The nurse is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.) a. Bathing b. Oral care c. Perineal care d. Foot care e. Patient communication

A, B, C, D, E Hygienic practices include bathing, oral care, perineal care (cleansing of the genital area, urinary meatus, and anus), foot care, and shaving. During hygiene care the nurse communicates with the patient, assesses the skin, and observes for any abnormalities.

The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.) a. History of any falls b. Falls risk assessment scores c. Patient and family education d. Use of assist devices e. Any fall or reported fall

A, B, C, D, E The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices is also documented. Thoroughly document a fall or reported fall, but do not document that an incident report has been filed in the medical record.

The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.) a. Location and size b. Characteristics of the wound bed c. Patient's response to wound treatment d. Patient's pain level e. Presence of drainage

A, B, C, E A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. The patient's pain level would be documented with his/her pain assessment.

The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.) a. Edema b. Shivering c. Bleeding d. Circulatory issues

A, B, D Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern). Bleeding is contraindicated in heat therapy.

The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.) a. Decreased cough reflex b. Decreased lung elasticity c. Increased activity of the cilia d. Abnormal swallowing reflex e. Increased sputum production

A, B, D The elderly are at an increased risk for respiratory infections as a result of decreased cough reflex, decreased elastic recoil of the lungs, decreased activity of the cilia, and abnormal swallowing reflex. They do not generally have increased sputum production.

The patient is on protective precautions. Which is true regarding these precautions? (Select all that apply.) a. A positive-pressure room with a HEPA filtration system is required. b. Special respirator masks should be available and one size fits all. c. No live plants are allowed in the room. d. The patient may eat any foods desired.

A, C Protective precautions require a positive-pressure room. No live plants, fresh flowers, fresh raw fruit or vegetables, sushi, or blue cheese may be brought into the room because they may harbor bacteria and fungi. Special masks are not required. The patient cannot eat just any foods because some are restricted.

The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which of the following statement(s) by the patient indicates further education is needed? (Select all that apply.) a. "I should take antibiotics every time I am sick." b. "I should take all antibiotics as prescribed." c. "I should save all unused antibiotics." d. "I should stop taking antibiotics when I feel better."

A, C, D The overuse of antibiotics and inappropriate use, such as not completing prescriptions and sharing antibiotics, has led to increased resistance. Taking antibiotics as prescribed helps to ensure the infection will be treated correctly.

The nurse appropriately delegates care of her patient to the properly trained UAP when she: (Select all that apply.) a. assigns the UAP to reposition the patient. b. assigns the UAP to complete the MORSE falls risk scale. c. assigns the UAP to provide range-of-motion exercises. d. assigns the UAP to ambulate the patient in the hallway.

A, C, D Unlicensed assistive personnel (UAP) provide hands-on care for immobilized patients under the direct supervision of registered nurses. Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP. UAPs may not assess patients because that is a nursing responsibility. The MORSE falls risk scale is a risk assessment.

In preparing to teach the patient, the nurse must consider: (Select all that apply.) a. background. b. race. c. pain level. d. emotional status. e. readiness to learn.

A, C, D, E Consideration must be given to the patient's background, readiness to learn, and current condition before education can occur. A patient's ability to read, write, and comprehend health care materials enhances health literacy. Race, by itself, is not a factor.

The nurse knows the knee-high SCD sleeves are correctly placed on the patient when the following conditions are met: (Select all that apply.) a. Both sleeves are connected to the SCD device. b. Two fingers fit inside when the SCDs are inflated. c. There are no kinks in the tubing. d. The ankle pressure is 55 to 65 mm Hg. e. The cooling control is on.

A, C, E Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. Wrap the sleeve around the leg, and fasten it with Velcro straps. Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated. Connect the sleeves to the device, ensure that there are no kinks in the tubing, and turn on the cooling and set it to 35 to 55 mm Hg.

According to the Healthy People 2020 initiative, health information and the associated access issues have become more complicated. There are many considerations when determining whether an individual has proficient health literacy. The patient should be able to: (Select all that apply.) a. read and identify credible health information. b. recognize abnormalities on an x-ray. c. navigate complex insurance programs. d. evaluate EKG findings. e. advocate for appropriate care.

A, C, E The patient should be able to exhibit certain competencies such as reading and identifying credible health information, understanding numbers in the context of the patient's health care, making appointments, filling out forms, gathering health records and asking appropriate questions of physicians, advocating for appropriate care, navigating complex insurance programs (Medicare or Medicaid, and other financial assistance programs), and using technology to access information and services. Interpreting EKGs and X-rays is beyond this scope.

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of the following: (Select all that apply.) a. Decreased tissue perfusion b. Loss of sensation c. Hemiparesis d. Diminished respiratory capacity

A, D Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person's ability to perform activities of daily living (ADLs) and exercise. Hemiparesis and loss of sensation are associated with nervous system disorders.

The nurse is providing discharge education for her patient who is going home with a walker. Which statement by the patient indicates a good level of understanding of safety in the home? (Select all that apply.) a. "I need to remove the throw rugs." b. "I should make sure I only take a bath." c. "I cannot use the stairs." d. "I need to place a nonskid mat in front of the kitchen sink."

A, D To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are. If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers. They can shower with a bench or chair in the shower for sitting.

The nurse has assisted the patient to wash his hands, face, axillae, and perineal area. What type of bath should the nurse chart? a. Sink bath b. Complete bed bath c. Partial bed bath d. Shower

ANS: C A partial bed bath is performed when only part of the body is washed. A complete bed bath is for patients who are completely bedridden or are totally dependent on others for care. A shower is usually for patients who are strong enough to shower independently. A sink bath is when the patient washes while standing or sitting in front of a bath basin or sink.

The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is: a. the wound will be completely healed in 72 hours. b. the wound will show signs of healing within 2 weeks. c. the patient will develop no new pressure ulcers. d. the patient will ambulate twice a day.

B A stage III pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of healing in 2 weeks. It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and ambulating twice a day is more of an intervention.

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed? a. Using an airflow bed b. Using a slide board c. Using a trochanter roll d. Using a gel mattress

B A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes. Patients can be repositioned or transferred with a minimum of force required. A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back. An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers. A foam or gel combination mattress reduces pressure.

The nurse knows active assistive range of motion is: a. when the patient is able to independently move all joints. b. when the patient is able to partially move all joints. c. when the caregiver must move the patient's joints. d. when the patient is performing isotonic exercises.

B Active assistive range of motion occurs when the caregiver minimally assists the patient or the patient minimally assists himself or herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy.

The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client? a. Orient the patient frequently. b. Apply restraints. c. Move the patient to a room close to the nurse's station. d. Encourage the family to spend time with the patient.

B All alternatives to physical restraints should be considered prior to their use.

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education? a. "The wound will be red." b. "The wound will have pus." c. "The wound will be warm." d. "The wound will need to be treated."

B An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105 per gram of tissue sampled when cultured. The wound will need to be treated for the infection.

As the health care community explores the concept of health literacy, many organizations recognize that: a. consumers need to understand has no governmental support. b. improvements are dependent on developing operational definitions. c. low literacy and low health literacy are interchangeable terms. d. interest in effective patient education is unique to the United States.

B As the health care community explores the concept of health literacy, many organizations recognize that before improvements can be made, operational definitions are imperative. The realization that consumers need to be able to understand the medical information delivered by health care providers has gained recognition at many governmental levels. The Healthy People 2020 publication describes a national movement that addresses the priorities of prevention and public health in the United States. Health literacy with its impact on this initiative is being recognized and has become a key component of the project. Although low literacy and low health literacy are related terms, they are not interchangeable. Low health literacy is content-specific, meaning that the individual may not have difficulty reading and writing outside the health care arena. Interest in effective patient education is not a phenomenon unique to the United States. The Institute of Medicine Roundtable on Health Literacy held a workshop in 2012 focused on international health literacy.

The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect? a. The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient. b. The nurse rolls dirty linens to the side then places the linens on the floor while finishing. c. The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens. d. The nurse wears gloves to remove dirty linens.

B Bed linens should be placed in the linen hamper, not on the floor, after they are removed from the bed. The patient turns to each side while the bed linens are changed, and the nurse wears gloves.

The patient has hepatitis A. Which isolation precaution is correctly implemented? a. Airborne b. Contact c. Droplet d. Protective

B Contact precautions are used when a known or suspected contagious disease may be present and is transmitted through direct contact with the patient or indirect contact with items in the patient's environment. Airborne precautions are used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods. Droplet precautions are used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Protective isolation is used for patients who have compromised immune systems.

Which of the following patients would most likely need to have adjustments made to the education plan for discharge because of role function? a. A 67-year-old married female who lives with her retired husband b. A 32-year-old single mother of a toddler following hysterectomy. c. A 13-year-old who lives at home with his parents after appendectomy d. A 50-year-old married mother with 2 child in college and teenager at home

B Exploration of the patient's roles is an important task that must be done before development of a patient education plan. For example, a 32-year-old, single mother of five young children who has just undergone a hysterectomy may require a different perspective in her discharge instructions than that in the instructions of a 67-year-old female living with her husband who recently retired after 35 years as a family practice physician. The first patient may have less support and less flexibility regarding rest, lifting limitations, and cost of prescriptions than the second. It is important not to stereotype and assign roles but rather to develop a plan in collaboration with the individual. The patient's support system should be taken into consideration when the nurse plans patient education.

The nurse is educating parents about firearm safety. Which of the following statements indicates a need for further education? a. "I should make sure I obtain the proper permits." b. "It is okay to store firearms with ammunition loaded." c. "I should store all firearms without ammunition." d. "I should make sure all firearms have trigger locks in place."

B Firearms should be stored in a secure location with trigger locks in place. Ammunition should be stored in a separate location also locked. Proper permits should be obtained as appropriate. Loaded firearms should never be stored where children can access them.

The nurse is implementing generalized falls precautions for his patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions? a. The bed is placed in the low position. b. The patient is wearing socks. c. The patient's cell phone is by the bedside. d. The patient's call light is within reach.

B If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position.

The nurse is educating the patient about the effects of immobility on the body. The following statements by the patient indicate a need for further education: (Select all that apply.) a. "I can become very weak." b. "I will gain weight." c. "I will lose muscle tone." d. "I can get bed sores."

B Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, and skin breakdown. Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient's risk and recognize signs of impending complications.

The nurse is implementing a patient teaching plan regarding diabetes mellitus. One of the short-term goals of the plan is that the patient will be able to verbalize three symptoms of hypoglycemia. This is an example of: a. psychomotor teaching. b. cognitive teaching. c. affective teaching. d. VARK teaching.

B Learners in the cognitive domain integrate new knowledge through first learning and then recalling the information. They then categorize and evaluate, making comparisons with previous knowledge that result in conclusions related to the new content. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes. Tools have been developed to help health care workers evaluate the health literacy of their patients. One such tool is the VARK (verbal, aural, read/write, kinesthetic) assessment of learning styles of people who are having difficulty learning

An appropriate goal for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired physical mobility is: a. the patient will interact with others. b. the patient will ambulate to the bathroom with assistance. c. the patient will have no skin breakdown. d. the patient will have a physical therapy consult.

B Patients with a diagnosis of Impaired physical mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.

The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be: a. ineffective health maintenance. b. readiness for enhanced self-care. c. hygiene self-care deficit. d. disturbed body image.

B Readiness for enhanced self-care is evidenced by a patient expressing a desire to be independent in ADLs. Ineffective health maintenance is an inability to maintain health, hygiene self-care deficit indicates they are unable to perform hygiene, and disturbed body image relates to how they view their body.

The nurse appropriately delegates care to the UAP when she: a. instructs the UAP to assess the patient's skin during a bath. b. instructs the UAP to reposition the patient using the trapeze. c. instructs the UAP to assess the patient's ability to perform range-of-motion exercises. d. instructs the UAP to notify the health care provider of any changes.

B Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments but should notify the nurse about any skin or musculoskeletal issues, not the health care provider.

The nurse is working with a student nurse to teach her about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints? a. "Having all four side rails up on the bed is considered a restraint." b. "The use of restraints has been shown to decrease fall-related injuries." c. "Death has been associated with the use of restraints." d. "Medications administered to control behavior are considered a chemical restraint."

B Restraints may be physical or chemical. A physical restraint is a mechanical or physical device, such as material or equipment attached or adjacent to the patient's body, used to restrict movement (CMS, 2006). Examples of physical restraints are wrist or ankle restraints, a jacket or vest, and side rails. A medication that is administered to a patient to control behavior is a chemical restraint. The use of restraints has been associated with patient injury including death and does not prevent patient falls.

For which situation is it inappropriate to use alcohol-based hand sanitizer? a. Patient with pneumonia b. Patient with C. difficile c. Status post-appendectomy d. Patient with HIV

B Soap and water must be used to thoroughly clean hands if there is any visible soiling or dirt and with certain infections such as Clostridium difficile and vancomycin-resistant enterococci when preparing for a sterile or surgical procedure, before and after eating, and after using the restroom. In all other situations, a hand sanitizer is as effective as soap and water.

The nurse recognizes that a patient is using a portable generator in the house as a power source. What source of poisoning does the nurse appropriately identify? a. Lead b. Carbon monoxide c. Antifreeze d. Pesticide

B Sources of carbon monoxide include automobiles, stoves, gas ranges, portable generators, lanterns, the burning of charcoal and wood, and heating systems. Lead is found in lead-based paints in toys, buildings, and ceramic dishes; sources of lead include water from lead pipes or pipes soldered with lead, gasoline or soil contaminated by gasoline, and household dust that may contain paint chips or soil. Antifreeze and pesticides are liquids.

The nurse knows a stage III pressure ulcer is: a. a pressure ulcer that involves exposure of bone and connective tissue. b. a pressure ulcer that does not extend through the fascia. c. a pressure ulcer that does not include tunneling. d. a partial-thick wound that involves the epidermis.

B Stage III pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Stage IV pressure ulcers involve exposure of muscle, bone, or connective tissue such as tendons or cartilage. Stage II pressure ulcers are partial-thickness wounds that involve the epidermis and/or dermis.

The nurse knows that manual lifting should only be done in the following situations: a. Patients who are less than 150 lb b. Life-threatening situations c. Postsurgical patients d. Patients who are less than 200 lb

B The National Institute for Occupational Safety and Health (NIOSH) and the American Nurses Association (ANA) support the Safe Patient Handling and Movement Guidelines released in March 2010. Under these guidelines and position statements, manual lifting should be used in a few extreme situations instead of using mechanical lift devices, such as in life-threatening situations, for pediatric or small patients, or for patients who mostly are bearing their own weight. Postsurgical patients may not fit the criteria. Patients less than 150 or 200 lb may not fit the criteria.

The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first? a. Hands b. Eyes c. Face d. Arms

B The nurse should start washing the patient's eye area, with the washcloth without soap, followed by the patient's face, hands, and arms.

The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is: a. the patient will remain free of wound infections during the hospitalization. b. the patient will report pain management strategies and reduce pain to a tolerable level. c. the patient will turn self in bed using over trapeze every two hours using assistance when needed. d. the patient will consume adequate nutrition to meet nutritional requirements within 1 week.

B The patient will report pain management strategies to reduce pain to a tolerable level is an appropriate goal for Impaired physical mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for Impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for Acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Imbalanced nutrition: less than body requirement.

The second line of defense that leads to local capillary dilation and leukocyte infiltration is known as: a. normal flora. b. inflammatory response. c. immune response. d. humoral immunity.

B The second line of defense is the inflammatory response. Inflammation is a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration. The immune response is the body's attempt to protect itself from foreign and harmful substances. Humoral immunity is an adaptive immunity and normal flora is a group of non-disease-causing microorganisms (e.g., bacteria, fungi, protozoa) that live in or on the body.

The nurse is preparing a teaching plan and is applying evidence-based practice. To promote involvement, the nurse must: a. provide the latest professional literature to the patient. b. ensure that the patient understands relevant information. c. use only one teaching method to reduce confusion. d. not review previously learned information.

B To promote involvement, nurses must ensure that patients understand the information relevant to their care. Nurses need to provide patients with easy-to-understand information and speak in a clear, distinct voice, using short sentences and understandable terminology. Multiple teaching methods should be used to meet the needs of all types of learners. Patient education sessions should be reassessed after two to three key points to ensure that the patient is still engaged in learning and ready to assimilate more information. Information taught at previous sessions can be reviewed before proceeding with new key points.

To teach effectively, nurses must recognize that: a. age and socioeconomic status play a large role in understanding. b. 90% of Americans possess rudimentary literary skills. c. the ability to comprehend is a very new concept in health care. d. most health care teaching is effective and understood.

B To teach effectively, nurses must recognize that patients of all ages come from diverse cultural and socioeconomic backgrounds. Each has a different ability to comprehend health care information. Results of the NAAL research indicate that among American adults, 30 million (14%) had below basic health literacy in English and 47 million (22%) had basic health literacy. This means that 77 million (36%) American adults possessed very rudimentary literacy skills that allowed them to read only short, simple printed and written materials. Although discussion of Nightingale's work often focuses on her efforts to distinguish nursing as a profession and address the impact of sanitation on health, she advocated exploring all aspects of the patient. She thought that patients needed care that is "delicate and decent" and that demonstrates "the power of giving real interests to the patient." Exploring patients' interests and abilities was an early acknowledgment that nurses must be aware of patients' ability to comprehend the health care information provided. Often, health care professionals assume that the explanations and instructions given to patients and families are readily understood. In reality, research has shown that these instructions are frequently misunderstood, sometimes resulting in serious errors.

The nurse is correctly demonstrating the use of a transfer belt when engaging in the following: (Select all that apply.) a. The belt is placed around the patient's hips. b. The belt is secure, leaving only enough room for the nurse to grasp the belt. c. The nurse stands on the weaker side. d. The nurse holds the belt on the side of the patient.

B, C Transfer belts should be used for patients with an unsteady gait or generalized weakness. Canvas transfer or gait belts are applied snugly around the patient's waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation. Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient's waist while ambulating.

The nurse notes that a trauma patient has multiple tangles in the hair. Which of the following actions taken by the nurse is appropriate? (Select all that apply.) a. Work the tangles to the ends of the hair, then trim with scissors. b. Apply warm water and conditioner. c. Apply detangler as available. d. Use a comb or fingers to work through tangles.

B, C, D Apply warm water and a conditioner or a detangler, if available, to release tangles and avoid injury to the scalp. Use a comb and/or fingers to work through the tangles individually before shampooing. The nurse avoids cutting the patient's hair unless first asking the patient's permission.

The nurse knows that which areas are at increased risk of excoriation? (Select all that apply.) a. Exposed areas such as the face b. Areas exposed to stool c. Skin on skin areas d. Area under pendulous breasts

B, C, D Excoriation (red, scaly areas with surface loss of skin tissue) occurs in patients whose skin is exposed to bodily fluids such as stool, urine, or gastric juices. Excoriation also occurs in areas where skin rests on skin, such as in the axilla (armpit); under large, pendulous breasts; or in abdominal folds. Exposed areas are more likely to become sun burned or wind burned.

The nurse is bathing a patient and notes reddened skin above the coccyx. Which action by the nurse is appropriate? (Select all that apply.) a. Apply a barrier cream and massage the area. b. Document and describe the area and report to the physician. c. Wash and dry the area and position patient without pressure on coccyx. d. Report the area to the charge nurse.

B, C, D Gently wash any reddened or swollen areas, and pat them dry. Use clean, nonsterile gloves as needed to comply with standard precautions. Document the findings from the assessment and report them to the physician, charge nurse, or other appropriate personnel per agency policies. Avoid massaging reddened areas on the skin during the bath. Further tissue breakdown can occur if reddened areas are massaged.

The nurse is providing education to a cardiac patient who has multiple life stressors that are impacting the patient's health. Which of the following statements by the patient indicate he has a good understanding of actions he can take to reduce his stressors? (Select all that apply.) a. "I should change my job." b. "I should plan some downtime." c. "I should meet with a financial counselor." d. "I should talk with my family about my situation." e. "I should make my family go to counseling with me."

B, C, D In adulthood, life stressors such as financial concerns, work-related demands, and efforts to balance work with family life are common challenges that can take a physical toll on the body. Individuals should plan relaxation periods or vacations. Meeting with financial counselors and talking with family can help to achieve that balance. Changing jobs may be beneficial but could also create more stress, and forcing family to go to counseling may also not be a wise choice.

When teaching children, the nurse should: (Select all that apply.) a. exclude the children from teaching. b. encourage parents or caregivers to be present. c. use age-specific strategies. d. consider the stages of development. e. remember that parents are not the targets of the teaching.

B, C, D Patient education provided for children should be age specific. Effective patient education involving a child requires the presence of a parent or caregiver, who is likely the target of teaching. Children should not be excluded from the learning session unless exclusion is deemed appropriate by the parent or caregiver; a presentation using an age-appropriate strategy may complement the instructions reviewed with the adult. The stages of development should be explored as the foundation for the choice of educational materials.

The nurse is explaining the National Patient Safety Goals (NPSG) to the student nurse. Which of the following answers indicates that the student has a good understanding of these goals? (Select all that apply.) a. The NPSG's focus on treating all infections quickly b. The NPGS's focus on improving staff communication c. The NPGS's focus on using medications safely d. The NPGS's focus on identifying patients correctly

B, C, D The NPSG focus on specific goals each year. The goals for 2014 included: identify patients correctly, improve staff communication, and use medicines safely. Although treating infections quickly is important, it is not an NPSG.

The nurse must provide patient education to a patient who has just been told by the patient that he has stage III lung cancer. The patient is complaining of chest and bone discomfort. Before providing the needed education, the nurse should: (Select all that apply.) a. draw the curtain in the semi-private room. b. medicate the patient to ease his pain. c. place the patient in a private room if possible. d. perhaps wait until later in the day. e. keep the room dark to provide solitude.

B, C, D The location of patient education influences the outcome. The setting should be quiet, and the session should have minimal interruptions. Providing privacy is difficult in settings such as emergency rooms, outpatient surgery centers, and semiprivate inpatient rooms, but the nurse should make every effort to ensure confidentiality. Environmental considerations such as good lighting and the availability of resources should be explored to enhance the outcome of patient education. The nurse should examine the patient's situation and comfort level before beginning teaching. For example, a postoperative patient who is rating pain at 7 of 10 will be much more receptive to learning after being medicated for pain. A patient who just received a diagnosis of metastatic cancer will learn and assimilate more information later in the day or perhaps the next day.

The nurse is demonstrating cultural sensitivity in performing perineal care when he/she does the following: (Select all that apply.) a. The male nurse delegates perineal care of a female patient to the female UAP. b. The male nurse asks a female patient if she would prefer a female to perform care. c. The nurse approaches the care in a sensitive, professional manner. d. The nurse assesses cultural preferences of the patient prior to care.

B, C, D The nurse assesses patient backgrounds and provides hygienic care in a manner that is sensitive to the differences in habits and customs. This includes asking the patient about their preferences and not assuming what their preferences will be. A female patient may be comfortable with a male nurse performing perineal care.

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions should the nurse perform? (Select all that apply.) a. Measure the amount of drainage in the device prior to emptying. b. Label each drain and record them separately. c. Recompress the device after emptying. d. Secure the device to the patient's gown above the level of the wound. e. Check for kinks in the tubing.

B, C, E Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage. After emptying, recompress the device to maintain suction. Secure the container(s) to the patient's hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

The nurse knows the following indicates orthostatic hypotension: (Select all that apply.) a. A decrease in systolic blood pressure by 30 mm Hg b. A decrease in diastolic blood pressure by 10 mm Hg c. An increase in heart rate by 30 beats/min d. An increase in systolic blood pressure by 20 mm Hg

B, D A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable nursing diagnosis for a patient with excessively dry skin? a. Imbalanced Nutrition: Less than body requirements b. Deficient fluid volume c. Risk for infection d. Acute pain

C Any interruption in the skin, which is the body's first line of defense, can potentially lead to infection. Both imbalanced nutrition and deficient fluid volume could have dry skin as a symptom. Acute pain is not appropriate.

The nurse is preparing to discharge a patient home. In providing instruction about the patients medications, the nurse should state: a. "Before taking Metoprolol, you need to take your BP and rate." b. "MS should be taken only when needed for pain." c. "Take 1 baby aspirin by mouth every morning." d. "Take your water pill bid and you should be fine."

C Do not use abbreviations or medical terminology when providing patients with instructions.

The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates she has a good understanding of the information? a. "Remove the label from the bottle and throw in the trash." b. "Flush the medication." c. "Mix the medications with kitty litter and place the mixture in a jar and put the jar in the trash." d. "Dissolve the medication in water and pour down the drain."

C Flushing or pouring the medication down the drain can contaminate the water system. Throwing the medication in the trash poses potential for someone to remove the medication and use it. This can be avoided by mixing it with an undesirable substance like kitty litter or coffee grounds.

The ER nurse is triaging a patient with suspected poisoning. Who should the nurse anticipate contacting first? a. Family services b. Radiology c. Poison Control Center d. Respiratory

C If poisoning is suspected, the National Poison Control Center should be contacted immediately. This information will be needed to determine treatment. Respiratory may be needed, and radiology and family services may also be needed, but that will be determined after the treatment plan is determined.

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What should the nurse do first? a. Notify the physician. b. Notify the wound care nurse. c. Stop the procedure. d. Give the patient pain medication.

C If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting. Then the nurse can determine what to do next based on the patient's response.

The nurse is admitting a patient who has cystic fibrosis. During the admission interview, it is apparent that the patient is well versed in most aspects of his illness. When asked about where he learned so much, the patient responds, "I learned most of it myself. I looked things up on the Internet and read books. You have to know what's wrong with you to be sure that you're being treated right." This is an example of: a. formal education. b. psychomotor learning. c. informal education. d. affective learning.

C Informal education is usually learner or patient directed. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding? a. "An example of this type of exercise is walking." b. "An example of this type of exercise is running." c. "An example of this type of exercise is Kegels." d. "An example of this type of exercise is weight lifting."

C Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise). Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding. Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise. Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting.

The nurse is educating the family of a patient on falls risk precautions. Which of the following statements by the family indicates a need for further education? a. "I should keep the wheelchair locked unless using it to move Mom." b. "I should always leave the bathroom light on." c. "I should use nonskid socks, not shoes." d. "I should keep her cell phone close to her bed."

C Leave lights on or off at night, depending on the patient's cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

A patient admitted after abdominal surgery has a nursing diagnosis of risk for infection. Which is the most appropriate goal? a. Patient will ambulate length of hallway this shift. b. Patient will consume 20% of meals by the end of the week. c. Patient's incision will be without signs or symptoms of infection at discharge. d. Patient will verbalize need to stop antibiotics medication when symptom free.

C Maintaining skin integrity is an appropriate goal for this patient to ensure the patient does not develop a wound infection. Ambulating will assist in preventing skin breakdown be getting the patient out of bed, but it is not the priority goal for a patient with an incision. Consuming only 20% of meals will not ensure adequate nutrition, and verbalizing the end of antibiotic administration is inappropriate. Antibiotics should be taken until the prescription is complete.

The nurse is explaining to the student nurse the purpose of occlusive dressings. Which statement by the student nurse indicates a lack of understanding? a. "Occlusive dressings are used for autolytic debridement." b. "Hydrocolloids are a type of occlusive dressing." c. "Occlusive dressings can be used on infected wounds." d. "Occlusive dressings support the most comfortable form of debridement."

C Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

The nurse has placed her sterile gloved hands below her waist. Her hands are now considered: a. sterile. b. aseptic. c. non-sterile. d. free of disease-causing organisms.

C Once the hands have been placed below the waist, they can longer be considered sterile or free from organisms. Asepsis refers to freedom from disease-causing contamination.

The nurse is caring for a patient who is comatose. Her intervention is appropriate when she performs oral care: a. every shift. b. twice daily. c. every 4 hours. d. daily.

C Oral care should be performed every 4 hours to prevent the colonization of bacteria. Less often than every 4 hours is not effective.

The nurse is preparing to assist her patient to walk to the bathroom after medicating her with a narcotic for pain management. Of what possible adverse effect should the nurse be immediately aware? a. Constipation b. Depression c. Dizziness d. Pain relief

C Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse's ability to safely ambulate the patient.

The nurse understands the rationale for drying a wound after irrigation is: a. to ensure the new dressing adheres to the wound. b. to ensure the new dressing remains occlusive. c. to prevent skin breakdown from moisture. d. to prevent infection from irrigate solution.

C Proper drying prevents further skin breakdown from moisture. Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound. The type of dressing will determine how it lays in the wound and whether or not it is occlusive. The drying does not prevent infection.

The increase focus in nursing on patient safety has resulted in a project funded by the Robert Wood Johnson Foundation called: a. OSHA. b. MSDS. c. QSEN. d. ADA.

C QSEN, or the Quality and Safety Education for Nurses, was funded by the RWJ to focus on preparing nurses of the future with the knowledge, skills and attitudes to advance quality and safety on the job. MSDS are material safety data sheets, OSHA is the Occupational Safety and Health Agency, and ADA is the Americans with Disability Act.

The nurse knows that which of the following is an appropriate way to tie restraints? a. Knot tied to the bed frame b. Quick-release knot tied to the side rail c. Bow tied to the bed frame d. Quick-release knot tied to the bed frame

C Restraints should never be tied in a knot because the knot may prohibit a quick exit in the event of an emergency requiring evacuation. Instead, use quick-release ties or mechanisms such as buckles. Restraints should never be tied to side rails because injuries may result when they are raised or lowered. They should be tied to a stable part of the bed such as the frame.

The nurse knows rheumatoid arthritis affects the musculoskeletal system by causing: a. muscle weakness. b. muscle wasting. c. muscle inflammation. d. muscle mobility.

C Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility. Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting.

Conversations about safe sexual practices, including the consequences of unprotected sex such as pregnancy and sexually transmitted infections, are important to begin in what patient population? a. Adults b. School-aged children c. Adolescents d. Older adults

C Sexual curiosity and experimentation occur in the adolescent patient population. Conversations about safe sexual practices, including the consequences of unprotected sex, such as pregnancy and sexually transmitted infections, are important. These conversations are also important for adults and older adults but are handled differently in context with their age-related needs. School-aged children may be too young depending on their age and their environment. The nurse must use judgment on when to have the conversation.

During patient teaching led by the nurse with goals established through cooperation of the nurse and patient, the patient asks questions as needed and the nurse answers. This is known as: a. formal teaching. b. informal teaching. c. both formal and informal teaching. d. psychomotor teaching.

C Some patient education sessions have formal and informal elements, because the nurse and patient may set goals together before the nurse formulates and implements the plan of care, and the patient is free to ask questions that may direct the session. The health care information is considered informal because it is situation and patient specific. Formal patient education is delivered throughout the community in the form of media, in a variety of educational and group settings, or in a planned, goal-directed, one-on-one session with a patient in the acute care setting. Informal education is usually learner or patient directed. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill.

The nurse is performing passive range-of-motion exercises on his patient when the patient begins to complain of pain. What is the first thing the nurse should do? a. Notify the health care provider. b. Hyperextend the joint. c. Stop the range of motion. d. Switch to active range of motion.

C Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced. Never hyperextend or flex a patient's joints beyond the position of comfort. Active range of motion is when the patient moves the joint. Notifying the health care provider would happen after you stopped.

The nurse is preparing to teach a 90-year-old patient. In teaching an elderly patient, the nurse realizes that: a. most elderly patients are highly literate. b. cognitive abilities always decline with age. c. sensory alterations often occur with aging. d. teaching methods are the same as for the middle aged.

C Teaching should be tailored to elderly patients. Reports indicate that two thirds of U.S. adults 66 years old and older have inadequate or marginal literacy skills, and 81% of patients 60 years old and older at a public hospital could not read or understand basic materials such as prescription labels. Although each patient must assessed individually, cognitive and sensory alterations often occur with aging, and the teaching materials should be adjusted accordingly.

The nurse is caring for a patient with a Penrose drain. She knows the patient will require the following care: a. The drain must be compressed after emptying to work properly. b. The drain must be connected to suction if ordered. c. The drain is not sutured in place so care is taken to not dislodge it. d. The suction pulls drainage away from the wound as it re-expands.

C The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction. Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

Which statement by the nurse correctly identifies the UAP role in patient restraint use? a. "The UAP can perform initial assessment." b. "The UAP can apply a restraint." c. "The UAP can assist with applying and monitoring of a physical restraint." d. "The UAP can contact the physician and request an order for restraints."

C The UAP cannot perform the initial assessment, and most facilities require that a registered nurse or licensed practical nurse Applying a restraint. The physician should be contacted by the nurse not the UAP. The UAP can assist with applying the restraint and can perform monitoring checks under the direction of a Registered Nursing

The nurse administers an immunization consisting of antibodies against hepatitis B. The nurse knows this is a form of what type of immunity? a. Naturally acquired passive b. Naturally acquired active c. Artificially acquired passive d. Innate

C The body did not have to work to develop the immunity; therefore, it is passive, and the patient was artificially exposed. It is not innate because it was provided. It was not naturally acquired because it was given in the vaccine.

An appropriate goal for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity is: a. the patient will ambulate twice a day. b. the patient will eat 50% of meals. c. the patient will have no further skin breakdown. d. the patient will interact with others.

C The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care? a. High Fowler's b. Prone c. Side lying d. Low Fowler's

C The side-lying position should be used to prevent aspiration. The high Fowler's, low Fowler's, and prone position will not prevent aspiration.

The nurse knows the layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect is: a. stratum germinativum. b. epidermis. c. subcutaneous layer. d. stratum corneum.

C The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect. The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells. The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

Which statement by the patient indicates a teaching need regarding safety in the home? a. "I will put a night light in every room." b. "I will not use an extension cord to plug in multiple items." c. "I will wash my throw rugs in the bathroom regularly." d. "I will keep all cleaning supplies out of reach of children."

C Throw rugs present a fall or tripping hazard. Nights lights help light halls to prevent falls, extension cords can present a trip hazard, and cleaning supplies can contain poisonous materials.

The nurse is educating the patient about the use of heat/cold therapy at home. The following statement by the patient indicates the need for further education? a. "I should fill my ice bag 2/3 full of ice." b. "I should use distilled water in my Aqua-K pad." c. "I can warm up my hot pack in the microwave." d. "I should check the order for how long to leave the compress on."

C Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating. Ice bags are filled two thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at: a. flat. b. 90 degrees. c. 30 degrees. d. 45 degrees

C When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

The nurse understands that which set of vitals most likely indicates infection? a. 98.6, 75, 18, 120/80 b. 99, 80, 19, 110/70 c. 100.5, 96, 22, 150/100 d. 98.9, 65, 18, 98/62

C With infection, temperature will rise and blood pressure will increase along with pulse and respiratory rate.

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a "popping sensation" and a wetness in her dressing. The nurse immediately suspects: a. a wound infection. b. the stitches came loose. c. wound dehiscence. d. wound crepitus.

C Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process. This is an emergency situation. Stitches can come loose, but there is no popping sensation. Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

The nurse is correctly assisting the patient in using a cane when the patient demonstrates the following: (Select all that apply.) a. The top of the cane is level with the patient's bent elbow. b. The patient holds the cane on his/her weaker side. c. The patient moves the cane forward first. d. The patient's arm is comfortably bent when walking.

C, D The top of the cane should be level with the hip joint, and the patient's arm should be comfortably bent when the patient is walking. The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg. This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to one side or looking down can jeopardize safety and cause poor posture.

The nurse knows to irrigate a deep wound with: a. A 5-mL syringe. b. A 10-mL syringe. c. A 3-mL syringe. d. A 30-mL syringe.

D A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath. Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi (Rodeheaver and Ratcliff, 2007).

The patient has a nursing diagnosis of risk for falls. Which goal is most important? a. Patient will ambulate twice a day. b. Patient will have no symptoms of infection. c. Patient will perform activities of daily living. d. Patient will have no injuries during hospital stay.

D All of the goals except lack of infection are appropriate for a patient with a risk-for-falls diagnosis; however, the most important goal is for the patient to have no injuries during the hospitalization.

The patient is reportedly well educated and employed as an engineer, but is struggling to comprehend terms found in health-related literature given to explain his disease process. This is evidence of: a. low literacy. b. psychomotor dysfunction. c. affective domain deficiency. d. low health literacy.

D Although low literacy and low health literacy are related terms, they are not interchangeable. Low health literacy is content specific, meaning that the individual may not have difficulty reading and writing outside the health care arena. These patients may struggle to comprehend the complicated, unfamiliar terms and ideas found in health-related materials or instructions. The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The nurse is explaining to the patient why she is receiving antibiotics. Her answer would be correct if she stated antibiotics are effective against which microorganism? a. Viruses b. Fungi c. Parasites d. Bacteria

D Antibiotics are effective against bacteria, and exact antibiotic sensitivity is tested so that appropriate antibiotics are prescribed. Infections that are caused by fungi are treated with antifungal medications. Certain antiviral medications are used to manage the symptoms of a viral infection. These medications, if given during the early phases of illness, can decrease the amount of time that the patient has viral symptoms. Treatment for parasitic infections varies depending on type of parasite.

The nurse knows that routine hygienic care does not include: a. massage with lotion. b. oral care with a toothbrush. c. shaving with a disposable razor. d. ear hygiene with cotton-tipped applicators.

D Cotton-tipped swabs or applicators should not be used in the ears for cleaning because this can push wax farther into the ears. A back massage may be given as part of a complete bed bath. Oral care is an essential nursing intervention that provides patient comfort, removes plaque and bacteria, reduces the risk of tooth decay, and decreases halitosis. Oral care includes brushing the teeth and tongue, flossing, rinsing the mouth, and cleaning dentures. Shaving a patient may be part of hygienic care and can be done with a disposable or electric razor.

The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education? a. "I should report any complaints of soreness to the nurse." b. "I should watch for indications that the patient has difficulties using the cane." c. "I should let the nurse or PT know if the cane doesn't seem to fit correctly." d. "I should teach the patient how to walk with the cane."

D Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness, difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.

The nurse knows that mechanical debridement involves all of the following except: a. wet to dry dressings. b. whirlpool baths. c. damp to dry dressing. d. enzymatic dressing.

D Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal. Mechanical debridement is a nonselective form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound. The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

The nurse correctly identifies that the most effective method to prevent hospital-acquired infections is: a. use of sterile technique. b. isolation protocols. c. antibiotic use. d. handwashing.

D Handwashing is the most effective method to prevent hospital acquired infections. Sterile technique is only used for certain procedures and isolation protocols are used for patients already infected or for protective isolation in immune-compromised patients and are not used for every patient. Antibiotics are used to treat infections.

The nurse displays an understanding of high-risk populations for MRSA when identifying which group as the lowest risk? a. Prison inmates b. College dorm residents c. Team athletes d. Food service workers

D High-risk populations for MRSA include those living in close quarters or those who have frequent skin-to-skin contact, including prison inmates, college dorm residents and team athletes. Food service workers work together but do not generally live in close quarters or have skin-to-skin contact frequently.

The nurse knows that a hydrocolloid dressing is appropriate for the following type of wound: a. A wound with a large amount of drainage b. A wound that is tunneling c. A postsurgical incision with staples d. A wound with a moderate amount of drainage

D Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose. They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed. A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a wound that is tunneling may require packing.

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do? a. Cover the wound with a sterile gauze pad. b. Cover the wound with a transparent dressing. c. Put pressure on the wound with a sterile gauze pad. d. Cover the wound with gauze soaked with normal saline.

D If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the physician immediately. Putting pressure on the wound could cause further complications. Transparent films are used for autolytic debridement. A gauze pad will allow the wound to become dry and cause further complications.

Individual factors affecting safety include those that are related to the functioning of body systems and those that are directly associated with a person's particular lifestyle. Changes in which body system affect overall mobility increasing the propensity of falling? a. Neurologic b. Hepatic c. Cardiopulmonary d. Musculoskeletal

D Impairments in the musculoskeletal system can impact mobility through restrictions of range of motion and strength, increasing the chances of falling. Changes to the neurologic system can impair cognitive functioning, changes to the hepatic system can affect mental status and changes to the cardiopulmonary system can affect activity tolerance.

What statement is true regarding oral care of patients on anticoagulants? a. Use an electric toothbrush daily. b. Avoid oral care. c. Use mouthwash only. d. Use a soft-bristled toothbrush.

D Oral care is important regardless of medication, but a soft-bristled toothbrush should be used related to increased risk of bleeding for any patient on an anticoagulant. An electric toothbrush is too aggressive, and mouthwash is not adequate.

The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action? a. Refuse to shave the patient because he is on an anticoagulant. b. Shave as usual with a safety razor. c. Offer to wax rather than shave the patient. d. Use an electric razor.

D Patients on anticoagulants should use an electric razor for shaving to avoid bleeding complications. Patients should have the option of shaving if they would like to shave. Waxing may not be an option.

Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient? a. Nurse b. Physical therapist c. Occupational therapist d. Podiatrist

D Patients with diabetes are usually seen by a podiatrist or diabetic specialist for foot care needs. Nurses can trim toenails of patients not at risk for infection. Physical therapists provide services that restore function and mobility. Occupational therapists use treatments to maintain or restore daily living and work skills.

The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing? a. Patient with asthma b. Patient with attention deficit hyperactivity disorder c. Patient with a stroke d. Patient with diabetes

D Patients with neurologic deficits such as peripheral neuropathy resulting from diabetes may not be able to identify extremes of hot and cold. Patients with attention deficit hyperactivity disorder and asthma are not likely to be injured by temperature extremes. Patients with a stroke may have some alteration in sensation on one side of their body but can compensate by using the other side, and they are at less risk than a patient with diabetes.

The nurse is preparing to reposition the patient in bed. What is the first step in this process? a. Position the patient's arms across his/her chest. b. Lower the side rails. c. Grasp the draw sheet. d. Raise the bed to a working height.

D Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe, and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.

The nurse is performing perineal care for the uncircumcised patient. Which of the following is true? a. The foreskin should not be moved. b. The foreskin should be retracted, pulling it away from the body. c. The foreskin should be left retracted and allowed to return to position naturally after care. d. The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying.

D The foreskin must be returned to its normal position after cleaning to prevent contraction and swelling. It is okay to move the foreskin to clean the penis. To retract the foreskin, gently push it toward the body. It should be returned to its position by the nurse, not left to return on its own.

Which collaborative team member would be most effective in assisting the nurse to identify medication alternatives that are less likely to cause drowsiness and dizziness to reduce the risk of falls in the elderly patient? a. Nursing house manager b. Charge nurse c. Physical therapist d. Pharmacist

D The nurse collaborates with the pharmacist and physician to identify and implement safe medication alternatives for older adults to minimize side effects such as drowsiness, dizziness, and orthostatic hypotension, which can increase fall risk. Although house managers and charge nurses might have some experience in this area, pharmacists are educated to focus on medication. Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking. They make recommendations for assistive devices such as canes and walkers to promote safe performance of these activities.

The nurse is concerned about helping the patient find resources to obtain assistive equipment to be used in the home. Which team member should the nurse contact first? a. Occupational therapist b. Physical therapist c. Physician d. Social worker

D The nurse should collaborate with the social worker to identify community resources for obtaining assistive equipment. The social worker facilitates contact with insurance companies or other agencies to assist with the financing of recommended therapeutic assistive and specialty devices. Occupational therapists evaluate the patient for safe performance of activities of daily living (ADLs) such as bathing, dressing, and grooming, and they make recommendations to enhance safe performance of these activities, such as the use of specialty equipment (e.g., grippers for pants, oversized shoehorns). Physical therapists evaluate the patient's ability to perform and maintain balance during routine activities such as sitting, standing, and walking. They make recommendations for assistive devices such as canes and walkers to promote safe performance of these activities. Physicians order the equipment.

The nurse anticipates correctly that what type of medication would be ordered to treat athlete's foot? a. Antiviral b. Antibiotic c. Antihelminth d. Antifungal

D The nurse would expect to treat athlete's foot with an antifungal because it is a fungal infection. An antibiotic treats bacterial infections, antivirals treat viral infections, and antihelminth treats parasitic worms.

The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of hygiene self-care deficit. Which goal is most appropriate on day one? a. Patient will ambulate independently twice a day. b. Patient will perform all of own ADLs. c. Patient will consume 75% of all meals. d. Patient will begin to perform 50% of own ADLs.

D The patient need to work towards achieving as much independence in self-care as possible; starting with 50% in a post-stroke patient on day one is more achievable than 100%. Ambulating and eating meals are not goals for a self-care deficit.

The nurse correctly teaches the patient to rise from a chair using crutches when the following interventions are used: a. Patient starts from the back of the chair. b. The weak leg is closest to the chair. c. The hand on the strong side holds the handbar of the crutch. d. The strong leg is closest to the chair.

D The patient's strongest leg should be close to the chair. The patient's hand on the weak side holds the handbar of the crutches, and the hand on the patient's strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.

The nurse is working with a diabetic patient, and is attempting to teach psychomotor skills. This is occurring when the nurse has the patient: a. verbally describe his feelings about diabetes. b. answer three of five true-or-false questions about diabetes. c. identify 3 positive lifestyle changes to manage blood sugar. d. draw up and self-inject insulin correctly.

D The psychomotor domain incorporates physical movement and the use of motor skills in learning. Teaching the newly diagnosed diabetic how to check blood sugar is an example of a psychomotor skill. Learners in the cognitive domain integrate new knowledge through first learning and then recalling the information. They then categorize and evaluate, making comparisons with previous knowledge that result in conclusions related to the new content. Affective domain learning recognizes the emotional component of integrating new knowledge. Successful education in this domain takes into account the patient's feelings, values, motivations, and attitudes.

The nurse's stethoscope most correctly represents which possible link in the chain of infection? a. Source b. Portal of exit c. Portal of entry d. Mode of transmission

D The stethoscope would be a means for the pathogen to travel from source to host. The source is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir of infection, and the portal of entry is where the microorganism enters the susceptible host.

The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of secretions. What PPE should be worn? a. Gloves and eyewear b. Gloves, gown, and mask c. Eyewear and gown d. Eyewear, mask, gown, gloves

D Use gloves routinely when blood or body fluid might be present. If splashing is possible, use your nursing judgment about what other PPE might be necessary. Forceful expulsion of secretions would require all PPE—gown, mask, eyewear, and gloves—to provide adequate protection.

The nurse knows the following types of wounds heal by tertiary intention: a. An acute wound in which the patient has sutures placed when it happened b. A pressure ulcer that was treated with dressing changes and healed c. An acute wound in which surgical glue was used to close the wound d. A wound that was left open initially and closed later with sutures

D When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds. This type of wound is said to heal by primary intention. When a wound heals by secondary intention, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.