Fundamentals

best ways to prevent error

- communication- interdiciplinary team and patient (confusion breeds error) - situational awarness- frequently assess

SWEAT TEST

- diagnostic in cystic fibrosis (genetic disease- abnormally thick secretions in lungs and other parts of body from abnormal transport of nacl into the epitheliel cells) - high sodium and choloride concentrations is diagnositic of CF - > than 60meq of chloride indicative of CF

MENIERE'S DISEASE

- dilaion of the endolymphatic syste by decreased reabsorption of endolymphatic fluid. manifestation include tinnitus, one sided hearing loss, and vertigo that can last for days.

A fellow student asks you about your legal liability when you do your clinical practice. What is true?

...

5 mL = X teaspoons

1 teaspoon = X mL

When assessing a client's gait, which does the nurse look for and encourage? 1.The spine rotates, initiating locomotion. 2.Gaze is slightly downward. 3.Toes strike the ground before the heel. 4.Arm on the same side as the swing-through foot moves forward at the same time.

1.The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward.

an advance directive is a consent that

spells out the incapacitated patient's wishes regarding test and treatments

Which of he following outcomes are correctly written? 1. Offer Mr Myer 60 mL fluid every 2 hours while awake. 2. During the next 24-hr period, the patient's fluid intake will total at least 2,000 mL. 3. By discharge Mrs Gaston will know how to bathe her newborn. 4. At the next visit, 12/23/12, the patient will correctly demonstrate relaxation exercises.

2 & 4

Use Maslow's hierarchy of human needs to prioritize the following patient problems from highest priority (#1) to lowest priority (#4): 1) Disturbed Body Image 2) Ineffective Airway Clearance 3) Spiritual Distress 4) Impaired Social Interaction

2, 4, 1, 3

Type of Syringe and Needle for IM

3ml 20-25g 1-1.5"

Type of Syringe and Needle for SQ

3ml 25-29 g 1/2-5/8"

normal fasting blood glucose no food for at least 8 hours

70-100

normal pre-prandial blood glucose level

90-130mg/dl

A GRADUATE NURSE IS ADMINISTERING SEVERAL MEDICATIONS TO A NEWLY ADMITTED PATIENT. WHO IS LEGALLY RESPONSIBLE FOR THE DRUGS ADMINISTERED BY THIS NURSE? A THE NURSE ADMINISTERING THE DRUG B PHARMACIST WHO DISPENSED C NURSE MANAGER D PHYSICIAN WHO WROTE THE ORDER

A

A flat macular hemorrhage is called a(n): A. purpura. B. ecchymosis. C. petechiae. D. hemangioma.

A

AT WHAT POINT SHOULD THE NURSE DO THE 3 CHECKS OF MEDICATION ADMINISTRATION? A AS THE NURSE REACHES FOR THE DRUG PACKAGE B WHEN REVIEWING THE PATIENT;S MAR C AT THE BEGINNING OF SHIFT D AFTER RETRIEVING THE DRUG

A

The production of red blood cells in the bone marrow is called: A. hematopoiesis. B. hemolysis. C. hemoptysis. D. hemianopsia.

A

What term refers to a linear skin lesion that runs along a nerve route? A. Zosteriform B. Annular C. Dermatome D. Shingles

A

When teaching a patient about wound healing, the nurse should tell the patient: A) Inadequate nutrition delays wound healing and increases risk of infection. B) Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. C) Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. D) Fat tissue heals more readily because there is less vascularization.

A

NREM stage 1

A few minutes, light sleep, easily aroused, gradual reduction in vital signs

Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.) A) Edema and pain B) Streak formation C) Pain and erythema D) Pallor and coolness E) Numbness and pain

A, D

Answer: B A theory is a set of concepts, definitions, relationships, and assumptions that explains a phenomenon. Theories do not formulate legislation, measure nursing functions, or reflect any domain of nursing practice.

A theory is a set of concepts, definitions, relationships, and assumptions that: A) Formulates legislation B) Explains a phenomenon C) Measures nursing functions D) Reflects the domain of nursing practice

How can you determine a patient's history of allergies? (Select all that apply.) A) By looking at the patient's allergy bracelet B) By looking at the MAR C) By asking the patient D) By looking at the front of the chart E) By administering a dose and monitoring the patient's response

ABCD

All of the following are examples of increased risk for pressure ulcers (select all that apply) A Wheelchair Bound B Peripheral Vascular Disease C Diabetes D Malnourishment E Incontinence

ABCDE

ACID BASE BALANCE AN POTASSIUM

ACIDOSIS- H+ will move into cells --> Potassium will move out --> hyperkalemia ALKALOSIS- H+ will move out of cell ---> potassium will move into cell --> hypokalemia

SIGNS OF ABDOMINAL ANEURYSM RUPTURE

ASSESS FOR: - abdominal pain that radiates - poor peripheral circulation - abdominal distention -eccchymosis on the lower back

Malpractice

Act of negligence as applied to a professional person such as a physician, nurse, or dentist

Question... A 78 year old client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the PN to consider before assisting this client.

Answer... Blood pressure of 86 over 54

Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) A) Repositioning patient every 1 to 2 hours while awake B) Using an objective, valid scale to assess patient's risk for pressure ulcer development C) Using a device to relieve pressure when patient is seated in chair D) Teaching patient how to shift weight at regular intervals while sitting in a chair E) A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes

All except A

Answer: B APNs are generally the most independently functioning nurses. An APN can work in a primary, acute, or restorative care setting. The setting may be a private, public, or university facility. The APN may function as a clinician, educator, case manager, consultant, or researcher.

Advanced practice nurses (APNs) generally: A) Work in acute care settings B) Function independently C) Function as unit directors D) Work in the university setting

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) A) Patient's weight B) Patient's level of cooperation C) Patient's ability to assist D) Presence of medical equipment E) 24-hour calorie intake

All except E

Question... Which instruction is most important for the PN to provide a client before leaving the unit to have an MRI?

Answer... Remove all metal objects from the body.

Precautions

Airborne - Gloves, mask - measles, TB, varicella Droplet - Gloves, mask - pneumonia, rubella, pertussis Contact - Gloves, gown (PRN mask/goggles) - MRSA, c. diff

puncture wound

An open wound that tears through the skin and destroys underlaying tissues. A penetrating puncture wound can be shallow or deep. A perforating puncture wound has both an entrance and an exit wound.

Defamation of Character

An intentional tort in which one party makes derogatory remarks about another that diminishes the other party's reputation; slander is oral defamation of character; libel is written defamation of character

Sentinel Event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

Question... When should the PN evaluate the client's pain level?

Answer (1) routinely with measurements of vital signs, (2) when the client initially complains of pain, (3) At the beginning and end of each shift, (4) 30 - 60 minutes after administration of an analgesic.

Question... A client, who is experiencing paralysis of the left are, curses at the PN and, using the right arm, throws a hairbrush against the wall. How should the PN respond?

Answer... "I can see you are upset. I want you to know that I am a good listener."

Selye's theory of general adaptation states that homeostasis will be regained

unless adaptive mechanisms are overwhelmed

Battery

Assault that is carried out

A patient of any age can develop a contracture of a joint when: A) The adductors muscles are weakened as a result of immobility. B) The muscle fibers become shortened because of disuse. C) The calcium-to-phosphorus ratio becomes disrupted. D) There is a deficiency in vitamin D.

B

DURING A SKIN ASSESSMENT, THE NURSE RECOGNIZES THE 1ST INDICATION THAT A PRESSURE ULCER MAY BE DEVELOPING WHEN SHE NOTICES THE SKIN IS WHICH COLOR? A BLUE B WHITE C YELLOW D RED

B

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? A) Binder B) Ice bag C) Elastic bandage D) Absorptive diaper

B

Functions of the skin include: A. production of vitamin C. B. temperature regulation. C. the production of new cells by melanocytes. D. the secretion of a drying substance called sebum.

B

3 types of extinguishers

☐ Class A is for paper, wood, upholstery, rags, or other types of trash fires. ☐ Class B is for flammable liquids and gas fires. ☐ Class C is for electrical fires.

THE NURSE WOULD RECOGNIZE WHICH OF THE FOLLOWING PATIENTS TO HAVE IMPAIRED WOUND HEALING A NPO FOLLOWING SURGERY B OBESE WOMAN WITH TYPE 1 DIABETES C MAN WITH SEDENTARY LIFESTYLE AND LIFELONG SMOKER D A WOMAN WHO'S BREAST RECONSTRUCTION SURGERY REQUIRED NUMEROUS INCISION

B

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump? A) 125 mL/hr B) 167 mL/hr C) 200 mL/hr D) 1000 mL/hr

B

The patient at greatest risk for developing multiple adverse effects of immobility is a: A) 1-year-old child with a hernia repair. B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular accident (CVA). C) 51-year-old woman following a thyroidectomy. D) 38-year-old woman undergoing a hysterectomy.

B

What does the Braden Scale evaluate? A) Skin integrity at bony prominences, including any wounds B) Risk factors that place the patient at risk for skin breakdown C) The amount of repositioning that the patient can tolerate D) The factors that place the patient at risk for poor healing

B

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? A) Tap water or bottled water B) Fluid that has sodium (salt) in it C) Fluid that has K+ and HCO3- in it D) Coffee or tea, whichever they prefer

B

Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing? A) Notify her health care provider that she is hyperventilating B) Provide frequent oral care to keep her mucous membranes moist C) Ask her to breathe slower and help her to calm down and relax D) Assess her for pain and request an order for a sedative

B

WHEN ADMINISTERING ORAL MEDICATIONS, WHICH OF THE FOLLOWING PRACTICES SHOULD THE NURSE FOLLOW(SELECT ALL THAT APPLYS) A DISPENSE MULTIPLE LIQUID MEDICATIONS INTO A SINGLE CUP TO REDUCE THE NUMBER OF CONTAINERS THE PATIENT MUST HANDLE B PERFORM HAND HYGIENE BEFORE AND AFTER MEDICATION ADMINISTRATION C STAY AT THE BEDSIDE UNTIL THE PATIENT HAS FINISHED ALL MEDICATIONS D KEEP THE PATIENTS MAR AT THE BEDSTIME AT ALL TIMES E VERIFY THE PATIENTS RESPONSE TO THE MEDICATION 30 MINUTES AFTER ADMINISTRATION, OR AS APPROPRIATE FOR THE DRUG

B C E

In the Snellen chart, the NUMERATOR represents the A. distance a "normal" person could read a particular line B. distance that a person stands away from the chart C. % of the # of letters a person can read on a line D. # of feet that a person has to move forward to read a line

B. distance that a person stands away from the chart the denominator is the distance a "normal" person could read a particular line

BP rates according to age

Babies tend to start with low BP that will continue to increase until they become elders

Differentiate the sounds of Vesicular, bronchovesicular and bronchial

Bronchial=Loud, High pitched inspiration over trachea Bronchovesicular= medium pitch, intensity heard over the larger airways Vesicular= low pitch and soft heard at the peripherals of the lungs

An example of a primary lesion is a(n): A. erosion. B. ulcer. C. urticaria. D. port-wine stain.

C

The divisions of the spinal vertebrae include: A. Cervical, thoracic, scaphoid, sacral, and clavicular. B. Scapular, clavicular, lumbar, scaphoid, and fasciculi. C. Cervical, thoracic, lumbar, sacral, and coccygeal. D. Cervical, lumbar, iliac, synovial, and capsular.

C

WHICH MEDICATION WILL DELAY HEALING OF A POST-OP WOUND A LAXATIVE B ANTIHYPERTENSIVE C CORTICOSTEROID D K+ SUPPLEMENT

C

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? A) Collection of wound drainage B) Reduction of abdominal swelling C) Reduction of stress on the abdominal incision D) Stimulation of peristalsis (return of bowel function) from direct pressure

C

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? A) 56-year-old with acute kidney renal failure B) 40-year-old with appendicitis C) 28-year-old who has acute pancreatitis D) 65-year-old with hypertension and asthma

C

Smell

CN 1

A scooped out, shallow depression in the skin is called a/an: A. ulcer. B. excoriation. C. fissure. D. erosion.

D

WHICH ONE OF THE NUTRITIONAL GUIDELINES SHOULD THE NURSE GIVE A WOMAN IN HER 2ND TRIMESTER OF PREGNANCY A EAT NORMAL NUMBER OF CALORIES BUT INCREASE FRUITS AND VEGETABLES B MAINTAIN REG CALORIE INTAKE, BUT TAKE SUPPLEMENTS C EAT AS MUCH AS YOU CAN D MORE CALORIES AND HIGH IN NUTRIENTS

D

Heat or Cold? Decreased blood flow to injured site

Cold

Heat or Cold? Helps prevent edema from forming

Cold

Heat or Cold? Increased Blood Viscosity

Cold

Heat or Cold? Local Anesthesia

Cold

Heat or Cold? Promotes blood coagulation at injury site

Cold

Misdemeanor

Crime of lesser offense than a felony and punishable by fines, imprisonment (usually for less than 1 year), or both

Which of the following is NOT considered a border for the oral cavity? A. lips B. cheeks C. tongue D. tonsils

D. tonsils

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education? A) "I usually go swimming with my family at the YMCA 3 times a week." B) "I need to ask my doctor if I should have a bone mineral density check this year." C) "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D) "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill. "

D

A patient had a left-sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small-bore nasogastric (NG) tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? A) Pale yellow urine B) Unilateral neglect C) Slight movement noted on the R side D) Coffee ground-like aspirate from the feeding tube

D

A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first? A) Serum albumin B) Serum sodium C) Hematocrit D) Serum potassium

D

A student nurse has been assigned to teach fourth graders about hygiene. While preparing, the student nurse adds information about the sweat glands. Which of the following should be included while discussing this topic? A. There are two types of sweat glands: the eccrine and the sebaceous. B. The evaporation of sweat, a dilute saline solution, increases body temperature. C. Eccrine glands produce sweat and are mainly located in the axillae, anogenital area, and navel. D. Newborn infants do not sweat and use compensatory mechanisms to control body temperature.

D

An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? A) Chronic pain B) Impaired skin integrity C) Risk for ineffective cerebral tissue perfusion D) Risk for activity intolerance

D

PRIOR TO STARTING A TUBE FEEDING, THE NURSE ASSESSES THE PH AND COLOR OF THE PATIENT'S GASTRIC CONTENTS AND RECEIVES A PH READING OF 6.2 AND THE ASPIRATE IS OFF-WHITE COLOR. A STOMACH B SMALL INTESTINE C COLON D RESPIRATORY TRACT

D

THE DRESSING CHANGE ON A DEEP UPPER-ARM WOUND IS PAINFUL FOR THE PATIENT. WHEN PREPARING A CARE PLAN FOR THE PATIENT, THE NURSE WILL INCORPORATE WHICH OF THE FOLLOWING MEASURES: A ADMINISTER ANALGESIC IMMEDIATELY BEFORE DRESSING CHANGE B PERFORM DRESSING CHANGE WHEN PATIENT IS FATIGUED FROM PT C PERFORM DRESSING CHANGE DURING MEALTIME SO PATIENT IS DISTRACTED D ADMINISTER ANALGESIC 30-45 MIN BEFORE DRESSING CHANGE

D

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

D

The knee joint is the articulation of three bones, the: A. femur, fibula, and patella. B. femur, radius, and olecranon process. C. fibula, tibia, and patella. D. femur, tibia, and patella

D

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? A) Necrotic tissue B) Wound drainage C) Drainage on the dressing D) Wound after it has first been cleaned with normal saline

D

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A) A local skin infection requiring antibiotics B) Sensitive skin that requires special bed linen C) A stage III pressure ulcer needing the appropriate dressing D) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

D

Position of Ear for child

Down and Back

Percussion of fluid filled organ

Dullness

Heat or Cold? Increased Capillary Permeability

Heat

Heat or Cold? Increased Tissue metabolism

Heat

Heat or Cold? Increases Blood flow

Heat

Heat or Cold? Vasodilation

Heat

the intent of diagnosis related groups(drg) was

contains hospital costs

Stage III pressure Ulcer

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Credentialing

General term that refers to ways in which professional competence is maintained

Illumination of the iris is for

Glaucoma

Heat or Cold? Decreased Blood Viscosity

Heat

Cane

Held on good side!

S/s of infection (INFECT)rt

I- Increased vital signs, WBC N- nodes enlarged F- function impaired E- erythema, edema, exudate C- complaint of pain T- elevated temp local or systemic

To hear pulmonic pulse

L of Sternum, Second ICS

to hear apical (mitral) pulse

L of sternum, 5 ICS

Statutory Law

Law enacted by a legislative body

fistula

abnormal passageway between two organs or between an internal organ and the body surface

hyponatremia

abnormally low level of sodium in the blood

WHAT IS THE PRIORITY FOR NURSING CARE OF AN ELDERLY CLIENT?

MAINTAIN A SAFE ENVIRONMENT -

MRI

Magnetic Resonance Imaging

open wound

an injury in which the skin is interrupted, exposing the tissue beneath

contusion

an injury to underlying tissues without breaking the skin and is characterized by discoloration and pain

Answer: A The client is the correct choice. The health care facility is where the client goes to receive treatment. The nursing process is how nurses proceed to plan care for the client. Cultural diversity is not the correct choice.

Nursing practice in the twenty-first century is an art and science that is centered on: A) The client B) The nursing process C) Cultural diversity D) The health care facility

PPE Order

ON = Gown, Mask, Goggle, Gloves (GoMa GoGl) OFF - Gloves, Goggles, Gown, Mask (GloGo Goma) PPE disposed of in clients room

Stage II pressure Ulcer

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Plaintiff

Person or government bringing a lawsuit against another

when a patient falls, you document in the nurse's notes

any patient-stated cause of fall

Health Promo

Primary = prevention Secondary = screening Tertiary = treatment

Certification

Process by which a person who had met certain criteria established by a nongovernmental association is granted recognition

Accreditation

Process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education

What are some things that can affect BP readings

Recent smoke or cup of caffeine, wait 30 min

Systolic murmurs are heard after S_ Diastolic Murmurs are heard after S_

S1, S2

LYME DISEASE

STAGE I- flulike symptoms such as headach, lethargy, rash STAGE II- cardiac conduction defects and nuerological disorders such as bell palsy and paralysis. - Caused by ricketsia rickettsi treated via doxycycline.

CARBON MONOXIDE POISONING

SYMPTOMS- tachycardia, tachypnea, and CNS depression NORMAL LEVELS- carboxyhemogobline levels are less than 5% for an adult. and 5-10% for heavy smoer

abrasion

Scraping or wearing away of the skin by friction; irritation

Rosenbaum chart is for

Strabismus

Whistle-Blowing

Term generally used to refer to employees who report their employers' violation of the law to appropriate law enforcement agencies outside the employers' facilities

Question... which client finding requires further action by the PN?

The drainage tube of an indwelling catheter is looped below the client's bladder.

Defendant

The one being accused of a crime or tort

Answer: C The nurse accurately assesses temperature by palpating the skin with the dorsum or back of the hand, because this area of the hand is more sensitive to temperature than is the base of the hands, the fingertips, or the palmar surface.

To correctly palpate the client's skin for temperature, the nurse uses which of the following? A) Base of the hands B) Fingertips of the hands C) Dorsal surface of the hands D) Palmar surface of the hands

Assault

Threat or an attempt to make bodily contact with another person without that person's permission

Answer: D Superficial lymph nodes are gently palpated using the pads of the index and middle fingers. The lymph nodes are small, and any other method would not be helpful.

To assess a client's superficial lymph nodes, the nurse: A) Deeply palpates using the entire hand B) Deeply palpates using a bimanual technique C) Lightly palpates using a bimanual technique D) Gently palpates using the pads of the index and middle fingers

Answer: D The dorsalis pedis pulse is felt on the top of the foot in line with the groove between the extensor tendons of the great toe and the first toe. The popliteal pulse is felt behind the knee. The posterior tibial pulse is felt in the groove behind the medial malleolus. Typically pulses are not palpated behind the lateral malleolus.

To assess the client's dorsalis pedis pulse, the nurse palpates: A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe

Answer: A The sounds of lung fields on one side of the body are compared with the sounds of the same fields on the opposite side of the body. The other answers would provide incorrect comparisons.

To auscultate the client's lung fields, the nurse uses a systematic pattern comparing: A) Side to side B) Top to bottom C) Anterior to posterior D) Interspace to interspace

Licensure

To be given a license to practice nursing in a state or province after successfully meeting requirements

True or False The character of the exudate, in amount, color and odor, can help to identify the exact nature of the infection

True

What kind of sound do you hear at percussion of abdomen

Tympany

Position of ear for adult

Up and Back

Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. This characteristic of the nursing process is described as: a. Systematic b. Dynamic c. Interpersonal d. Outcome oriented

b. Dynamic

Tort

Wrong committed by a person against another person or his property

reactive hyperemia

a bright red flush on the skin occurring after pressure is relieved

best definition of total quality management(TQM)

a method of system operation and management used to achieve continuous quality improvement

As a nurse, you follow the guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors. b. By not requiring sick days from work. c. By never exposing others to any type of illness d. By not being overweight

a. By being a role model for healthy behaviors. (Good personal health enables the nurse to serve as a role model for patients and families.)

Which of the following levels of basic human needs is most basic? a. Physiologic b. Safety & Security c. Love & belonging d. Self-actualization

a. Physiologic

You tell your instructor that your patient is fine and has "no complaints." You are likely to hear: a. You made an inference that she is fine because she has no complaints.How did you validate this? b. She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship. c. Sometimes everyone gets lucky. Why don't you try to help another patient? d. Maybe you should reassess the patient. He has to have a problem. Why else would he be here?

a. You made an inference that she is fine because she has no complaints.How did you validate this?

NORMAL URINE OUTPUT

adult - 30 ml/hr newborn - 2-5 ml/kg/hr

when nursing was taken out into the community nursing education was essentially

an apprenticeship

Which of the numbered areas is considered sterile on a person in the operating room? You may assume that all articles were sterile when applied.

area 1 Rationale: Sterile objects are considered unsterile if placed lower than the waist. Only area 1 in this situation would be considered sterile. Above the neck, higher than 2 inches above the elbow, below the waist/table, and the back are all considered unsterile.

B

besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch

A client diagnosed as morbidly obese has been counseled to begin an exercise program. During the most recent clinic visit, the client was complaining of increased pain in both knees that increases with walking. Which of the following can the nurse say to help this client? a. Keep walking. The pain will go away. b. I would find a surgeon who can replace your knees now. c. Have you tried anything to help reduce the pain in your knees? d. I'm sure you will need knee replacements after you lose this weight.

c. Have you tried anything to help reduce the pain in your knees?

Of the following statements, which one is true of self actualization? a. Humans are born with fully developed self-actualization b. self-actualization needs are met by having confidence and indepence c. The self-actualization process continues throughout life. d. loneliness and isolation occur when self-actualization needs are unmet

c. self actualization, or reaching one's full potential is a process that continues through life

Evaluation of pain therapy requires the consideration of the ________ character of pain, ____ to therapy, ___ to function, and patient's perception of a therapy's effectivness

changing response ability

Which of the following nursing degrees prepares a nurse for advanced practice as a clinical specialist or nurse practitioner? a. LPN b. ADN c. BSN d. Master's

d. A Master's degree prepares advanced practice nurses.

hypoxia

deficiency of oxygen

dyspnea

difficulty breathing

NIKOLSKY SIGN

epidermis can be rubbed off by slight friction- (seen in pemphigus)

a way to promote trust with a patient is to

follow through when you say you will do something

pain modulation

hindering the transmission of pain by release of inhibitory neurotransmitters (endorphins&enkephalins) that produce an analgesic effect

diet consideration for hepatic disorders

inability to convert ammonia to urea. - therefore to avoid ammonia buildup avoid taking foods high in ammonia such as meats.

hypostatic pneumonia

inflammation of the lung from stasis or pooling of secretions from lack of movement and exercise

what is an acute illness

influenza

What is the purpose of a spacer?

it helps the medication reach the lungs used in children and elderly helps avoid mouth fungus,nervousness and other side effects

which statement is true about fraud

it results from a deliberate deception intended to produce unlawful gain

the oblique side lying(lateral) position is helpful because

it takes the pressure of the trochanter and shoulder

malnutrition contributes to the susceptibility to infection because

it upsets homeostatic balance in the body

the reason for lengthening hand hygiene time when hands are contaminated is

mechanically remove as many microorganisms as possible

transmission of pain

movement of pain impulses from the periphery to the spinal cord & then to the brain

Snellen chart is for

myopia

an example of administrative law that affects nursing is

nurse practice acts

an example of communication through the visual channel is

observing that the client looks away from the nurse when discussing a certain subject

dysuria

painful or difficult urination

medical asepsis differs from surgical asepsis in that medical sepsis is aimed at

preventing transmission of microorganisms

if a nurse suspects a coworker is abusing chemicals the nurse should

report the coworker to nursing administration

a person who has continuous dry rattling sounds

rhonchi

the practice of nursing is regulated by

state board of nursing

Crutches

step up with the good - crutches in one hand, other hand on railing - crutches go with bad leg Step down with the bad - crutches go with bad leg

the person who makes harsh high sounds upon inspiration has what kind of respiratory condition

stridor

if a patient requires a pelvic examination you would position the patient on the table in which position

supine

incision

surgical cut or wound produced by a sharp instrument

nocturia

urination at night

RULE OF NINES

used to assess extent of burns. trunk- 36% each leg= 18% each arm= 9% pernineum= 1% head= 9%

Walker

walker forward 12 inches bad leg then good leg

ARTERIAL INSUFFICIENCY VS VENOUS INSUFFICIENCY

- Arterial- intermittent claudication (leg pain that gets worse with exercise and alleviates with rest), pallor, cyanosis, ulcers are round smooth minimal drainage no odor - VENOUS- leg pain that is achy and gets worse as day progresses, edema, warm and tender, uclers are not round and have drainage always wt

ORTHOSTAIC HYPOTENSION

- CAUSES TO CONSIDER- pregnancy, meds (diuretics, etc), SURGERY - SYMPTOMS- dizziness, nausea, tachycardia, pallor, seeing spots. - INTERVENTIONS- get out of bed slowly, dangle feet at edge of bed prior to getting up

BREASTFEEDING EDUCATION

- PROMOTE prenatal vitamins and fluids. increase o f 200-500 calories - SIGNS OF BREASTFEEDING PROBLEMS- falling asleep after 5 minutes, not opening mouth to latch, tongue thrusting, dimpling of cheeks, smakcking or clicking sounds, choppy motion of the jaw.

ADDISONS DISEASE

- endocrine dysfunction of the adrenal gland- does not produce enough glucocoritcoids and mineralcoritcoids - ADDISONIAN crisis- can cause hyponatremia, hyperkalemia, hypoglycemia, and shock - treated with ACETATE (FLORINEF)- has mineralcoritcoid and glucocorticoid activity- enhances the reabsorption of sodium and chloride and eretions of potassium and hydrogen.

Frequent side effect of ACE inhibitors (opril)

- frequent dry cough - normal only notify if bothersome

An attorney was careful to explain in her defense that she had specialty knowledge, experience, and clinical judgment and had met certain criteria established by a nongovernmental association, as a result of which she was granted recognition in a specified practice area. What is this sort of credential called?

...

Damages are the actual harm or injury resulting to the patient.

...

If review of a patient's record revealed that she had never consented to the eye surgery, of which intentional tort might the surgeon have been guilty?

...

If you harm a patient by administering a medication (wrong drug, wrong dose, etc.) ordered by a physician, what is true?

...

ACTIONS FOR PULMONARY EDEMA

1) place in high fowlers position 2) Oxygen delivery 3) O2 stat and heart monitor 4) Check vital signs 5) administration of meds- morphine (reduces anxiety and promotes peripheral vasodilation) 6) call RT if ventilator needed - other interventions- insertion of foley catheter, and administration of diuretics.

NREM stage 3

15-30 min, early phase of deep sleep, snoring, relaxed muscle tone, little/no physical movement, difficult to arouse

NREM stage 4

15-30 min, shortens toward morning, deep sleep, sleep-walking, sleep-talking, bed-wetting may occur

Type of Syringe and Needle for ID

1ml 25-27 g 3/8-5/8"

During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to do which of the following? 1) Formulate and validate prioritized nursing diagnoses 2) Identify expected patient outcomes 3) Select evidence-based nursing interventions 4) Communicate the plan of nursing care

2, 3 & 4

The nurse would call the primary care provider immediately for which laboratory result? 1.Hgb = 16 g/dL for a male client. 2.Hct = 22% for a female client. 3.WBC = 9 x 10³/mL³ 4.Platelets = 300 x 10³/mL³

2.Hct = 22% for a female client. Rationale: Option 2 is very low and can lead to death. The client's red blood cells participate in oxygenation. Options 1, 3, and 4 are within normal range and should not be reported to the primary care provider.

The client has a urinary health problem. Which procedure is performed using indirect visualization? 1.Intravenous pyelography (IVP) 2.Kidneys, ureter, bladder (KUB) 3.Retrograde pyelography 4.Cystoscopy

2.Kidneys, ureter, bladder (KUB) Rationale: A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization.

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1.Hire only competent nurses. 2.Improve the nurse's ability to multitask. 3.Establish a reporting system for "near misses." 4.Communicate effectively. 5.Create a culture of trust

3. Establish a reporting system for "near misses." 4.Communicate effectively. 5.Create a culture of trust. Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions.

C

52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant: a) temperature b) radial pulse c) respiratory rate d) oxygen saturation

Hypothermia is below

95 F

Expected range for SaO2

95-100% is normal but 91-100 is also accepted, anything below 90 is hypoxemia!

Normal Range Oral temperature

96.8-100.4, for rectum/temporal its usually a degree higher and for the armpit/tympani its a degree lower.

Newborns should be kept in what temp range

97.7-99.5

normal post-prandial blood level taken 2 hours after a meal

<180mg/dl

A nurse on a pediatric unit is preparing the assignment for the evening shift. The unit employs unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? a) setting up Bryant's traction b) completing the FACES pain scale for a child with sickle cell crisis c) obtaining post-operative vital signs on a client status post-tonsillectomy d) setting up an intravenous therapy pump

A

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

A

An operating room nurse has just finished setting up a sterile field for a kidney transplant surgery. She gets word that the donor organ will not be available for another thirty minutes. Which of the following is the best course of action? A) Personally watch the sterile field to ensure that it is not broken. B) Place cones or barriers in front of the main OR doors. C) Place sterile drapes over all surfaces. D) Thirty minutes is too long. The sterile field will need to be broken and reestablished later

A

The nurse has delegated administration of 10am medications to an LPN/LVN. At 10:15am, the nurse notes none of the medications have been administer yet. Which is the best action for the nurse to take? a) ask another LPN/LVN assigned to the unit to help administer medications b) begin administering the medications c) report he situation to the head nurse d) ask the LPN/LVN to give the nurse a status report

A

What is the removal of devitalized tissue from a wound called? A) Debridement B) Pressure reduction C) Negative pressure wound therapy D) Sanitization

A

Answer: A In the staff model of an MCO, the physicians are salaried employees. In the group model, the MCO contracts with a single group practice. An independent practice association is a group of physicians who are under contact to the organization but are not members of it and whose practices include fee-for-service and capitated clients. The MCO contracts with multiple group practices and/or integrated organizations in the network model.

A client is receiving health care from a health care provider who is a salaried employee. Which model is being followed by the managed care organization (MCO) to which the client belongs? (Select all that apply.) A) Staff model B) Group model C) Network model D) Independent practice association

An internal corneal reflex would be demonstrated by which of the following? A. a bilateral blink B. a bilateral pupillary constriction C. a bilateral horizontal deviation of the eye D. bilateral tearing

A. a bilateral blink reflect to protect the eyes from damage by foreign objects

Tuning fork hearing tests measure hearing by which of the following mechanisms? A. air/bone conduction B. bone/vestibular conduction C. air/water conduction D. bone/water conduction

A. air/bone conduction

The roof of the mouth is divided into 2 parts known as the: A. hard and soft palates B. anterior and posterior palates C. frontal and ethmoid arches D. superior lingual and uvular arches

A. hard and soft palates

Which of the following patients have risk factors for developing a wound infection? (Select all that apply.) A) An 80-year-old man who has a burn B) A 17-year-old patient who has a metal fragment lodged in his thigh C) A 30-year-old female who had an episiotomy after childbirth D) A patient receiving chemotherapy who has a surgical incision E) A patient with peripheral vascular disease and an ulcer on the heel

ABDE

Which of the following guidelines for outcome writing are correct? 1. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis. 2. The patient (and family) values the outcomes. 3. The outcomes are supportive of the total treatment plan. 4. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.

All of the above

Answer: C The nurse is assessing the client. Diagnosis occurs after all assessments are completed. Then a plan is developed and implemented. The process is completed with evaluation.

An 18-year-old woman is in the emergency department with fever and cough. The physician asks the nurse to measure vital signs, auscultate lung sounds, listen to heart sounds, determine the level of comfort, and collect blood and sputum samples for analysis. The nurse is performing what aspect of practice? A) Diagnosis B) Evaluation C) Assessment D) Implementation

D

An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic

Answer: D Additional training in anesthesia medicine would be required to be a certified registered nurse anesthetist.

An APN is pursuing a job change. Which of the following positions would the APN be unable to fill without meeting additional criteria? A) Case manager B) Nurse manager C) Nurse educator D) Certified registered nurse anesthetist

Answer: B Surgical clients are the client population of interest (P) in the PICO (population, intervention, comparison, outcome) question. Chlorhexidine use is the comparison of interest, and povidone-iodine use is the intervention of interest. The operating room nurse is not an element of the PICO question.

An operating room nurse is talking with colleagues during a meeting and asks, "I wonder if we would see fewer wound infections if we used chlorhexidine instead of povidone-iodine to clean the skin of our surgical clients? In this example of a PICO question, the P is: A) Povidone-iodine use B) Surgical clients C) Chlorhexidine use D) Operating room nurses

Question... The PN is applying the finger probe for continuous pulse oximetry on a client. Which actions should help prevent skin irritation or breakdown?

Answer... (1) rotate probe location site every 4-8 hours, (2) cleanse with soap and water as needed, (3) Secure with gauze if client has allergy to adhesives.

Question... Which information should the PN provide to a client whose vision is being tested with a Snellen chart?

Answer... Cover one eye while reading the chart with the other.

Answer: D As a science, nursing draws on scientifically tested knowledge applied in the practice setting.

As an art, nursing relies on knowledge gained from practice and reflection on past experiences. As a science, nursing relies on: A) Experimental research B) Nonexperimental research C) Physician-generated research D) Scientifically tested knowledge

Which is an outcome for a patient diagnosed with osteoporosis? A) Maintain serum level of calcium. B) Maintain independence with activities of daily living (ADLs). C) Reduce supplemental sources of vitamin D. D) Reverse bone loss through dietary manipulation.

B

A nurse is performing wound care. Which of the following practices violates surgical asepsis? a. Holding sterile objects above the waist b. Considering a 1″ edge around the sterile field as being contaminated c. Pouring solution onto a sterile field cloth d. Opening the outermost flap of a sterile package away from the body

C

Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first? a. Assess the drainage in the dressing. b. Slowly remove the soiled dressing c. Wash hands thoroughly. d. Put on latex gloves.

C

Risk factors that may lead to skin disease and breakdown include: A. loss of protective cushioning of the dermal skin layer. B. decreased vascular fragility. C. a lifetime of environmental trauma. D. increased thickness of the skin.

C

THE NURSE WOULD RECOGNIZE THAT AN OBESE MALE PATIENT WHO HAS BEEN DIAGNOSED WITH OBSTRUCTIVE SLEEP APNEA FACES AN INCREASED RISK OF WHICH OF THE FOLLOWING? A DEPRESSION B RESPIRATORY ACIDOSIS C HEART DISEASE D SEIZURES

C

THE PHYSICIANS ADMITTING ORDERS INDICATE THAT THE PATIENT IS TO BE PLACED IN A FOWLERS POSITION, UPON POSITIONING THIS PATIENT, HOW MUCH WILL THE NURSE ELEVATE THE HEAD? A 15 B 90 C 45-60 D 30

C

Which description best fits that of serous drainage from a wound? A) Fresh bleeding B) Thick and yellow C) Clear, watery plasma D) Beige to brown and foul smelling

C

Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? A) Keeping the buttocks exposed to air at all times B) Using a large absorbent diaper, changing when saturated C) Using an incontinence cleaner, followed by application of a moisture-barrier ointment D) Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

C

Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? A) 700 mL B) 900 mL C) 1000 mL D) 1100 mL

C

If sound lateralizes to one ear when performing the Weber test, which of the following occurring? A. sound is heard LONGER in one ear than the other. B. higher FREQUENCIES of sound are heard better in one ear C. sound is heard LOUDER in one ear D. electrical impulses are amplified in one ear

C. sound is heard LOUDER in one ear

Shoulders for strength

CN 11

DECORTICATE AND DECEREBRATE

CORTICATE- flexed CEREBRATE- extended- indicative of worsening nuerological condition

Felony

Crime punishable by imprisonment in a state or federal penitentiary for more than 1 year; crime of greater offense than a misdemeanor

When taking the health history, the patient complains of pruritus. What is a common cause of this symptom? A. Excessive bruising B. Hyperpigmentation C. Cancer D. Drug reactions

D

When comparing air conduction vs. bone conduction, which is expected to occur? A. bone conduction is normally 2 times as long as air conduction B. bone conduction and air conduction are equal C. air conduction is normally 3 times as long as bone conduction D. air conduction is normally 2 times as long as bone conduction

D. air conduction is normally 2 times as long as bone conduction

When examining the set of the ear, the top of the pinna should match an imaginary line drawn from the A. tip of the lateral point of the eyebrow to the occiput B. tip of the nose to the crown of the head. C. tip of the corner of the mouth to the crown of the head D. corner of the eye to the occiput

D. corner of the eye to the occiput

Ventricular Diastole of the heart, ventricles relax and exert minimal pressure against the arterial walls, and represents the minimum amt of pressure exerted on the arteries

Diastolic BP

Answer: D Kyphosis (hunchback) is an exaggeration of the posterior curvature of the thoracic spine and is common in older adults. Lordosis (swayback) is increased lumbar curvature. Scoliosis is lateral spinal curvature. Hypotonic muscle has little tone and feels flabby, usually because of atrophy of muscle mass.

During general inspection of the musculoskeletal system of an older client, the nurse notes kyphosis. Kyphosis is: A) Lateral spinal curvature B) Loss of or decrease in muscle tone C) Increased lumbar curvature D) Exaggeration of the posterior curvature of the thoracic spine

S/S of respiratory distress

EARLY SIGNS- tachypnea, dyspnea, restlessness LATER SIGNS- pallor, cyanosis COMPLICATIONS- pulmonary edema manifested as diffuse crackles and rhonci.

Answer: C The domain contains the subject, central concepts, values and beliefs, phenomena of interest, and the central problems of the discipline. A paradigm is a model that explains the linkage of science, philosophy and theory that is accepted and applied by the discipline.

Each science has a domain, which is the perspective of the discipline. This domain: A) Represents the recipients of the benefits of the science or discipline B) Is a model that explains the linkage of science, philosophy, and theory that is accepted and applied by the discipline C) Describes the subject, central concepts, values and beliefs, phenomena of interest, and central problems of the discipline D) Is a dynamic state of being in which the developmental and behavioral potential of the individual is realized to the fullest

Answer: D The result of theory-generating or theory-testing research is to increase the knowledge base of nursing. As these research activities continue, clients become the recipients of evidence-based nursing care.

Evidence-based nursing practice is the end result of: A) Prescriptive theory B) Use of practical knowledge C) Application of theoretical knowledge D) Theory-generating and theory-testing research

Stage IV pressure Ulcer

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with this type of pressure ulcer.

Heat or Cold? Decreases Spasmodic Pain

Heat

Heat or Cold? Improves delivery of antibiotics to wound

Heat

Heat or Cold? Improves delivery of leukocytes to wound

Heat

EPS- electrophysiology studies

Invasive proceude to study the hearts electrical system . wire is introduced into the heart to produce dysrythmia. Client NPO prior. - sedation is aoided.

Common Law

Law resulting from court decisions that is then followed when other cases involving similar circumstances and facts arise; just as binding as civil law

Liability

Legal responsibility for one's acts (and failure to act); includes responsibility for financial restitution of harms resulting from negligent acts

Answer: A The goal of Leininger's theory is to provide the client with culturally specific nursing care, in which the nurse integrates the client's cultural traditions, values, and beliefs into the plan of care.

Leininger's theory of cultural care diversity and universality specifically addresses: A) Caring for clients from unique cultures B) Understanding the humanistic aspects of life C) Identifying variables affecting a client's response to a stressor D) Caring for clients who cannot adapt to internal and external environmental demands

Answer: C The first level of Maslow's hierarchy of needs includes the need for air, food, and water—basic elements of survival. Love and belonging are on the second level, esteem and self-esteem are on the fourth level, and self-actualization is the final level.

Maslow's hierarchy of needs is useful to nurses, who must continually prioritize a client's nursing care needs. The most basic or first-level needs include: A) Self-actualization B) Love and belonging C) Air, water, and food D) Esteem and self-esteem

What are the 10 Rights of Medication Administration

Medication Assessment Dose Documentation Route Patient Education Timing Evaluation Refusal (MADDRPETER)

Answer: D Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Grand theories are described as broad and complex. Prescriptive theories address nursing interventions and predict the consequence of a specific nursing intervention. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena.

Mishel's theory of uncertainty in illness focuses on the experience of clients with cancer who live with continual uncertainty. The theory provides a basis for nurses to assist clients in appraising and adapting to the uncertainty and illness response and can be described as: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

Medication positions

NASAL- supine with neck hyperextended (tilted back) EYES- head tilt back, place hand on forehead pull the lower lid down and place drop lower outer conjunctival sac, close eye, apply pressure on the inner canthus (prevents systemic absorption) EARS- ADULT (up and back), UNDER 3 (down and back) administer at room temp to prevent dizzines nausea and pain.

Stage I pressure Ulcer

Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators

Expert Witness

Nurse who explains to the judge and jury what happened based on the patient's record and who offers an opinion as to whether the nursing care met acceptable standards of practice

Fact Witness

Nurse who has knowledge of the actual incident prompting a legal case; bases testimony on firsthand knowledge of the incident not on assumptions

Six cardinal positions gaze is for

Nystamus

POTENTIAL COMPLICATION FOR SALICYLATE/ ASPIRIN OVERDOSE?

PULMONARY EDEMA- DUE TO SEVERE METABOIC ACIDOSIS.

1, 5, 2, 4, 3

Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37.3 (99.4) 4) HR= 72 BPM 5) RR= 28 BrPM

Answer: A A positive benefit of a professional nursing staff is a decreased length of stay. The diagnosis-related group has greater influence on the rate of readmission. The ancillary personnel need to remain so that registered nurses can spend the necessary time to assess and manage clients. Nosocomial infections decrease with a professional nursing staff.

Recent research provided evidence that a professional nursing staff affects health care financing. These results indicated that the positive benefit of a professional nursing staff is: A) Decreased length of stay B) Decreased rate of readmission C) Increased rate of nosocomial infections D) Decreased need to hire ancillary personnel

Functions of Sleep

Restoration, reducing fatigue,stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the immune system,promoting cellular growth and repair, improving the capacity for learning and memory storage

blood

Sanguinous

Answer: C This is the description of an MCO. In a PPO, choice of care providers is limited to those listed in the group. Medicare is a federally funded national health insurance program. Private insurance is a traditional fee-for-service plan.

The client's health insurance changed, and instead of having a limited number of physicians from whom to choose, the client is voluntarily enrolled in a plan in which medical care is provided by a special group of caregivers. This arrangement is known as: A) Medicare B) Private insurance C) Managed care organization (MCO) D) Preferred provider organization (PPO)

D

The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering

AV Fistula

Used for hemodialysis access- filtering of blood waste products such as creatinine and urea when the kidneys do not work - Complications- infection, clot, steal syndrome - NURSING - ensure patency- palpate for thrills and auscultate for bruits q 4 hours or as per hospital protocal. DO NOT draw blood, or take BP or IV,

Answer: C Prescriptive theories address nursing interventions for a phenomenon and predict the consequence of a specific nursing intervention. Descriptive theories describe the phenomena, speculate on the reason the phenomena occur, and predict nursing phenomena. Grand theories are broad and complex and provide a structural framework for broad, abstract ideas about nursing.

Which of the following statements about prescriptive theories is accurate? A) They describe phenomena. B) They have the ability to explain nursing phenomena. C) They reflect practice and address specific phenomena. D) They provide a structural framework for broad abstract ideas.

Answer: D An oxygen saturation of 89% should be addressed first, because this indicates that a client needs oxygen. The high respiratory rate may be a result of hypoxemia and may decrease as the oxygen saturation climbs. The blood pressure is high, but this might be attributed to hypoxemia or anxiety. The heart rate and temperature are within normal limits.

Which of the following values for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic

D

Which of the following vlues for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic

Answer: C The prospective payment system is one of the most significant factors influencing payment for health care. The prospective payment system groups payments into diagnosis-related groups for Medicare and Medicaid clients. Managed care organizations are systems in which there is administrative control over primary health care services for a defined client population.

Which of the following was most significant in influencing competition in health care costs? A) Medicare and Medicaid B) Diagnosis-related groups C) Prospective payment system D) Managed care organizations

Answer: C Obtaining a sterile specimen requires insertion of a catheter, a procedure that must be performed by a licensed nurse. Therefore, this would not be an appropriate task to delegate to an assistive person. Assistive personnel would be able to ambulate a client, give a bed bath, and add to the I&O record.

Which task is it not appropriate for a professional nurse to delegate to assistive personnel? A) Ambulate a client B) Complete a bed bath C) Obtain a sterile urine specimen D) Complete the intake and output (I&O) record

Answer: B Developmental theories discuss human growth from conception to death. The other options are incorrect.

Which theories describe an orderly process beginning with conception and continuing through death? A) Systems theories B) Developmental theories C) Interdisciplinary theories D) Stress and adaptation theories

Name the three important dimensions to consistently measure to determine wound healing.

Width, length and depth

To determine the significance of a blood-pressure reading of 148/100, it is first necessary to: a. Compare this reading to standards b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure d. Consult with collleagues.

a. Compare this reading to standards

The nurse calculates a client's body mass index as being 25.2. According to the Classification of Body Mass Index in Adults, which of the following can the nurse accurately document about this finding? a. This client is overweight. b. This client is mildly malnourished. c. This client is of normal weight. d. This client is obese.

a. This client is overweight.

An experienced nurse tells you not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underline your response? a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years. It's time to champion intuitive, creative thinking! d. It's simply a matter of preference. Some of us are logical, scientific thinkers, and some are intuitive, creative thinkers

a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches.

Which of the following levels of basic human needs is most basic? a. physiologic b. safety and security c. love and belonging d. self-actualization

a. physiologic

The agent-host-environment model of health and illness is based on the concept of: a. risk factors b. infectious diseases c. behaviors to promote health d. stages of illness

a. risk factors (The interaction of the agent-host-environment creates risk factors that increase the probability of disease)

crushing injury

an injury caused by compression that involves both direct tissue injury caused by circulation disturbance resulting from pressure on blood vessels

the hospitalized client's uncle, who is a physician asks the nurse for the client's chart. the uncle is not the physician on the case. the best response for the nurse is to

ask the client for written consent before allowing the relative to see the chart

when you are conducting a home care admission interview, time will be saved by

asking open-ended questions to obtain essential data

PERMPHIGUS

autoimmune disease that causes blister formation- symptoms include nikolssky sign (empidermis can easily be rubbed off). , flaccid bullae that rupture eaisly and emit foul smelling drainage, common seen on face back and chest

after being told that surgery would probably benefit the client, the client refuses to have the surgery. in accepting the client's choice of action, the nurse is acting on which ethical principle

autonomy

when performing passive range of motion exercise

avoid moving the joint to the point of discomfort

Which of the following is one element of a healthy community? a. meets all the needs of its inhabitants b. offers access to healthcare services c. has mixed residential and industrial areas d. is little concerned with air and water quality

b. A healthy community offers access to healthcare services to treat illness and to promote health.

Maslow's Hierarchy of basic human needs is useful when planning and implementing nursing care as it provides a structure for : a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care

b. Establishing priorities of care

Of the following statements, which is most true of health and illness? a. Health and illness are the same for all people b. Health and illness are individually defined by each person c. People with acute illness are actually healthy d. People with chronic illnesses have poor health beliefs

b. Health and illness are individually defined by each person

The nursing process ensures that nurses are patient centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristics of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situatins

b. Interpersonal (Each of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process)

A young hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What should the nurse do? a. Use short words and talk more loudly? b. Ask an interpreter for help c. Explain why care can't be provided d. Provide instructions in writing.

b. Many agencies have a qualified interpreter who understands the healthcare system and can reliably provide assistance.

A nurse is providing care based on Maslow's hierarch of basic human needs. For which of the following nursing activities is the approach useful? a. making accurate nursing diagnoses b. establishing priorities of care c. communicating concerns more concisely d. integrating science into nursing care

b. Maslow's hierarch of basic human needs is useful for establishing priorities of care.

Which was the first state to identify diagnosing as part of the legal domain of professional nursing? a. New Jersey b. New York c. North Carolina d. North Dakota

b. New York

This text is based upon a notion of blended skills. .Simply described, this means: a. Nursing works best when nurses competently use the intellectual and technical skills that achieve patient outcomes. Nursing has been held back by outdated notions of care and compassion (interpersonal skills), which can be done by anyone. b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation. c. All of the blended skills are important, but not every nurse has to be skilled in each area. d. Every nursing situation demands the same blend of basic nursing skills, intellectual, technical, interpersonal, and ethical/legal skills.

b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation.

One element of a healthy community is that it: a. Meets all the needs of its inhabitants b. Offers access to healthcare services c. Has mixed residential and industrial areas d. Is little concerned with air and water quality

b. Offers access to healthcare services

A client who is undernourished is seen in the clinic for an infected foot wound. The nurse realizes this client is at continued risk for: a. Elevated iron level b. Ongoing infections c. Elevated albumin level d. The development of type 2 diabetes

b. Ongoing infections

A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness e. Syndrome

b. Risk

Careful hand-washing and using sterile techniques are ways in which nurses meet which basic human need? a. Physiologic b. Safety & Security c. Self-esteem d. Love & belonging

b. Safety & Security (By carrying out careful hand-washing and using sterile technique, nurses provide safety from infection)

Of the following characteristics, which one is not a part of chronic illness? a. Permanent change in body structure or function b. Self-treatment that relieves symptoms c. Long period of treatment and care d. Often has remission and exacerbation

b. Self-treatment that relieves symptoms

What is the purpose of the ANA's Scope and Standards of Practice? a. To describe the ethical responsibility of nurses b. To define the activities that are special and unique to nursing c. To establish nursing as an independent and free standing profession d. To regulate the practice of nursing

b. The ANA's Scope and Standards of Practice define the activities of nurses that are specific and unique to nursing.

A nurse wants to acquire knowledge of a specific culture. What could be done first? a. talk to coworkers b. review literature c. talk to family members of the patient d. ask others with more experience for help

b. reviewing literature about a specific culture can provide the nurse with a starting point for information about cultural values, dietary practices, family lines of authority, and helth and illness beliefs and practices.

Which phrase best describes the science of nursing? a. The skilled application of knowledge b. The knowledge base for care c. Hands-on care, such as giving a bath d. Respect for each individual patient

b. the science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing.

While administering a medication to relieve a patient's pain, you wonder if there are some nonpharmacologic interventions that would enhance relief by complementing the pain medication. When you discuss this with your instructor you are most likely to hear: a. "You should wait until after you evaluate the effect of the medication you just administered before planning a different intervention" b. "One step at a time, dear. Don't start planning a new intervention until you evaluate the old." c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap." d. "Think about this patient. Nonpharmacologic interventions wouldn't be effective with her."

c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap."

Identify all of the following that are purposes of diagnosing. The purpose of diagnosing is to identify: 1. How an individual, group, or community responds to actual or potential health and life processes. 2. Factors that contribute to or cause health problems (etiologies) 3. Strengths the patient can draw on to prevent or resolve problems. 4. Nursing interventions to resolve health problems a. 1 & 2 b. 3 & 4 c. 1, 2, & 3 d. All of the above

c. 1, 2, & 3

The patient is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond? a. Ask the son if he is willing to translate and be sure to thank him if he says yes. b. Determine if the son can translate medical information, and if so, begin. c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity. d. Explain to the son that hospital policy forbids using family members as translators and find a hospital approved translator.

c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity.

The nurse is preparing to conduct skin-fold measurements on a male client being treated for obesity. Which of the following should the nurse instruct the client to do prior to completing this measurement? a. Ask the client to raise their arm above their head. b. Ask the client to cross their arm and touch the opposite shoulder until the measurement is done. c. Ask the client to have their arm hang freely during the measurement. d. Ask the client to bend their arm until the measurement is done.

c. Ask the client to have their arm hang freely during the measurement.

A nurse is interviewing a newly admitted patient. Which question would be considered culturally sensitive? a. do you think you will be able to eat the food we have here? b. Do you understand that we can't prepare special meals? c. What types of food do you eat for meals? d. Why cant you just eat our food while you are here?

c. Asking patients what types of foods they eat for meals is culturally sensitive

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be: a. Nuclear family b. Extended family c. Blended family d. Cohabiting family

c. Blended family

A nurse states, I know I am cleaner than most of my patients. What does this statement indicate? a. cultural assimilation b. racism c. ethnocentrism d. sterotyping

c. Ethnocentrism occurs when one believes that one's own ideas and practices are superior to those of others.

Although all of the following are important to culturally competent nursing care, which one is the most basic? a. learning another language b. having signifigant information c. treating each person as an individual d. recognizing the importance of family

c. In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care.

Of the following clinic patients, which one is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, because her best friend had a benign breast lump removed. b. Sarah, who lives in a low-income neighborhood. c. Tricia, who has a family history of breast cancer. d. Nancy, because her family encourages regular physical examinations

c. Tricia, who has a family history of breast cancer.

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be described as which of the following: a. nuclear family b. extended family c. blended family d. cohabitating family

c. a blended family is formed when parents bring unrelated children from previous relationships together to form a new family

secondary intention

complex healing of a larger wound involving sealing of the wound through scab formation, granulation or filling of the wound, and constriction of the wound. (full thickness)

when nurses set priorities of patient needs according to Maslow's hierarchy they should

consider airway place self esteem before security place activity needs before belonging needs

S/S of pulmonary tuberculosis

cough, anorexia, fatigue, low grade fever, chills and night sweats, dypnea, hemoptysis, chest pain

the person who has abnormal nonmusical sounds during inspiration

crackles

One of the developmental tasks of the older adult family is to: a. Maintain a supportive home base b. Prepare for retirement c. Cope with loss of energy and privacy d. Adjust to loss of spouse

d. Adjust to loss of spouse (A developmental task of the older adult family is adjusting to the loss of a spouse)

A 68-year-old client in the hospital with a chronic illness is 25% overweight. This client refuses to eat vegetables and continues to ask for food to be delivered from the local pizza restaurant. Which of the following might this client be experiencing? a. Protein-calorie malnutrition b. Undernutrition c. Overnutrition d. Both over and undernutrition

d. Both over and undernutrition

Which of the following is an optional element in a measurable outcome? a. Subject b. Verb c. Performance criteria d. Conditions e. target time

d. Conditions (Conditions specify the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions.)

Which nurse in history is credited with establishing nursing education? a. clara barton b. lilian wald c. lavinia dock d. florence nightingale

d. Florence Nightingale established nursing education

What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Health as a constantly changing state (both these models view health as a dynamic, constantly changing state)

Altered Health Maintenance is an example of: a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing problem (because it describes a problem that can be treated by nurses within their scope of independent nursing practice)

Following the birth of his first child and after reading about the long-term effects of nicotine, John decides to stop smoking. This behavior change is most likely based on John's perceptions of all but one of the following. Which one is not true? a. His susceptibility to lung cancer b. How serious lung cancer would be c. What benefits his stopping smoking will have d. Personal choice and economic factors

d. Personal choice and economic factors (the others are components of the health-belief model)

Which of the following is one of the developmental tasks of the older adult family? a. maintain a supportive home base b. prepare for retirement c. cope with loss of energy and privacy d. adjust to loss of a spouse

d. a developmental task of an older individual is to cope with the loss of a spouse.

What is the best broad definition of family? a. a father, a mother, and children b. a gruop whose members are biologically related c. a unit that includes aunts, uncles, and cousins d. a group of people who live together

d. although all of the responses may be true, the best definition is a group of people who live together

a nursing theory is

existing information

CELIAC DISEASE

intolerance to gluten (protein component of wheat, barley, and oats) - stools are manifested as bulky, soft, malodorous,

which document refers specifically to the client's right for an advance directive

patient's bill of rights

the function of feedback in communication is to

provide the sender with information about the receiver's perception of the information

the skin is the first line of defense and protects the body by

providing an intact physical barrier secreting bactericidal substances

tachypnea

rapid breathing

nonblanchable hyperemia

redness of the skin due to dilation of the superficial capillaries. The redness persists when pressure is applied to the area, indicating tissue damage

blanchable hyperemia

redness of the skin due to dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color

hematoma

the collection of blood under the skin as the result of blood escaping into the tissue from damaged blood vessels. bruise

a statement about relationships among concepts or facts, based on existing information

theory

a major reason clients in the Us are sicker when they are admitted to the hospital is that

they are unable to gain access to preventative services so their illness progresses to an acute stage before they seek help

Rinne Test

to assess bone conduction, place base against mastoid bone and note how long it takes until the patient can no longer hear the sound air conduction, place next to auditory canal

an example of secondary health care services is the clients who

undergoes an appendectomy for a rupture appendix

a patient's says I don't know what to do about this problem. the most therapeutic response is

what options are you considering

purulent sputum

yellowish or greenish sputum

catheter irrigation after surgery

- to clear clots - if output more than input check tube for kinks - increase in spasms may indicate occulusion of catheter with a foreign object such as a blood clot

helpful communication techniques per type or patient

- validation techniques - useful for confused or disoriented - reminiscence- useful for older adults - reality orientation- for confused or disoriented

Question... an elderly female client calls the clinic and states she feels very weak and dizzy. Further assessment by the PN indicates that the client self-administered an enema of 3 liters of tap water because she felt constipated. What is the most likely cause of the client's symptoms?

Answer... water intoxication. Tap water is a hypotonic fluid which can leave the intestine and enter the interstitial fluid by osmosis.

If you wanted to find a list of the violations that can result in disciplinary actions against a nurse, you should read _?

...

THE NURSE IS PREPARING TO ADMINISTER A MEDICATION VIA NG TUBE. WHAT GUIDELINE IS APPROPRIATE FOR THE NURSE TO FOLLOW WHEN ADMINISTERING A DRUG VIA THIS ROUTE? FLUSH THE TUBE WITH WATER BETWEEN EACH MED

...

Those bringing charges against someone are called _?

...

What must be established to prove that malpractice or negligence has occurred in this case?

...

When a state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication order, this is an example of what type of law?

...

When the attorney representing the patient's family calls "Jean" and asks to talk with her about the case so that he can better understand her actions, how should she respond?

...

When you seek the advise of the ANA, you are likely to read what reason for purchasing a personal professional liability insurance policy?

...

one of the most common charges brought against nurses

...

Strength scale for pulses

0=absent 1=diminished 2= normal (brisk) 3- increased 4=full volume, bounding

Question... The PN is assisting a client to ambulate with a cane. Arrange the steps in ascending order from 1st to last.

Answer.... (1) explain the procedure to the client, (2) apply the gait belt, (3) Have client hold cane in hand of unaffected extremity, (4) Advance cane and the affected leg, (5) lean on cane while moving the unaffected leg forward.

Question... the PN is observing a new unlicensed assistive personnel (UAP) perform indwelling catheter care for a female client who is incontinent of feces. What action should the PN suggest the UAP change?

Answer...Frequently rinses the wash cloth used to clean the perineum.

Question... A male client tells the PN that he does not know where he is or what year it is. what documentation is the most accurate for the PN to make?

Answer...Is disoriented to place and time.

Question... The wife of a client with terminal cancer gives the PN a copy of her husbands living will. What action should the PN take?

Answer..Notify the health care provider of the client's wishes..

Which of the following are examples of well-stated nursing interventions? 1. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. 2. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. 3. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. 4. Manage patient's pain.

1, 2, 3

LUMBAR PUNCTURE

for CSF fluid analysis normal CSF finding- SMALL LEVEL WBCs, PROTEIN, FLUCOSE Abnormal findings- RBC- inidcative of meningeal irritation or blood vessel rupture.

a holistic nursing assessment of a patient is

formulating an effective nursing care plan

Unstageable

full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar

Question... When performing sterile wound care in the acute care setting, the PN obtains a bottle of normal saline from the beside table that is labeled opened and dated 48 hours prior to the current date. What is the best action for the PN to take?

Answer... discard the saline solution and obtain a new and unopened bottle.

Question... Which action is most important for the PN to implement when donning sterile gloves.

Answer... keep gloved hands above the elbows. Gloved hands held below the waist are considered unsterile.

Question... when reading a prescription, what should the PN verify in addition to the "five rights" of medication administration?

Answer... the Prescriber's signature

the best definition of a vulnerable population

client who are unable to gain access to health care when needed

current views of health include the concept of

expressing the full range of one's potentialities

fecal incontinence

- assist the client to a commode or bedpan 30 minutes after a meal because the gastrocoloic reflex promotes stool elinination is activated after eating especially in the morning.

FOOT CARE FOR DIABETIC PT

- at risk of injury due to peripheral nueropathy - DO not soak, inspect, file dont cut, lanolin for dryness, patt dry, prevent injury, and extreme temps

PHYSIOLOGY OF ACIDOSIS

- body will try to compensate increase H+ by absorbing them into cell and pushing potassium out--> hyperkalemia (s/s- hyperpnea, CNS depression, twitching, seizures) - CAN occur from ketone accumulation

GUILLIAN BARRE SYNDROME

- autoimmune disorder manifests as motor weakness and paralysis. - ascending symmetricla muscle weakness, decreased or absend deep tendon reflexes, respiratory compromise, and respiratory failure, loss of bladder and bowel control - sensory manifestation- pain, paresthesia - facial weakness, dysphagia, difficulutly speaking

A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. True False

false

RADIATION THERAPY for CANCER CONSIDERATION

- avoid skin exposure to direct sunlight - no lotions, creams, perfumes - radiation marks should remain on skin - skin protected from extreme temps. - wear cotton and avoid irritation from tight clothes

NEWBORN ABDOMINAL DEVELOPMENTAL ABNORMALITIES

- OMPHALOCELE: viscera outside theabdominal cavity but inside translucent sac - GASTOSCHISIS- visera outside the abdominal cavity not covered by sac - UMBILICAL HERNIA- viecera inside abdominal cavity and under the skin

IMMUNOSUPPRESANTS

- avoid things that would cause infection- had wash, small crowds, sick people, fresh fruits and vegetables - adverse side effects- nephrotoxicity (minfests as low urine output increaseing serum creatinine level), headace, tremor, hypertension,

BODY MECHANICS

- BEND AT HIPS- DONT BEND AT WAIST - DONT TWIST - LOW CENTER OF GRAVITY - FLEX HIPS AND KNEES - PROPER ALIGNMENT- SHOULDERS ABOVE HIPS - SLIDE AND PUSH INSTEAD OF PULL AND LIFT. - USE LEG MUSCLES NOT BACK MUSCLES.

how do you correctly administer eye drops

- CLIENT LOOKS UPWARD AND TILTS HEAD BACK - PULL LOWER LID DOWN - ADMINISTR IN CONJUCTIVAL SAC - APPLY PRESSURE ON INNER CANTHUS TO REDUCE SYSTEMIC BSORPTION AND PROMOTE EYE ABSORPTION

POSTOPERATIVE COMPLICATIONS

- DVT (calf or Groin pain, sudden onset unilateral edema, increased temp, tenderness, pain ) - PULMONARY EMBOLI (crackles, dyspnea, shorntess of breath) - INFECTION (fever, swelling, redness, purulent exudate odor)

THYROID STORM- MANIFESTATIONS AND PRIORITIES

- FEVER, TACHYCARDIA, HYPERTENSION - maintain patent airway and monitor vital signs.

ASSISTIVE DEVICES

- GAIT BELTS ARE USED FOR THOSE WHO CAN BEAR WEIGHT AND NEED MINIMAL ASSISTANCE. NEVER BE USED TO HELP LIFT CLIENT - BACK BELTS NOT RECOMMENDED IN WORK PLACE - WALKER- ADVANCE 6-8 INCHES , MOVE - CANE- hold close to body at stronger side.

RESTRAINTS (key points)

- Least restrictive first - physician order must be obtainted- reordered every 24 hours. - jackets & limb restraints removed every 2 hours and repositioned or ROM - should be able to fit two fingers between patient and restrtraine. - document reason for restraint - those in restraints- locate near nursing room, frequent assessments (minimize time in restraints, circulatory and nuerosensory,)

COmmon complicaitions of newborns

- MACOSOMIC- shoulder dystocia, hypoglycemia - PRETERM- respiratory distress syndrome due to immature lungs (signs that it is improving is increased urinary output as fluids are being filtered from the ungs into the blood. - POSTTERM- meconium aspiration syndrome and respiratory distress - C-SECTION- transient tachypnea

ASO TITER

- assess streptococcal antibodies - EX: elevated level is suggestive of rheumatic fever.

IV THERAPY (including CENTRAL LINES)- (nursing considerations, interventions)

- PICC line- inserted peripherally basilic or cephalic vein. can be inserted by trained RN - Implanted- Accessed via noncoring needle - Hickman catheter, Goshong (tunneled percutaneous) inserted in subclavian or jugular vein) - Assessment- placement via X ray, site (dressing, swelling, redness), fluid compatibility, flushing line per protocol, date (IV fluids should not be hung longer than 24 hrs) - Complications- infection, bleeding, pain, fluid overload, allergic rxn, central lines (air embolus- intervention is tredelendburg position to trap air so nurse can aspirate)

Safety checks and Assessments (essential in order to situationally aware and prepared)

- Physical environment- any fall hazards, lighting, pathway clear? - equipment- safety equipment nearby, maintain all safety equipment nearby (bag and resucitation equipment, oxygen mask, etc)troubleshooting of equipment (are they all working), - Patient safety- call light in reach, bed in low position, side rails up x2 - identify any at risk patients- elderly, visual, auditory deficiencies, medications (orthostatic hypotension (ie beta blockers diuretics, sedation, drowsiness),

STANDARD THERAPUETIC INTERVENTION FOR PULMONARY EMBOLUS

- Proper positioning- (semi fowlers, tredelenburg Left side) - Oxygen - IV analgesics (ie- morphine sulfate- relieves pain and anxiety can diminision the congestion of blood within the pulmonary arteries due to vasodilation. ) - AVOIDED- extreme flexion of hip (high fowlers), laying flat,

CONSIDERATIONS WITH CLEFT PALATE

- RISK OF OTITIS MEDIA- hearing loss as manifested by unresponsiveness - after repair avoid placing any object in mouth

MEDS TO BE CAUTIOS OF ADVERSE

- SSRIs- (ie: fluoxetine (prozac)- causes drowsiness and dizziness - Loop diuretics (ie- furosemide (lasix)- cause orthostatic hypotension - levothyroxine and beta adrenergic agonist- bronchodilators- isopropternol - hyertension

CARDIOVASCULAR PROCEDURES

- STENT Placement- meshlike device that will stay open - Percutaneous transluminal coronoary angioplasty- aloon tipped catheter that compresses plaque against the wall - CORONOARY ARTHERECTOMY- cut away plaque using blade - CORONARY CATHETIERIZATION- baloon catheter placed in coronary artery to take pressure measurements.

REYE'S SYNDROME

- acute encephalopathy that occurs following viral infection - complications: increased ICP, hypoglycemia. associated with aspirin and viral infection in children. causes ICP and fatty liver. begins with rash on palsm of hands and feet.

COMPLICATIONS OF DIURETICS ("semide")

- acute profound water loss, electrolyte depletion, dehydration, orthostatic hypotension, decreased blood volume, and circulatory collapse - NURSE- moniotr I/Os lab values,bP, weight,

THINGS TO ALWAYS ASSESS & THINGS TO REMEMBER ABOUT ASSESSMENT AND DOCUMENTATION

- always make baseline assessment - deviations from assessment- document interventions, and response - medications- document response and adverse side effects, and intervention - document safety assessment - document patient teaching.

tube feedings

- check residual- should be less than 120 ml- over indicates malabsorption . residual is checked prior to feedings and every 4 hrs - gravity speeds administration, should be adjusted to prevent rapid administration - clamp tube prior to insertion of syringe- prevents air from entering and distentsion - folwers position should be done and maintain for an hour after = pH should be 1-4

INDICATORS OF MYOCARDIAL DAMAGE FROM MI

- chest pain - ncreased levels of creatine kinase (CK) and troponin.

proper use of patches

- clean with water and non antimicrobial - rotate sites to prevent irritation - keep skin dry prior to application - remove the first patch before application

ESOPHAGEAL ARTRESIA

- disorder during development seen in newborns where the esophaus terminates prior to entering the stomach. therefore fluids accumulate as fluids entering the esophagus cannot enter the stomach resulting in lack of stool and continous drooling. `

ABGs protocol

- document- when sample taken, ventilator setting, room air or oxygen, temperature of the pt, - must be transported to the lab within 15 minutes

TYPES OF SKIN GRAFTS

- heterograft- skin from another species - homograph- skin from another human - autograph- skin from the client. autografting provides permeanent wound dressings

SYMPTOMS OF GRAFT REJECTION

- hypertension, fever, malaise, graft tenderness. treatment- immedietly initiate corticosteroids and possible monoclonal antibodies.

INCREASED THORACIC PRESSURE

- ie- pneumothorax, PEEP - causes a fall in blood pressure and increase in heart rate.

full thickness wound repair

- inflammatory (up to 3 days) - proliferative (3-24 days) - remodeling (up to 1 yr.)

partial thickness wound repair

- inflammatory response (24hrs.) - epithelial proliferation/migration - reestablishment of epidermal layers

INCREASES RISK FOR ASPIRATION

- laying flat - cough -sedation - nasogastric tube - enteral feedings - decreased LOC

SYMPTOMS OF LOW THYROID HORMONES

- low basal metabolic rate- cold intolerance, weakness, fatigue, decrease in heat production,

SYMPTOMS OF RENAL DISEASE

- low urine output - Anemia- because kidneys make erythropoiten - hypertension and tachycardia

CHF

- major complication is fluids in lung- manifests as congestive heart failure

CAR SEAT SAFETY

- minimum- under 1 year old 20 pounds- Rear facing seat - minimum- under 4 years 40 pounds- front facing seat - booster seat until seatbelt can fit about 4 9"

CONGENITAL HYPOTHYROIDISM IN INFANT

- mottled skin, large fontanel, large tongue, slow reflexes, bradycardia, distended abdomen, , proonged jandice, constipation, feeding problems, coldness to touch, umbilical hernia, excessive sleeping, hoarse cry

WHEN ARE PVCs considered dangerous

- multifocal - occur in pairs - fall on the T wave, - frequent- more than 6 per minute

ALUMINUM HYDROXIDE

- must be chewed - can cause constipation - client should increase fiber intake

POTASSIUM CHLORIDE IV ADMINISTRATION

- never given as abolus because it would cause cardiac arrest - Irritating to veins so must be diluted to prevent phlebitis

WATER INTOXICATION

- occurs with fluid retention which can occur with vasopressors - s/s: headache, drowsiness, and confusion, weight, gain, seizures, and coma.

SYMPTOMS OF GLOMERULONEPHRITIS

- predominant cause infection of with streptococcus - edema, hematuria, proteinuria

TREATMENT FOR DVT

- rest, warm compress - elevate the legs - calf measurements per day - no vigorous activity to prevent pulmonary embolus

PREVENTION OF ICP

- semi fowlers position to promote venous return - avoid extreme head and neck flexion - maintain head in nuetral position.

CORTIOCOSTEROIDS

- steroid hormone released from adrenal gland, include glucocorticoids (coritsol= stress and immune response) and mineralcoriticoids (electrolyte balance- sodium retension , potassium exretion) - EX: prednisone- irritating to stomach should not be taken with a NSAIDs or aspririn

TRACH CARE

- suction with inner cannula - wet inner cannula should not be put in place - keep a tracheostomy obturator and tube of same size for emergency replacement.

minimizing bone loss- useful for clients who have bone disorders such as kyphosis

- supplemental calcium and vitmin D - weight bearing exercises

BRAINSTEM INJURY CONSIDERATIONS

- this is where the respiratory center- therefore it is important to not only check glasgow coma scale should also check cranial nerve functioning and respiratory rate and rythm.

Advantages of Oral, Buccal and Sublingual Routes

--Conveinent and comfortable --Economical --Sometimes produce local or systemic effects --rarely cause anxiety

Disadvantages of Oral, Buccal and Sublingual Routes

--GI irritation

Disadvantages for Skin

--absorption occurs too rapid over abrasions --medications overall absorb slowly through this route

Advantages of Parenteral Routes

--can be used when oral drugs are contraindicated --more rapid absorption --epidural provides excellent pain control

Disadvantages for MM

--highly sensitive --awkward(vaginal and rectal)

Disadvantages of Parenteral Routes

--introducing infection --tissue damage --more expensive --quicker absorption=quicker adverse reactions --more painful

Advantages for MM

--local application provides therapeutic effects --aqueous solutions readily absorbed and capable of causing systemic effects --potential ROA when oral drugs are contraindicated

Advantages for Skin

--local effect --painless --limited side effects

Advantages for Inhalation

--rapid relief

Disadvantages for Inhalation

--serious systemic effects

ASCITES & CIRRHOSIS

-Ascites is the accumulation of fluid in peritoneal cavity a complication of cirrhosis as the protal vein pressure increases. can manifest as difficulty breathing - interventions: elevate head of bed, reposition every 2 hrs, ausculate the lungs every 4 hours, encourage deep breathing every 2 hrs - paracentesis can be performed to remove abdominal fluid.

BLOOD TRANSFUSIONS

-Prior to administration check for leaks, bubbles, color, and clots. if any send back to blood bank - smallest Guage intravenous needle is 19G RXN INTERVENTIONS - STOP the infusion - hang 0.9% normal saline to maintain IV volume - preserve IV access - monitor provider and blood bank - follow policy and procdure regarding further actions

Which is the most effective nursing action for controlling the spread of infection? 1.Thorough hand hygiene. 2.Wearing gloves and masks when providing direct client care. 3.Implementing appropriate isolation precautions. 4.Administering broad-spectrum prophylactic antibiotics.

1. Thorough hand hygiene. Rationale: Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand hygiene is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring standard precautions (option 2). Isolation precautions are used for clients with known communicable diseases (option 3). Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms (option 4).

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1.Activity Intolerance. 2.Risk for Activity Intolerance. 3.Impaired Physical Mobility. 4.Risk for Disuse Syndrome.

1.Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4).

During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client? Select all that apply. 1.Alanine aminotransferase (ALT) 2.Myoglobin 3.Cholesterol 4.Ammonia 5. Brain natriuretic peptide or B-Type natriuretic peptide (BNP)

1.Alanine aminotransferase (ALT) 4.Ammonia Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease.

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1.Automobile crashes Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints.

1.Document the behavior(s) that require continued use of the restraints. 3.Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints. Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint

Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1.Elbow flexion with eating and bathing. 2.Elbow extension with shaving and eating. 3.Wrist hyperextension with writing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking.

1.Elbow flexion with eating and bathing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3).

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1.Increase muscle tone and improve circulation. 2.Increase blood pressure. 3.Increase muscle mass and strength. 4.Decrease heart rate and cardiac output. 5.Maintain joint range of motion.

1.Increase muscle tone and improve circulation. 3.Increase muscle mass and strength. 5.Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2).

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1.Goggles 2.Gown 3.Surgical mask 4. Clean gloves

1.goggles Rationale: Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused.

NREM stage 2

10-20 min, can be awakened w/effort, deeper relaxation

A fever is harmful if it exceeds

102.2 F

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 1.Eliminate the reservoir. 2. Block the portal of exit from the reservoir. 3. Block the portal of entry into the host. 4.Decrease the susceptibility of the host.

2. Block the portal of exit from the reservoir. Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Since the carrier person is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir (option 1). Blocking the entry into a host (option 3) or decreasing the susceptibility of the host (option 4) will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir.

A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? 1.Place the client supine in the Trendelenburg position. 2.Position the client in a seated position with elbows on the overbed table. 3.Instruct the UAP to measure vital signs. 4.Administer an opioid analgesic.

2. Position the client in a seated position with elbows on the overbed table. Rationale: The puncture site is usually on the posterior chest. The client should be positioned leaning forward. This will allow the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be placed in the Trendelenburg position because the site would not be exposed. Option 3 is incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is incorrect. The client does not need to be medicated for pain with this procedure.

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2. "We must wash or peel all raw fruits and vegetables before eating." 3. "A wound or sore is not infected unless we see it draining pus." 4. "We should not share toothbrushes but it is OK to share towels and washcloths."

2."We must wash or peel all raw fruits and vegetables before eating." Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels (option 4).

The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. 1.Mixes the reagent with the stool sample before applying to the card. 2.Collects a sample from two different areas of the stool specimen. 3.Assesses for a blue color change. 4.Asks a colleague to verify the pink color results. 5.Asks the client if he has taken vitamin C in the past few days.

2.Collects a sample from two different areas of the stool specimen. 3.Assesses for a blue color change. 5.Asks the client if he has taken vitamin C in the past few days. Rationale: The nurse should obtain the stool specimen from two different areas of the stool. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification.

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1.Place a padded tongue depressor at the head of the bed. 2.Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment

2.Pad the bed with blankets. 5.Test oral suction equipment. Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy.

The nurse evaluates the chart of a 65-year-old client and concludes that which immunizations are current? (Select all that apply.) 1.Last tetanus booster was at age 50. 2.Receives a flu shot every year. 3.Has not received the hepatitis B vaccine. 4.Has not received the hepatitis A vaccine. 5.Has not received the herpes zoster vaccine.

2.Receives a flu shot every year. 3.Has not received the hepatitis B vaccine. 4.Has not received the hepatitis A vaccine. Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note, this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination.

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1.Heart rate 86 2.Reddened area on sacrum 3.Nonproductive cough 4.Urine output of 50 mL/hour

2.Reddened area on sacrum Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits.

The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. 1.Collect the specimen in the evening. 2.Send the specimen immediately to the laboratory. 3.Ask the client to spit into the sputum container. 4.Offer mouth care before and after collection of the sputum specimen. 5.Collect a specimen for 3 consecutive days.

2.Send the specimen immediately to the laboratory. 4.Offer mouth care before and after collection of the sputum specimen. 5.Collect a specimen for 3 consecutive days. Rationale: The sputum specimen should be sent immediately to the laboratory. The client should be provided mouth care before and after the specimen is collected. The sputum specimen should be collected for three consecutive days. Option 1 is incorrect because the sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because the term spit indicates that saliva is being examined. The client needs to cough up or expectorate mucus or sputum.

To increase stability during client transfer, the nurse increases the base of support by performing which action? 1.Leaning slightly backward. 2.Spacing the feet farther apart. 3.Tensing the abdominal muscles. 4.Bending the knees.

2.Spacing the feet farther apart. Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support.

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1.Wear a mask during dressing changes. 2. Provide disposable meal trays and silverware. 3. Follow standard precautions in all interactions with the client. 4. Use surgical aseptic technique for all direct contact with the client.

3. Follow standard precautions in all interactions with the client. Rationale: Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room. A mask is indicated when working over a sterile wound rather than an infected one (option 1). Disposable food trays are not necessary for clients with infected wounds unlikely to contaminate the client's hands (option 2). Sterile technique (surgical asepsis) is not indicated for all contact with the client (option 4). The nurse would utilize clean technique when dressing the wound to prevent introduction of additional microbes.

The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? 1.Fasting blood glucose 2.Capillary blood specimen 3.Glycosylated hemoglobin 4.GGT (gamma-glutamyl transferase)

3. Glycosylated hemoglobin Rationale: A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1."Going up, the strong leg goes first, then the weaker leg with both crutches." 2."Going down, the weaker leg goes first with both crutches, then the strong leg." 3."The weaker leg always goes first with both crutches." 4."A cane or single crutch may be used instead of both crutches if held on the weaker side."

3."The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct.

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1."Using proper body mechanics will prevent you from injuring yourself." 2."You are physically fit and at lesser risk for injury when transferring the client." 3."Use the mechanical lift and another person to transfer the client from the bed to the chair." 4."Use the back belt to avoid hurting your back."

3."Use the mechanical lift and another person to transfer the client from the bed to the chair." Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place.

When assisting with a bone marrow biopsy, the nurse should take which action? 1.Assist the client to a right side-lying position after the procedure. 2.Observe for signs of dyspnea, pallor, and coughing. 3.Assess for bleeding and hematoma formation for several days after the procedure. 4.Stand in front of the client and support the back of the neck and knees.

3.Assess for bleeding and hematoma formation for several days after the procedure. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture.

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1.Sports contribute to an adolescent's self-esteem. 2.Sunbathing and tanning beds can be dangerous. 3.Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3.Guns are the most frequently used weapon for adolescent suicide. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.

A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? 1.Instruct the client to empty his bladder and save this voiding to start the collection. 2.Instruct the client to use sterile individual containers to collect the urine. 3.Post a sign stating "Save All Urine" in the bathroom. 4.Keep the urine specimen in the refrigerator.

3.Post a sign stating "Save All Urine" in the bathroom. Rationale: Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration.

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1.Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3 Provide a bedside commode. 4. Keep the side rails up.

3.Provide a bedside commode. Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1.Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

3.Risk for Poisoning Rationale: A home that was built prior to 1978 has lead-based paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint.

The nurse determines that a field remains sterile if which of the following conditions exist? 1. Tips of wet forceps are held upward when held in ungloved hands. 2. The field was set up 1 hour before the procedure. 3. Sterile items are 2 inches from the edge of the field. 4. The nurse reaches over the field rather than around the edges.

3.Sterile items are 2 inches from the edge of the field. Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4).

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? A) Stage I B) Stage II C) Stage III D) Stage IV

A

The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? 1.Find another nurse for help. 2.Return the client to her room as quickly as possible. 3.Tell the client to take rapid, shallow breaths. 4.Assist the client to a nearby chair.

4.Assist the client to a nearby chair. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3).

1, 2, 4, 7

82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. HR 2. Skin turgor 3. Smoking history 4. Allergies to antibiotics 5. Recent BM's 6. BP in right arm 7. Client's normal temperature 8. BP in distal extremity

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inch. What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair. 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand. 3. Ask a colleague to assist by unrolling the cuff. 4. Leave the cuff rolled under.

4.Leave the cuff rolled under. Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the glove (option 3).

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1.Keep all of the side rails up. 2.Review prescribed medications. 3.Complete the "get up and go" test. 4.Place the bed in the lowest position.

4.Place the bed in the lowest position. Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option 3 would help the nurse to assess a client's risk for falling but would not prevent injury.

Which noninvasive procedure provides information about the physiology or function of an organ? 1. Angiography 2.Computerized tomography (CT) 3.Magnetic resonance imaging (MRI) 4.Positron emission tomography (PET)

4.Positron emission tomography (PET) Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ.

A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1.Restrain the client in bed. 2.. Ask a family member to stay with the client. 3..Check the client every 15 minutes. 4.Use a bed exit safety monitoring device.

4.Use a bed exit safety monitoring device. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1.Exercises past the point of resistance. 2.Performs each exercise one time. 3.Performs each series of exercises once a day. 4.Uses the same sequence during each exercise session.

4.Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3).

The following are all classic elements of evaluation. What is the correct sequence? 1. Interpreting and summarizing findings 2. Collecting data to determine whether evaluative criteria and standards are met. 3. Documenting your judgment 4. Terminating, continuing, or modifying the plan 5. Identifying evaluative criteria and standards (what you are looking for when you evaluate, eg, expected pt outcomes)

5,2,1,3,4

Bundles of muscle fibers that compose skeletal muscle are identified as: A. fasciculi. B. fasciculations. C. ligaments. D. tendons.

A

Crepitation is an audible sound that is produced by: A. roughened articular surfaces moving over each other. B. tendons or ligaments that slip over bones during motion. C. joints that are stretched when placed in hyperflexion or hyperextension. D. flexion and extension of an inflamed bursa.

A

Heberden and Bouchard nodes are hard and nontender and are associated with: A. osteoarthritis. B. rheumatoid arthritis. C. Dupuytren contracture. D. metacarpophalangeal bursitis.

A

In which of the following ethnic groups has the lowest incidence of osteoporosis? A. African Americans B. Whites C. Asians D. American Indians

A

THE NURSE SHOULD USE EXTREME CAUTION WHEN APPLYING HEAT THERAPY TO WHICH OF THE FOLLOWING PATIENTS: A UNCONSCIOUS B HIGH PAIN SENSITIVITY C VENOUS ULCER D RECEIVING STEROIDS

A

The components of a nail examination include: A. contour, consistency, and color. B. shape, surface, and circulation. C. clubbing, pitting, and grooving. D. texture, toughness, and translucency.

A

The musculoskeletal system functions include: A. protection and storage. B. movement and elimination. C. storage and control. D. propulsion and preservation.

A

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding in regard to wound dehiscence? A) The nurse should be alert for an increase in serosanguineous drainage from the wound. B) Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. C) The nurse should administer cough suppressant to prevent wound dehiscence. D) The condition is an emergency that requires surgical repair.

A

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? A) Cream of broccoli soup with whole wheat crackers and tapioca for dessert B) Hamburger on soft roll with a side salad and an apple for dessert C) Low-fat turkey chili with sour cream and fresh pears for dessert D) Chicken salad on toast with tomato and lettuce and honey bun for dessert

A

To determine if a dark skinned patient is pale, the nurse should assess the color of the: A. conjunctivae. B. ear lobes. C. palms of the hands. D. skin in the antecubital space.

A

UPON RESPONDING TO A PATIENTS CALL BELL, THE NURSE DISCOVERS THAT THE PATIENT'S WOUND HAS DEHISCED. INITIAL NURSING MANAGEMENT INCLUDES WHICH OF THE FOLLOWING A COVERING THE WOUND AREA WITH STERILE TOWELS MOISTENED WITH STERILE 0.9% SALINE B CLOSING WOUND WITH STERI STRIPS C HOLDING WOULD TOGETHER AND COVER WITH BLANKET D POURING H202 INTO ABDOMINAL CAVITY AND PACKING WITH GAUZE

A

When assessing for the presence of a herniated nucleus pulposus, the examiner would: A. raise each of the patient's legs straight while keeping the knee extended. B. ask the patient to bend over and touch the floor while keeping the legs straight. C. instruct the patient to do a knee bend. D. abduct and adduct the patient's legs while keeping the knee extended.

A

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A) Auscultate dependent portions of lungs B) Check color of urine C) Assess muscle strength D) Check skin turgor over sternum or shin

A

Answer: D A knowledge-focused trigger is a question regarding new information available on a topic. A problem-focused trigger is one faced while caring for a client or noting a trend. The PICO (population, intervention, comparison, outcome) format is a way to phrase a question to help clarify the question and the parts. A hypothesis is a prediction about the relationship between study variables.

A new nurse on an orthopedic unit is assigned to care for a client undergoing skeletal traction. The nurse asks a colleague, "What is the best practice for cleaning pin sites in skeletal traction?" This question is an example of which of the following? A) Hypothesis B) PICO question C) Problem-focused trigger D) Knowledge-focused trigger

Answer: D Restorative care assists an individual in regaining the maximum possible level of functioning. Home care includes professional and paraprofessional services that are rendered in the home setting. Extended care is intermediate medical or nursing care for individuals with an acute or chronic illness or disability. Assisted care is a setting in which the client is able to function at a higher level of autonomy within a homelike environment but in which care can be given when needed.

A client discharged after suffering a stroke is transferred from a tertiary care facility to another facility for additional care to help the client recover and continue to regain function. This type of care facility is known as: A) Home care B) Assisted care C) Extended care D) Restorative care

Answer: D Implementation is the actual delivery of care. Assessment is data gathering. Then the information is developed into a diagnosis and the planning occurs with the diagnosis. Evaluation is the final step of the nursing process.

A client is wheezing and short of breath. The physician orders a medicated nebulizer treatment now and in 4 hours. The nurse is providing what aspect of care? A) Planning B) Evaluation C) Assessment D) Implementation

Answer: A, B, C, D All are factors that will impact the client's potential to change.

A nurse at the community clinic nurse cares for a 40-year-old woman who takes insulin to manage diabetes. She is having increasing difficulty controlling the disease, and the nurse wants her to try a new insulin pump to help her manage her diabetes. Which of the following change factors increase the likelihood that she will accept this new insulin pump? (Select all that apply.) A) The innovation or change must be perceived as more advantageous than other alternatives. B) The innovation or change must be compatible with existing needs, values, and past experiences. C) The innovation must be tried on a limited basis. D) Simple innovations or changes are more readily adopted than those that are complex.

Answer: C Review of the literature is the first step in the orderly research process to determine what is already known about the problem. Recruiting clients occurs later in the process, after identifying the problem, researching the literature, and designing the study. Experimenting with new nursing procedures that have not been tested or approved is a risk to clients. Surveys are designed to obtain information from large study populations and would not be a first step in the research process.

A clinical nurse develops a better way to secure an intravenous access device in a client and wants to see if it would benefit other clients. The first step in initiating a study should be to: A) Recruit clients to participate in the study. B) Use the new technique and gather client feedback. C) Review current literature related to the clinical problem. D) Survey clients regarding their preferences and feelings regarding the procedure.

Answer: C Pallor would appear as yellowish brown in brown-skinned people. Pallor would manifest as bluish skin in light-skinned people. Pallor would appear as ashen gray skin in black-skinned people. Shiny skin indicates edema.

A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client? A) As shiny skin B) As bluish skin C) As yellowish skin D) As ashen gray skin

Answer: A, B, C, D In this case, all four options are correct. The community health nurse is providing information for the community and helping its members learn to access the help that is available, but not dictating the steps that need to be taken.

A community health nurse is caring for members of a Bosnian community. The nurse determines that the children are undervaccinated and that the community is unaware of this resource. As the nurse assesses the community, the nurse determines that there is a health clinic within 5 miles. The nurse meets with the community leaders and explains the need for immunizations, the location of the clinic, and the process for accessing the health care resources. Which of the following is the nurse doing? (Select all that apply.) A) Improving children's health care B) Teaching the community about illness C) Educating about community resources D) Promoting autonomy in decision making

Answer: C A case manager's competency is defined as the ability to establish an appropriate plan of care that is based on assessment of clients and families and coordinates the provision of needed resources and services across a continuum of care. A collaborator's competency is described as engaging in a combined effort with all those involved in care delivery. A change agent's competency is to implement new and more effective approaches to problems. A client advocate presents the client's point of view so that appropriate resources can be obtained.

A competent community-based nurse must be skilled in fulfilling a variety of roles. The ability to establish an appropriate plan of care that is based on assessment of clients and families and coordinates the provision of needed resources and services across a continuum of care defines the competency of: A) Collaborator B) Change agent C) Case manager D) Client advocate

Answer: B Assessing the learner's needs and readiness to learn are important to increase the success of the learning process. Options A and D are negative responses and would block the learning process. Repeating the old teaching plan is nonproductive and an inefficient application of the nursing process.

A home care nurse educator has repeatedly counseled a 33-year-old male diabetic client concerning the need for dietary compliance. In writing an effective teaching plan the nurse will first: A) Reprimand the client for noncompliant behavior B) Assess the client's learning needs and readiness to learn C) Repeat the old teaching plan to ensure the client's comprehension D) Provide a detailed description of complications associated with the disease process

Answer: D The homeless person's lack of a storage site for medication and inability to obtain nutritious meals are factors that contribute to poor management of chronic disease. Homeless people are often stereotyped as having a lack of concern for their situations. Poor attire and lack of hygiene are not causes of chronic illness exacerbation. They are signs of the client's status as a member of an at-risk population. It is incorrect for the nurse to assume that the client lacks education and the ability to read.

A nurse is caring for a 64-year-old homeless woman with a chronic respiratory disease in the local community-based clinic. The nurse realizes that the client is at risk of experiencing exacerbation of the disease process related to: A) Poor attire and cleanliness practices B) The client's lack of education and ability to read C) The individual's lack of concern about the disease D) The client's lack of a storage site for medication and the inability to obtain nutritious meals

Answer: A, C Clients being discharged home need education regarding how to take their medication and when to call their health care provider. There is not enough information here to determine if options 2 and 4 are appropriate, although hand hygiene after toileting is always important.

A nurse is planning a client's discharge from a subacute care unit to home. Education should be provided on which of the following topics? (Select all that apply.) A) Medication administration B) Stress reduction techniques with blood pressure assessment C) Circumstances in which the client should call the health care provider D) Hand-washing hygiene when assisting with transfer to the bathroom

Answer: B A counselor helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems. An educator helps the community gain greater skills, including through the presentation of educational programs. A collaborator is an individual who engages in a combined effort with other individuals to develop a mutually acceptable plan that will achieve common goals.

A nurse is practicing in an occupational health setting. There are a large number of employees who smoke, and the nurse designs an employee assistance program for smoking cessation. This is an example of which nursing role? A) Educator B) Counselor C) Collaborator D) Case manager

Answer: B, C The case manager coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care for the client, with a focus on discharge planning. Therefore, coordination of transfer to a step-down rehabilitation unit and follow-up after discharge to evaluate that needs have been met are the correct answers.

A nurse is working in an acute care hospital that uses a case management model. About which of the following activities should the nurse communicate with the case manager? (Select all that apply.) A) Management of a client transfer to the radiology department B) Coordination of a client transfer to the step-down rehabilitation unit C) Follow-up after a client's discharge to evaluate whether needs have been met D) Permission for a family to bring in special food for a client

Answer: B Effective qualitative research can be carried out, because through narrative interviews the participants' perceptions can be compared and common characteristics can be discovered. It is difficult to collect data about perceptions or feelings without talking to those involved. Quantitative research involves precise measurements and would not be of use in this study of perceptions. Although obtaining suggestions for possible solutions could be useful, it does not help to identify the problems on this specific unit. The data must be collected first.

A nurse manager is researching the effects of staff shortages on job satisfaction among new graduates. It would be most effective for the nurse to gather data by: A) Directly observing the nursing behaviors on the unit B) Interviewing staff nurses on the unit regarding their perceptions C) Setting up an experimental group and a control group for the study D) Calling on other nurses in the facility to suggest ways of handling the problem

Answer: C Evaluation research is aimed at finding out how well a program, practice, policy, or procedure is working. A survey studies a large group to identify general information, opinions, attitudes, or perceptions. A grounded theory is a theory developed through the collection and analysis of qualitative data. Experimental research collects information about human subjects who are divided into a control group and a comparison group.

A nurse manager wants to determine how well a new policy is working in the clinical area. It would be appropriate to use: A) Survey methods B) Grounded theory C) Evaluation research D) Experimental research

Answer: D Describing, explaining, predicting, and/or prescribing interrelationships among concepts are stated purposes of research.

A theory is a set of concepts, definitions, relationships, and assumptions or propositions to explain a phenomenon. The purposes of the components of a theory are to: A) Describe concepts or connect two concepts that are factual B) Formulate a perceptual experience to describe or label a phenomenon C) Express the global view about the individual, situations, or factors of interest to a specific discipline D) Describe, explain, predict, and/or prescribe interrelationships among the concepts that define the phenomenon

Answer: B A qualitative study involves inductive reasoning to develop generalizations or theories from specific observations or interviews. Historical research establishes facts and relationships concerning past events. Correlational research explores the interrelationships among variables of interest without any intervention by the researcher. An experimental study used tightly controlled subject groups, variables, and procedures to eliminate bias and ensure that findings can be generalized to similar groups of subjects.

A nurse researcher interviews senior oncology nurses, asking them to describe how they deal with the loss of a client. The analysis of the interviews yields common themes describing the nurses' grief. This is an example of which type of study? A) Historical study B) Qualitative study C) Correlational study D) Experimental study

Answer: A Because the clients at the clinic are allowed their choice of the traditional versus the new exercise program, the sampling in this study is not random sampling and can bias study results.

A nurse researcher is designing an exercise study that involves 100 clients who attend a wellness clinic. As the clients come to the clinic, each has a choice as to whether they want to be in the new exercise program or remain in the traditional program. The nurse plans to measure the clients' self-report of exercise before and 6 months after the program begins. What factor might influence the results of this study in an unfavorable way? A) Bias B) Anonymity C) Sample size D) Sampling method

Answer: D Taking blood pressure measurements is illness prevention. Health promotion includes activities like exercise classes. Secondary care is often known as traditional care. It would include rehabilitation after a stroke in an individual with a history of elevated blood pressure.

A nurse volunteers to take blood pressure measurements after church services. This is an example of which level of health care service? A) Secondary care B) Restorative care C) Health promotion D) Illness prevention

Answer: C The nurse who has held the same position for 2 to 3 years and understands the specific area and client population is termed a competent nurse. The expert is a nurse with diverse experience who can focus on a specific problem and offer multidimensional solutions. The proficient nurse has more than 2 to 3 years' experience and applies knowledge and experience to a situation. The advanced beginner nurse has at least some level of experience.

A nurse who has filled a position on the same unit for 2 years understands the unit's organization and the care of the clients on that nursing unit. Benner defines this nurse as able to anticipate nursing care and to formulate long-range goals; this nurse is given the title: A) Expert nurse B) Proficient nurse C) Competent nurse D) Advanced beginner

Answer: B This process may be carried out with other members of the health care team, and client and family members may be included. All nurses use critical thinking. An advanced care nurse has advanced educational preparation. An evidence-based practitioner draws on research findings as well as clinical expertise and client values. A multidisciplinary practice includes health care members from various fields of activity, such as physical therapy and dietary therapy, along with nursing.

A nurse who uses critical thinking in the decision-making process to provide effective quality care to individuals is known as: A) An advanced care nurse B) A clinical decision maker C) A member of a multidisciplinary practice D) An evidence-based practitioner

Answer: B Quality client care is always the primary focus of nursing practice. Cost control would be a benefit but is not the primary focus. Research is not about technology. Many "old" procedures can be improved through research. Although research is a professional function of nursing, it is not done to serve the profession.

A priority goal for nursing research is: A) Controlling cost for hospitals B) Improving client care C) Keeping up with technological advances D) Maintaining the professional climate in nursing

Answer: D Change must be perceived as advantageous, compatible with existing values, and easily adaptable to be successful and accepted. Up-front cost, managerial framework, building plans, contractors, compliance with building codes, and regulations for governmental agencies are all incorporated in proposals but do not provide convincing reasoning that leads to change.

A proposal written by a community-based nurse for a new, higher quality older adult care center will have increased probability of acceptance if the proposal includes: A) All building plans and a list of contractors to complete the job B) Compliance with the codes and building requirements of local government agencies C) The up-front cost and managerial framework of the new older adult center D) Description of how advantageous, realistic, compatible, and adaptable the change will be when implemented

Answer: D Informed consent means that the research subjects are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternate methods of treatment. Confidentiality rules guarantee that any information the subject provides will not be reported to people outside the research team. Bias is any personal opinion or judgment that may be interjected into the results.

A researcher gives a subject full and complete information about the purpose of a study. This is an example of: A) Bias B) Anonymity C) Confidentiality D) Informed consent

When is an application of a warm compress indicated? (Select all that apply.) A) To relieve edema B) For a patient who is shivering C) To improve blood flow to an injured part D) To protect bony prominences from pressure ulcers

A, C

Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.) A) Measuring oral intake and urine output B) Preparing intravenous (IV) tubing for routine change C) Reporting an IV container that is low in fluid D) Changing an IV fluid container

A, C

Question... A client weighing 110 pounds receives a prescription for a 5 mg dose of a drug. The oral preparation of the drug is available as 3 mg per capsule. Which intervention should the PN implement?

Answer... Call the health care provider about the prescribed dose

ANTIDOTES

ACETAMINOPHEN= acetycysteine (mucomyst)- administered orally or via NG tube MAGNESIUM SULFATE= Calcium gluconate TENSILON = ATROPINE HEPARIN = PROTAMINE SULFATE WARFARIN (COUMADIN)= VITAMIN K LEAD POISONING = SUCCIMER (CHEMET) EDTA (chelating agent) SALICYLATE POISONING- sodium bicarbonate RESPIRATORY DEPRESSION- NARCAN

Question... the daughter of an older adult who is confused asks the PN for guidance regarding the use of alternative dietary supplements to treat Alzheimer disease. Which information should the PN provide?

Answer... Carefully review information regarding research findings.

Question... The HIV unit nursing team (RN case manager, RN's, LPNs ) is meeting to discuss a client who has developed anorexia related to HIV medications. The client has lost 15 pounds in the last 2 months. Which actions should the team implement to continue the nursing process?

Answer... Collaborate with the client to set goals

Question... The PN is instruction a male client in the proper use of a metered-dose inhaler. which instruction should the PN reinforce to the client to ensure the optimal benefits from the drug?

Answer... Compress the inhaler while slowly breathing in through the mouth.

Question... A client's plan of care includes a nursing diagnosis of " altered sleep patterns related to nocturia." which client information is important for the PN to provide/

Answer... Decrease intake of fluids after the evening meal.

Question... The PN is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next?

Answer... Document that the client responds to painful stimulus.

Question... While providing morning care, a male client becomes restless, agitated, and confused. The client's heart rate is elevated, and his respiratory rate is 24 breaths per minute. which additional finding should the PN identify as an early sign of hypoxia?

Answer... Elevated blood pressure. The BP becomes elevated during the early stages of hypoxia in an effort to increase perfusion to distal tissues.

Question... During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the PN implement?

Answer... Encourage additional oral intake of juices and water. Dark amber is characteristic of fluid volume deficit.

Question... A 65 year old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which information is most important for the PN to provide?

Answer... change positions in the chair at least every hour.

Question... The PN obtains lying and standing blood pressure measurements for a female client who complains of dizziness every time she stands from the computer at work. The PN determines that her systolic pressure decreases 24 mm Hg when she stands. What intervention is most important for the PN to implement.

Answer... Encourage the client to flex her feet before rising. Orthostatic hypotension is a sudden fall in BP, usually greater than 20/10 mm Hg that occurs when suddenly rising.

Question... While performing colostomy care, the PN observes skin irritation around the stomal site. What action should the PN take when reapplying the colostomy bag?

Answer... Ensure that the hydrocolloidal stomal wafer covers the peristomal skin.

Question... The PN is caring for a dyspneic client whose O2 saturation rate is currently 90%. What position is best for this client?

Answer... Fowler with both legs supported.

Question... Which nursing diagnosis has the highest priority that the PN should identify when planning care for a client with an indwelling urinary catheter?

Answer... High risk for infection.

Question... In assessing a client's vital signs, which finding requires the most immediate action by the practical nurse?

Answer... Hyperthermia.

Question... Which action should the PN implement to ensure that eye ointment is distributed evenly across the eye and lid margin?

Answer... Instill the ointment along the lower, inner edge of the of the eyelid from the inner to outer canthus.

Question... Following an open reduction of a fractured femur, a client is placed in skeletal traction. based on the nursing diagnosis, "potential impairment of skin integrity related to immobility," which nursing intervention should the PN implement?

Answer... Lubricate the hands, slide them under the client, and give back care.

Question... The PN is administering medications to a client via a NG tube. The 0900 medications include a sustained released spansule. Which action should the PN take when administering the sustained released drug via the NG tube?

Answer... Open the spansule and flush the pellets through the tubing.

Question... the PN is providing a sponge bath for an independent adult male client who has a plaster cast on his right forearm. Which action should the PN implement?

Answer... Provide back care and foot care

Question.. A representative of the hospital's accrediting agency is performing an on-site visit at the hospital and asks to see the nurses' notes from a client's medical record. What action should the PN take?

Answer... Provide the agency rep with the information.

Question... A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the PN?

Answer... Purulent Sputum

Question..A client who had a chest tube removed 2 hours ago is now experiencing dyspnea and tachypnea. What action should the practical nurse take first?

Answer... Raise the head of the bed

Question... To administer a saline enema to a client, the PN inserts the enema tubing 3 inches into the rectum, and elevates the saline container 6 inches above the clients body. After the PN opens the clamp, the saline solution does not infuse. What is the best action for the PN to take?

Answer... Raise the saline container 6 more inches. The saline flows by gravity, and should be held about 12 inches above the body.

Question... The PN is performing nasotracheal suctioning. After the client's trachea is suctioned for 15 seconds, large amounts of thick yellow secretions return. What action should the PN implement next?

Answer... Re-oxygenate the client before attempting to suction again

Question... A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the PN to implement?

Answer... Review the schedule of outdoor breaks with the client.

Question... Which serum laboratory value should the PN monitor carefully for a client who has a nasogastric tube to suction for the past week?

Answer... Sodium

Question... The PN enters a client's room and finds the client on the floor after a fall. How should the PN communicate this situation to the risk management team?

Answer... Submit a completed incident report describing the situation to the unit manager.

Question... The PN determines that a client's radial pulse is irregular. What action should the PN take next?

Answer... Take an apical pulse for one full minute to verify irregularity. Too much digital pressure can obliterate radial pulsations.

an unexpected patient care occurrence that results in death or serious injury to the patient

sentinel event

FLAIL CHEST

sever dyspnea, cyanosis, paradoxical chest movement, Respirations are shallow, rapid and grunting.

Question... The PN is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

Answer... Taking anticoagulants for the past year.

Question... A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the PN identify that best demonstrates the client's readiness to manage his wound care after discharge?

Answer... The client demonstrates the wound care procedure correctly.

Question... before doing a fecal occult blood test or guaiac test on a stool specimen, the PN should ask the client about the regular use of which vitamin/

Answer... Vitamin C. A false positive result can occur from the regular use of vitamin c.

Question... the PN is administering a rectal suppository to a client. what action should be implemented to prevent discomfort during administration?

Answer... allow the suppository to become soft before insertion.

Answer: D This client has a fever, potentially secondary to the pneumonia previously diagnosed. His blood pressure is within normal limits. His oxygen saturation is at 92%, so this will need to be addressed second. His respiratory rate is high, which can be a result of the fever.

An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic

Answer: A Care provider is a staff position, a nurse who provides direct care. The nurse specialist has clinical expertise in a specific area. The nurse practitioner has advanced training in assessment and pharmacology and is able to provide health care in specific settings. The case manager has additional experience and is able to coordinate activities of other members of the health care team.

An APN is the most independently functioning of all professional nurses. All of the following are examples of a clinically focused APN except: A) Care provider B) Case manager C) Nurse specialist D) Nurse practitioner

Question... The PN is counting a client's respiratory rate. During the 30 second interval, the PN counts 6 respiration's and the client coughs 3 times. In repeating the count for a second 30 second interval, the PN counts 8 respiration's. What respiratory rate should the PN document?

Answer... 16

Question... A mother calls the clinic and states that she does not know how many teaspoons of medication to give her child because the directions on the bottle read, "give 15 mL." how many teaspoons should the PN instruct the mother to administer to her child?

Answer... 3 (teaspoons)

Question... The PN is teaching a male client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep despite following the same routine every night. What action should the PN take first?

Answer... Ask the client to describe the routine he is currently following.

Question... Which intervention is most important for the PN to implement for a male client who is experiencing urinary retention?

Answer... Assess for bladder distention.

PATIENT TELLS NURSE "I CANT GET ANY SLEEP AROUND HERE" NURSES FIRST RESPONSE: A ADD MORE CARBS TO DINNER B ASSESS FACTORS THAT PATIENT BELIEVES TO BE PROBLEM C TEACH PATIENT RELAXATION TECHNIQUES AND REDUCE NOISE ON THE UNIT D OBTAIN PRN ODER FOR SEDATIVE

B

When testing for muscle strength, the examiner should: A. observe muscles for the degree of contraction when the individual lifts a heavy object. B. apply an opposing force when the individual puts a joint in flexion or extension. C. measure the degree of force that it takes to overcome joint flexion or extension. D. estimate the degree of flexion and extension in each joint.

B

Which of these patients do you expect will need teaching regarding dietary sodium restriction? A) An 88-year-old with a fractured femur scheduled for surgery B) A 65-year-old recently diagnosed with heart failure C) A 50-year-old recently diagnosed with asthma and diabetes D) A 20-year-old with vomiting and diarrhea from gastroenteritis

B

A home care nurse is preparing the home for a patient who is discharged to home following a left-sided stroke. The patient is cooperative and can ambulate with a quad-cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) A) The rubber mat in the walk-in shower B) The three-legged stool on wheels in the kitchen C) The braided throw rugs in the entry hallway and between the bedroom and bathroom D) The night-lights in the hallways, bedroom, and bathroom E) The cordless phone next to the patient's bed

B, C

An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.) A) B/P = 128/84 B) Respirations 26 per minute on room air C) HR 114 D) Crackles heard on auscultation E) Pain reported as 3 on scale of 0 to 10 after medication

B, C, D

The red light reflex is caused by the A. refraction of light off the conjunctiva B. reflection of light off the inner retina C. reflection of light off the choroids layer D. condenstaion of light as it passes through the aqueous humor.

B. reflection of light off the inner retina

Patency of the nostrils is assessed by having the individual: A. breathe through both nares rapidly B. sniff inward through one nairs while the other is occluded C. blow of through each naris while the other is occluded D. observe each naris for flaring during each inhalation and exhalation

B. sniff inward through one nairs while the other is occluded

Answer: B Hypertension is often asymptomatic until pressure is very high. Headache (usually occipital), facial flushing, nosebleed, and fatigue are common symptoms of hypertension. Restlessness and dusky or cyanotic skin that is cool to the touch, dizziness, mental confusion, and mottled extremities are all signs and symptoms of hypotension. Unexplained pain and hyperactivity are very vague complaints.

Besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch

A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: A) Call the health care provider to report this change in condition. B) Give the patient a paper bag to breathe into to decrease her anxiety. C) Assess her vital signs, perform a respiratory assessment, and be prepared to start oxygen. D) Explain that this is normal after such trauma and administer the ordered pain medication.

C

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? A) Allow the area to be exposed to air until all drainage has stopped B) Place several cold packs over the area, protecting the skin around the wound C) Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration D) Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

C

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? A) Stage II B) Stage IV C) Unstageable D) Suspected deep tissue damage

C

Which of the following clients would least likely be at risk of developing skin breakdown? a. A client incontinent of urine feces b. A client with chronic nutritional deficiencies c. A client with decreased sensory perception d. A client who is unable to move about and is confined to bed

C

Which of the following defining characteristics is consistent with fluid volume deficit? A) A 1-lb (0.5 kg) weight loss, pale yellow urine B) Engorged neck veins when upright, bradycardia C) Dry mucous membranes, thready pulse, tachycardia D) Bounding radial pulse, fl at neck veins when supine

C

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? A) The patient is 5 feet 6 inches and weighs 120 lbs. B) The patient speaks and understands English. C) The patient received an injection of morphine 30 minutes ago for pain. D) You feel comfortable handling a patient of his size and with his level of cooperation.

C

COMPLICATION OF CASTS AND CRUTCHES

CASTS- circulatory impairment, peripheral nerve damage- assess circulation and sensation CRUTCHES- with poor upper body strneth pts tend to put pressure on the axillae nerve causing forearm muscle weakness. to avoid it there should be two or three fingerbreaths between the axilla and top of crutch

Before inserting an otoscope in an adult client, which of the following maneuvers should the examiner perform A. irrigate the ear canal to make sure the tympanic membrane is visible B. have the client blow his or her nose to make sure pressure is equalized between the external ear and the middle ear. C. pull the pinna up and back to straighten the auditory canal D. tilt the client's head toward the side being examined

C. pull the pinna up and back to straighten the auditory canal

A consensual light reflex is present when which of the following occurs? A. the right pupil dilates when a light is shone on the left pupil B. the left pupil dilates immediately after the light is removed from the left pupil C. the right pupil constricts when a light is shone into the left pupil D. the left pupil constricts after the light is removed from the right pupil

C. the right pupil constricts when a light is shone into the left pupil

Which of the following is a true statement about the paranasal sinuses? A. they're fully developed in newborns and shrink in size during puberty relative to the growth of the skill of the bones B. they're totally absent in newborn and rapidly develop during puberty C. they're not all present in the newborn but grow and develop with the child, reaching full development after puberty.

C. they're not all present in the newborn but grow and develop with the child, reaching full development after puberty

The oropharynx is separated from the mouth by which of the following? A. Frenulum B. posterior pharyngeal wall C. tonsillar pillars D. dorsum of the tongue

C. tonsillar pillars

Visual nerve?

CN 2

What nerve :the face for strength and sensation

CN 5

The face for symmetrical movement

CN 7

Hearing

CN8

WAYS OF HEAT LOSS

CONDUCTION- loss from cold surface CONVECTION- loss from air EVAPORATION- Wet dissipation RADIATION- radiates to colder surface.

Heat or Cold? Reduced cell metabolism

Cold

Heat or Cold? Reduces Inflammation

Cold

Heat or Cold? Reduces O2 needs of tissues

Cold

Heat or Cold? Relieves Pain

Cold

Heat or Cold? Vasoconstriction

Cold

Ishihara test is for

Color blindness

Answer: A, B, C, D Each of the options is an example of a professional role or responsibility of the professional nurse.

Contemporary nursing requires that the nurse possess knowledge and skills to carry out a variety of professional roles and responsibilities. Examples include which of the following? (Select all that apply.) A) Autonomy and accountability B) Advocacy C) Provision of bedside care D) Health promotion and illness prevention

A patient with left-sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would be your best therapeutic response? A) "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." B) "Would you like me to walk on your right side so you feel more secure?" C) "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." D) "By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint.

D

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? A) Flat neck veins B) Tachycardia C) Hypotension D) Oliguria

D

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse is noticing? A) These are expected findings for this postoperative time period. B) The patient may becoming dependent upon pain medication. C) The nurse should observe the patient more closely for wound dehiscence. D) The patient is demonstrating signs of a postoperative wound infection.

D

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to: A) Prevent varicose veins. B) Prevent muscular atrophy. C) Ensure joint mobility and prevent contractures. D) Promote venous return to the heart.

D

Which of the following describes a hydrocolloid dressing? A) A seaweed derivative that is highly absorptive B) Premoistened gauze placed over a granulating wound C) A debriding enzyme that is used to remove necrotic tissue D) A dressing that forms a gel that interacts with the wound surface

D

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? A) Notify a health care provider B) Insert an indwelling catheter C) Alert the blood bank D) Stop the transfusion

D

Answer: D The nurse may delegate vital signs measurement to unlicensed assistive personnel when the client is in stable condition, the results are predictable, and the technique is standard. The preoperative client is the only client listed who meets these guidelines.

Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension

D

Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension

Answer: A When dealing with clients who are at risk for or may have suffered abuse, it is important to provide protection. Educating the mother on the developmental issues of her infant is important but provides no protection for the victim. Providing protection and eliminating the fear of retribution is a priority upon discovery of abuse. By disregarding the mother's situation, the nurse has failed to intervene for the family in crisis in the community.

During a well-baby visit, the community-based nurse observed patterned bruises and skin abrasions on the face, arms, and throat of the infant's 21-year-old mother. In questioning the mother, the nurse discovers that she is a recent victim of spousal abuse. An important principle in dealing with this client is: A) Ensuring the protection of the mother B) Informing the authorities of the attack C) Educating the mother on well-baby developmental issues D) Continuing with the well-baby examination and disregarding the mother's situation

Answer: C Evidence-based practice is a problem-solving approach to clinical practice that uses the best available evidence, along with the nurse's expertise and the client's preference and values, in making decisions about care. The other answers are incorrect.

Evidence-based practice is defined as: A) Nursing care based on tradition B) Scholarly inquiry embodied in the nursing and biomedical research literature C) A problem-solving approach to clinical practice based on best practices D) Quality nursing care provided in an efficient and economically sound manner

Answer: D Adduction is movement toward the body. Abduction is movement away from the body. Flexion is movement that decreases the angle of the joint, whereas extension is movement that increase the angle of the joint.

The client is being assessed for range of joint movement. The nurse asks the client to move the arm toward the body to evaluate: A) Flexion B) Extension C) Abduction D) Adduction

Answer: D Healthy People 2010 was established to create ongoing health care goals, including increasing life expectancy and quality of life, and eliminate health disparities through improved delivery of health care services. Gathering information, assessing needs, and developing and implementing public health policies are steps in achieving the goals set forth by Healthy People 2010.

Healthy People 2010's overall goals are to: A) Assess the health care needs of individuals, families, or communities B) Develop and implement public health policies and improve access to care C) Gather information on incident rates of certain diseases and social problems D) Increase life expectancy and quality of life and eliminate health disparities

Heat or Cold? Promotes Muscle Relaxation

Heat

Heat or Cold? Promotes movement of wastes and nutrients

Heat

Heat or Cold? Reduced muscle tension

Heat

Answer: B In Healthy People 2010, the assurance role of public health is defined as making essential community-wide health services available and accessible. In Healthy People 2010, public development and implementation refer to the role of health professionals in providing leadership in development of policies that support the population's health. Population-based public health programs focus on disease prevention, health promotion, and health protection. A healthy environment for each individual, family, and community is the overall goal of Healthy People 2010.

In Healthy People 2010, assurance refers to the role of public health in: A) Providing disease prevention, health protection, and health promotion B) Making essential community-wide health services available and accessible C) Providing leadership in developing policies that support the population's health D) Achieving a healthy environment for each individual, family, and community

Answer: C Wheezes are adventitious breath sounds that are high-pitched, continuous musical sounds, such as a squeak heard continuously during inspiration or expiration. Pleural friction rub has a dry, grating quality and is heard best during inspiration. Crackles can be fine, high-pitched, short, interrupted crackling sounds; moist, low sounds in the middle of inspiration; or coarse, loud, bubbly sounds. Rhonchi are loud, low-pitched, rumbling, coarse sounds heard during inspiration.

In assessing the client's lungs the nurse hears adventitious breath sounds that are high-pitched, continuous musical sounds, such as a squeak heard continuously during inspiration or expiration, usually louder on expiration. These adventitious breath sounds are known as: A) Crackles B) Rhonchi C) Wheezes D) Pleural friction rub

Answer: C Resonance is the low, hollow sound of normal lungs. Hyperresonance can be heard over emphysematous lungs as a booming sound. Tympany is the high-pitched, drumlike sound heard over a gastric air bubble. Dullness is the soft, thudlike sound that is heard over dense organ tissue.

In assessing the client's lungs, the nurse notes that the lungs are normal upon percussion. This means that the nurse detected: A) Dullness B) Tympany C) Resonance D) Hyperresonance

Answer: A Phenomena are defined as aspects of reality that can be consciously sensed or experienced.

Nursing theories focus on the phenomena of nursing and nursing care. Which of the following is true of phenomena? A) They are aspects of reality that can be consciously sensed or experienced. B) They convey the general meaning of concepts in a manner that fits the theory. C) They are statements that describe concepts or connect two concepts that are factual. D) They are mental formulations of an object or event that come from individual perceptual experience.

Answer: D Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing.

Nursing's paradigm includes: A) Health, person, environment, and theory B) Concepts, theory, health, and environment C) Nurses, physicians, models, and client needs D) The person, health, environment/situation, and nursing

Crime

Offense against people or property; the act is considered to be against the government, referred to in a lawsuit as "the people," and the accused is prosecuted by the state

Answer: A A nurse who is new to practice has not developed the experience required for research but can begin at the less complicated level of data collection. An experienced researcher is more qualified to identify problems for formal research, although input from all levels of nursing is valuable. Nurses with doctoral-level training are typically prepared for obtaining financial backing. An American Nurses Association position paper cites a master's degree as qualification for implementing research-based change in nursing practice.

Nurses who are new to practice can best contribute to nursing research by: A) Assisting with data collection B) Identifying clinical problems in nursing C) Obtaining financial backing and public interest D) Implementing research-based change in nursing practice

List some medications that can decreased respiratory rate and depth

Opioids Sedatives Bronchodilators general anesthetics

fall risk assessments

Other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems (cerebral palsy, injury, multiple sclerosis) and cognitive dysfunction. Side effects of medications (orthostatic hypotension, drowsiness) can also increase the client's risk for falls. - indentify risk factor and intervene based on problem- ie orthostatic hypotension.

Negligence

Performing an act/failing to perform an act that a reasonably prudent person under similar circumstances would not do/would do

Litigation

Process of a lawsuit

Restore client to the state that existed before the development of an illness

Purpose of Tertiary Care

brown green or yellow

Purulent

To hear the aortic pulse you need to put stethoscope at

R of Sternum, Second ICS

Percussion of lung area?

Resonance

blood+water

Serosanguinous

watery drainage

Serous

Answer: D Therapies such as tepid water or alcohol sponge baths should be avoided because they lead to shivering, which stimulates body heat. Antipyretics, not analgesics, are the medications that lower body temperature.

The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

Answer: A Lying in the supine position with the ipsilateral arm behind the head helps the breast tissue to flatten evenly against the chest wall. The other options do not allow the tissue to spread on the chest wall.

So that breast tissue will be spread evenly over the chest wall during an examination, the nurse asks the client to lie supine with: A) The ipsilateral arm behind the head B) Hands clasped just above the umbilicus C) Both arms overhead with palms upward D) The dominant arm straight alongside the body

Answer: C Substance abusers avoid health care for fear of judgmental attitudes by health care providers and concern about being turned in to the criminal authorities. Options 1, 2, and 4 are not primary concerns that result in avoidance of health care.

Substance abusers frequently avoid health care providers because of: A) Fear of the cost of health care B) Fear of institutions and people C) Fear of being turned in to the criminal authorities D) Fear of being without the recreational drug of choice

Upon Ventricular systole of the heart, when the ventricles force blood out of the aorta and it represents the maximum amt of pressure exterted on the arteries

Systolic BP

D

The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

Answer: B Rhonchi are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration. Crackles are moist sounds heard during inspiration that are not cleared with coughing. Normal lungs produce no sounds such as that described. Wheezes are high-pitched continuous muscles sounds such as a squeak heard continuously during inspiration and expiration.

The client's respiratory assessment reveals loud, low-pitched, rumbling, coarse sounds heard during inspiration and expiration. The nurse interprets these sounds as: A) Normal B) Rhonchi C) Crackles D) Wheezes

Answer: C Since the "up ad lib" orders are new and the client has been on bed rest, checking orthostatic blood pressure before allowing the client to ambulate is the correct answer. If no sign of orthostatic hypotension is present, then a nursing assistant could assist him to the bathroom. Giving the client a urinal is not a good choice if the client is asymptomatic when orthostatic blood pressure is checked.

The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.

C

The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.

Answer: C Healthy People 2010, a federal document, outlines goals for the public. Notes on Nursing set forth Nightingale's first nursing philosophy. The Last Acts Campaign has developed standards and policies for end-of-life care. Nursing Principles and Practice 2010—current readings in journals are necessary for all nurses in practice.

The document that developed goals and objectives to meet the health of the public is known as: A) Notes on Nursing B) Last Acts Campaign C) Healthy People 2010 D) Nursing Principles and Practice 2010

Answer: D The RN licensure examination provides a minimum standard of knowledge for nurses. The examination cannot guarantee or ensure care for clients.

The examination for the registered nurse (RN) licensure is exactly the same in every state in the United States. This examination: A) Guarantees safe nursing care for all clients B) Ensures standard nursing care for all clients C) Ensures that honest and ethical care is provided D) Provides a minimal standard of knowledge for practice

Answer: C Option 3 defines the focus of community health nursing. Community health nursing focuses on the individual, family, and community. Educational requirements for community-based nurses are not as clearly defined as those for public health nurses. An advanced degree is not always required.

The focus of community health nursing differs from that of public health nursing because the nursing care: A) Is directed at the individual client only B) Is provided by nurses with a graduate degree in community health nursing C) Provides direct care to subpopulations who make up the community as a whole D) Is administered to a collection of individuals who have in common one or more personal or environmental characteristics

Answer: D The scientific method is the foundation of research and the most reliable and objective of all methods of gaining knowledge. Experience, critical thinking, and evidence are not the foundation of research.

The foundation of research is which of the following? A) Evidence B) Experience C) Critical thinking D) Scientific method

Answer: C A critical pathway is a multidisciplinary treatment plan with interventions prescribed within a structured framework. A discharge plan includes an assessment and anticipation of the client's needs. Medicare is a federal health insurance plan for those 65 years of age and older. Standard nursing care is the minimum care to be given to a client.

The nurse completes the standard orders on a client's first day postoperatively. The instrument that is used to coordinate the client's care is: A) A Medicare plan B) A discharge plan C) A critical pathway D) Standard nursing care

Answer: D The anterior hypothalamus controls heat loss by initiating the mechanisms of sweating and vasodilation of blood vessels. Blood is redistributed to surface vessels (flushing of the skin) to promote heat loss, not heat retention. The posterior hypothalamus controls heat production by initiating the mechanisms of shivering, vasoconstriction of blood vessels, and reduction of blood flow to the skin and extremities.

The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering

Answer: B The Nurse Practice Act regulates the license and practice of nursing; it describes the scope of practice and is the correct answer. The NCLEX-RN national licensure examination is administered in each state to test that candidates have the minimum knowledge level required for practice. Passage of an examination and requirements for certification signify additional knowledge and competence in a specific area. The ANA Congress for Nursing is an organization that addresses legal aspects of nursing practice.

The licensure and practice of nursing is regulated by: A) The NCLEX-RN B) The Nurse Practice Act C) The certification examination D) The ANA Congress for Nursing

Answer: A Secondary intervention includes disease prevention after a health issue has been identified. Primary intervention is prevention of a health problem that has not yet occurred in the community. Tertiary intervention occurs after a problem has occurred and aims at preventing long-term negative impacts or recurrences in a population.

The local health department received information from the Centers for Disease Control and Prevention that the flu was expected to be very contagious this season. The nurse is asked to set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention? A) Primary intervention B) Tertiary intervention C) Nursing intervention D) Secondary intervention

Answer: A An educator helps clients, families, and communities gain greater skills and knowledge to provide their own care. An advocate is someone who helps clients walk through the system, identifies services, and plans for accessing appropriate resources. A collaborator is an individual who engages in a combined effort with other individuals to develop a mutually acceptable plan that will achieve common goals. A case manager develops and implements a plan of care.

The local school has an increasing number of adolescent parents. The nurse works with the school district to design and teach classes about infant care, child safety, and time management. These are examples of which nursing role? A) Educator B) Advocate C) Collaborator D) Case manager

Answer: C Case management is a model of organizing care in which the case manager monitors, directs, and advises the nursing care personnel on specific care issues and the progress of a client. In team nursing, care might be provided by groups composed of registered nurses, licensed practical nurses, and possibly assistive personnel. Nursing process is used to plan the nursing care for a client. Interdisciplinary care is care provided by a team whose members come from a variety of disciplines.

The multidisciplinary care model used to move clients efficiently from admission to discharge is known as: A) Team nursing B) Nursing process C) Case management D) Interdisciplinary care

Answer: D This common adage embodies an abstract idea, and explaining it indicates the client's ability to perform abstract reasoning. Judgment involves comparison and evaluation of facts and ideas to understand their relationships and to form appropriate conclusions. Knowledge is understanding or awareness of information gained through learning or experience. Association involves finding similarities between concepts.

The nurse asks the client to interpret the saying, "Don't count your chickens before they're hatched." The client's response provides information about the client's: A) Judgment B) Knowledge C) Association D) Abstract reasoning

Answer: D The movement of the head and shoulders is controlled by cranial nerve XI, the spinal accessory nerve. The facial nerve innervates the face. The hypoglossal nerve innervates portions of the tongue. The trigeminal nerve is a sensory and motor nerve enervating the side of the face and jaw.

The nurse asks the client to shrug the shoulders and turn the head side to side against the resistance of the examiner's hand. These actions allow the nurse to evaluate which cranial nerve? A) VII—Facial B) V—Trigeminal C) XII—Hypoglossal D) XI—Spinal accessory

Answer: A The general survey focuses on general appearance and behavior, including gender and race, age, signs of distress, body type, posture, gait, hygiene and grooming, dress, affect, mood, and speech. The other actions are carried out in different parts of the assessment.

The nurse conducts a general survey of an adult client, which includes: A) Checking appearance and behavior B) Measuring vital signs C) Observing specific body systems D) Conducting a detailed health history

Answer: B The apical pulse gives the nurse the most information and accuracy when assessing irregular cardiac rhythm. The carotid or femoral pulses are usually used to assess a client in shock. The radial pulse is adequate for determining routine postoperative vital signs and for checking changes in orthostatic heart rate.

The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.

B

The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.

Answer: D All questionable blood pressure readings should be rechecked. Ensuring the client's safety is a necessary safeguard, because low blood pressure is generally accompanied by weakness. For the majority of people, low blood pressure (systolic pressure of 90 mm Hg or below) is an abnormal finding and should be reported. Giving a client orange juice may raise blood glucose level but is not recommended to elevate blood pressure. Ambulating a client with hypotension would not be following safety precautions.

The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.

D

The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.

Answer: D Evidence-based practice draws on both research and clinical experience. Competencies are evidence that skills have been demonstrated. Critical thinking is the questioning thought process that nurses need to use in practice. Primary care is health care provided in the community by one caregiver who takes responsibility for managing a client's care.

The nurse found that using tympanic thermometers was quick, easy, and yielded temperatures as reliable as those obtained using oral thermometers. This finding represents: A) Primary care B) Critical thinking C) Competency testing D) Evidence-based practice

Answer: B Critical thinking involves analyzing the data, learning, and problem solving to come up with a course of action. Tradition limits the ability to learn new ways and overlooks what research has to offer. The advice of experienced practitioners may limit research because experience may mean doing things the same way they have been done for years. Using personal opinion overlooks the objective data that are available.

The nurse involved in scientific research effectively analyzes the information collected and determines a course of nursing action by: A) Depending on tradition B) Using critical thinking C) Seeking the advice of experienced practitioners D) Relying on personal perspective or opinion

Answer: C An advocate helps speak for the client, communicating the client's concerns and wishes to family and other caregivers. A caregiver assists in meeting all health care needs of the client, including taking measures to restore emotional, spiritual, and social well-being. A manager coordinates all the activities of the members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibilities for a specific nursing unit or agency. An educator explains concepts and facts about health, demonstrates procedures such as self-care activities, reinforces learning or client behavior, and evaluates the client's progress in learning.

The nurse is caring for a client with end-stage lung disease. The client wants to go home on oxygen therapy and be comfortable. The family wants the client to undergo a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the client's wishes with the family. The nurse is acting as the client's: A) Manager B) Educator C) Advocate D) Caregiver

what would be consider an invasion of patient privacy

discussing the comatose patient's condition with his father in law posting a blog on your personal website about the patient and their day discussing the outcome of a test with another nurse while in an elevator

Answer: C Health promotion includes dietary counseling. Blood glucose monitoring at the pharmacy is an example of illness prevention. Restorative care is care of a client who, for instance, is recovering from complications of diabetes. Any diagnostic procedure or tests completed in the hospital would be examples of such care.

The nurse is giving discharge instructions to a client with newly diagnosed diabetes. The nurse discusses with the client what the dietary intake should be. This is an example of which health care service? A) Tertiary care B) Restorative care C) Health promotion D) Illness prevention

Answer: B Painless, pea-sized nodules should be checked by a health care provider. Testicular self-examination should be performed monthly and should be done after a bath or shower. The testes feel smooth, rubbery, and free of nodules.

The nurse is teaching a client how to perform a testicular self-examination. The nurse tells the client which of the following? A) "The testes are normally round, moveable, and have a lumpy consistency." B) "Contact your health care provider if you feel a painless pea-sized nodule." C) "The best time to do a testicular self-examination is before your bath or shower." D) "Perform a testicular self-examination weekly to detect signs of testicular cancer."

Answer: D Postponing this assessment is definitely a judgment call by the nurse. Postponing is appropriate unless the assessment of respiration is a critical aspect of the test and the client is leaving for the test immediately. Otherwise, it is probably not necessary to invade the client's privacy and disrupt the visitation. Agency policy will dictate whether the respiration rate should be documented as "deferred" or whether documentation can wait until the rate is obtained. Respirations should be counted when the client is "at rest"; therefore, counting respirations during the visitation would not be appropriate. Waiting at the bedside until the visitor leaves is an invasion of privacy for the client and a waste of the nurse's time.

The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respirations. C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.

D

The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respirations. C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.

Answer: D Cheyne-Stokes respiration is an irregular respiratory rate and depth with alternating periods of apnea and hyperventilation; it begins with slow breaths and climaxes in apnea before respiration resumes.

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

D

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

Answer: D The code of ethics is the philosophical ideals of right and wrong that define the principles the nurse will use to provide care to clients. A code of ethics does not ensure identical care to all clients (which would not be acceptable). The nursing code of ethics does not protect clients from harm or improve self-health care.

The nurse practices nursing in conformity with the code of ethics for professional registered nurses. This code: A) Improves self-health care B) Protects the client from harm C) Ensures identical care to all clients D) Defines the principles by which nurses' provide care to their clients

Answer: C The conduct of research must meet ethical standards in which the rights of human subjects are protected. The research participants must be told about the study's purpose and procedure, and their roles in the study. The researcher is always legally responsible for his or her actions. Control of variables is related to the study design, not to informed consent. Confidentiality is part of the ethical nature of research but is not the focus of informed consent.

The nurse researcher obtains informed consent from participants in a study primarily to: A) Release the researcher from legal liability. B) Control variables that might affect the study. C) Ensure that the study subjects understand their roles in the study. D) Maintain the confidentiality of the researcher and the participants.

Answer: B Publication of research results provides other nurses with the scientific background of the study before they apply its findings in practice. Study subjects and setting should be similar to duplicate a study. Nurses should not change from accepted to unproven ways of providing care without careful research and collaboration with colleagues. Experimenting with new nursing measures is inappropriate and may place a client at risk.

The nurse researcher who gains new knowledge regarding a procedure can most effectively share the information with the nursing profession by: A) Duplicating the study using different clients in different settings B) Communicating the research findings in a professional journal C) Recruiting clients who are willing to demonstrate the new technique D) Asking individual nurses to report their experiences related to the new procedure

Answer: B Sitting upright provides full expansion of the lungs and provides better visualization of the symmetry of upper body parts. The lateral recumbent position aids in detecting heart murmurs. The dorsal recumbent position is used for abdominal assessment because it allows relaxation of abdominal muscles. The supine position provides easy access to pulse sites.

The nurse should assist the client to a sitting position to provide the best position to examine which of the following? A) Heart B) Lungs C) Abdomen D) Pulse sites

Answer: D Aortic, pulmonic, tricuspid, mitral areas are the sites for auscultation assessment of cardiac function. Auscultation of the carotid arteries is not the same as auscultation of the heart itself. The sternal region is not an appropriate site. There are no costal sites where heart sounds can be heard well. Anterior, posterior, and lateral are too vague.

The nurse should use which anatomical sites for the auscultatory assessment of cardiac function? A) Inner costal, outer costal, and sternal B) Aortic, carotid, coronary, and jugular C) Apical, lateral, anterior, and posterior D) Aortic, pulmonic, tricuspid, and mitral

Answer: C Pigmented skin lesions that are asymmetrical, have irregular borders, have variegated colors, and are larger than 6 mm in diameter are lesions that are suspect and should be reported to a medical provider.

The nurse teaches the client to inspect all skin surfaces and to report pigmented skin lesions that: A) Are symmetrical B) Are uniform in color C) Have irregular borders D) Are smaller than 6 mm in diameter

Answer: C To measure pulse deficit the nurse and a colleague assess the radial and apical pulse rates simultaneously and subtract the radial from the apical pulse rate. The result is the pulse deficit. Tachycardia and bradycardia are assessed by measuring the pulse rate for 1 minute. A rate of more than 100 beats per minute is categorized as tachycardia, whereas a rate of less than 60 beats per minute constitutes bradycardia.

The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference

C

The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference

Answer: A The "Do" step consists of selecting an intervention based on a data review and implementing the change, plus studying the results of the change. The "Plan" step includes reviewing the available data to understand existing practice conditions or problems to identify the need for change. The results of the change are evaluated in the "Study" step. The "Act" step is the incorporation of the findings into current practice.

The nurses on a medical unit have seen an increase in the number of pressure ulcers developing in their clients. The nurses decide to initiate a quality improvement project using the PDSA (plan, do, study, act) model. Which of the following is an example of the "Do" step of that model? A) Implement a new skin care protocol on all medical units. B) Review the data collected on clients cared for using the new protocol. C) Review the quality improvement reports on the six clients who developed ulcers over the previous 3 months. D) Based on findings from clients who developed ulcers, implement an evidence-based skin care protocol.

Answer: B Identified linkages of a nursing paradigm are the person, health, environment/situation, and nursing itself. Concepts, definitions, relationship, and assumptions are components of a theory. The individuals, groups, situations, and interests specific to nursing are potential subjects for middle-range theories. Description, explanation, prediction, and prescription of an interrelationship of nursing are purposes of nursing theory.

The nursing paradigm identifies four linkages of interest to the nursing profession. These four linkages are: A) Concepts, definitions, relationships, and assumptions B) The person, health, environment/situation, and nursing C) The individual, groups, situations, and interests specific to nursing D) Description, explanation, prediction, and prescription of an interrelationship of nursing

Answer: C An open system is defined as a system that interacts with the environment, exchanging information between the system and the environment.

The nursing process is an example of an open system. An open system: A) Is universal and dynamic B) Represents a relationship between two concepts C) Interacts with the environment by exchanging information D) Is a process through which information is returned to the system

Answer: B The question describes the nursing theory developed by Fay Abdellah and others. Rogers' theory considered the individual as an energy field existing within the universe. Henderson's theory defines nursing as "assisting the individual, sick, or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death." Nightingale viewed nursing as providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition.

The nursing theory that emphasizes the delivery of nursing care for the whole person to meet the physical, emotional, intellectual, social, and spiritual needs of the client and family is: A) Rogers' theory B) Abdellah's theory C) Henderson's theory D) Nightingale's theory

Answer: B Mary Mahoney, the first African American professional nurse, worked to bring respect to individuals regardless of race, color, background, or religion. Tubman assisted slaves to freedom during the Civil War. Hampton founded the Nurses Associated Alumnae of the United States and Canada, which later became the American Nurses Association (ANA). Nutting was instrumental in the affiliation of nursing education with universities.

The professional nurse responsible for increasing respect for the individual and awareness of cultural diversity was: A) Harriet Tubman B) Mary Mahoney C) Isabel Hampton D) Mary Adelaide Nutting

Answer: D The utilization review committee reviews admissions, diagnostic procedures, and treatments ordered by physicians. Review of the quality, quantity, and cost of care is more similar to the functions of a professional standards review organization. Review of reimbursement fees and appropriation of funds involves review of diagnosis-related groups. Reviewing the utilization of the payment mechanism is similar to capitation.

The purpose of a utilization review committee is to: A) Review quality, quantity, and cost of care B) Review the utilization of the payment mechanism C) Review reimbursement fees and appropriation of funds D) Review admissions, diagnostic tests, and treatments ordered by physicians

Answer: D The nurse begins with inspection and then follows with auscultation. It is important to perform auscultation before palpation and percussion, because palpation and percussion may alter the frequency and character of bowel sounds.

The techniques of physical assessment are inspection, palpation, percussion, and auscultation. The order in which these techniques are used is slightly different during abdominal examination than during examination of other body areas. The nurse should perform which two of the following first? A) Palpation and inspection B) Inspection and percussion C) Palpation and auscultation D) Inspection and auscultation

Answer: C Prescriptive theory addresses nursing interventions and predicts the consequence of a specific nursing intervention. Middle-range theories are limited in scope, less abstract than grand theories, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Grand theories are broad and complex.

The type of theory that tests the validity and predictability of nursing interventions is: A) A grand theory B) A descriptive theory C) A prescriptive theory D) A middle-range theory

Answer: A Grand theories are described as broad and complex. Middle-range theories are limited in scope, less abstract, address specific phenomena or concepts, and reflect practice. Descriptive theories describe phenomena, speculate as to why the phenomena occur, and describe the consequences of phenomena. Prescriptive theories address nursing interventions and predict the consequence of a specific intervention.

Theories that are broad and complex are: A) Grand theories B) Descriptive theories C) Middle-range theories D) Prescriptive theories

Answer: C Theories will be tested to describe or predict client outcomes as nursing is addressed as a science and an art. Scientists will not make nursing decisions, and nursing will base client care on the practice of nursing science, which will be guided by multiple theories.

There is a contemporary move toward addressing nursing as a science or as evidenced-based practice. This suggests that: A) One theory will guide nursing practice. B) Scientists will make nursing decisions. C) Theories will be tested to describe or predict client outcomes. D) Nursing will base client care on the practice of other sciences.

Answer: C Interdisciplinary theories provide a systematic view of a phenomenon. Developmental theories, health and wellness theories, and systems theories are examples of other types of theories.

To practice in today's health care environment, nurses need a strong scientific knowledge base in nursing and other disciplines, such as the physical, social, and behavioral sciences. This relates to which of the following? A) Systems theories B) Developmental theories C) Interdisciplinary theories D) Health and wellness model

Answer: D To assess skin turgor, a fold of skin on the back of the forearm or sternal area is grasped with the fingertips and released. When turgor is good the skin lifts easily and snaps back immediately. The skin stays pinched when turgor is poor. The hands and neck are not the best places to test turgor, because the skin is normally loose and thin in those areas.

Turgor is the skin's elasticity, which can be diminished by edema or dehydration. Which is the best place for the nurse to assess skin turgor in the older adult? A) Side of the neck B) Back of the hand C) Palm of the hand D) Over the sternal area

Answer: A Although early morning temperatures are routinely low, the best practice is for the nurse to check the client's previous temperatures. Clients may routinely have a low temperature. Depending on the client's temperature history, the nurse may retake the temperature with another thermometer to check for a malfunction. If everything seems satisfactory, the nurse should chart the temperature and check the client for signs of hypothermia.

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.

A

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.

Answer: D A normal tympanic membrane is translucent, shiny, and pearly gray. Dark yellow and sticky describes normal moist cerumen (earwax) in front of the tympanic membrane. A white color indicates pus behind the membrane. A pink or red bulging membrane is an indication of inflammation.

Using an otoscope, the nurse can inspect the tympanic membrane. A normal tympanic membrane appears: A) Round and white B) Pink and bulging C) Dark yellow and sticky D) Translucent, shiny, and pearly gray

Answer: A Vulnerable populations are defined as specific populations with unique health care problems. Vulnerable populations are not limited to the very young or older adults. Such individuals are those living in poverty, homeless persons, abused clients, substance abusers, and so on. Members of most vulnerable populations come from different cultures and have different beliefs and values. Vulnerable populations are at risk of experiencing poorer outcomes in response to interventions because of the multiple stressors that affect their daily lives.

Vulnerable populations are more likely to develop health problems. Which of the following is true of these populations? A) They are specific populations with unique health care problems. B) They are limited to the very young and older adult age groups. C) They live in communities with similar cultures, beliefs, and values. D) They frequently experience positive outcomes in response to community health interventions.

Answer: D Vulnerable population are defined as clients who are more likely to develop health problems as a result of excess risks, who have limits in access to health care services, or who are dependent on others for care.

Vulnerable populations of clients are those who are more likely to develop health problems as a result of: A) Chronic diseases, homelessness, and poverty B) Poverty and limits in access to health care services C) Lack of transportation, dependence on others for care, and homelessness D) Excess risks, limits in access to health care services, and dependence on others for care

Answer: C The community has three components: structure or locale, people, and social systems. To develop a complete community assessment, the nurse must take a careful look at each of the three components to begin to identify needs for health policy, health programs, and health services.

What are the three elements included in a community assessment? A) Environment, families, and social systems B) People, neighborhoods, and social systems C) Structure or locale, people, and social systems D) Health care systems, geographic boundaries, and people

Answer: D No individual client assessment should occur in isolation from the environment and conditions of the client's community. Industrial development, types of pollution, and cultural and religious groups are individual elements in the community.

When completing an individual total assessment of a client, the community-based nurse will include consideration of: A) The type of pollution present in the community B) The amount of industrial development in the past 5 years in the community C) The predominant cultural and religious groups found in the community D) The community structures, the population, and the local social system in which the client lives

Answer: A Standards of care describe the competency level of nursing care as described by the ANA. The Nurse Practice Act regulates the licensing and practice of nursing; it describes the scope of practice. Accreditation allows the facility, school, or hospital to operate and be recognized in good standing according to standards set by peers. National council licensure is the standardized national examination that assess for a minimum knowledge base relevant to the client population that the nurse serves.

Which of the following assures clients that they will receive quality care from a competent nurse? A) Standards of care B) Nurse Practice Act C) Accreditation certification D) National council licensure

Answer: B, D Extended care encompasses intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities. Extended care facilities include intermediate care facilities and skilled nursing facilities.

Which of the following clients should be cared for in an extended care facility with skilled nursing? (Select all that apply.) A) Client who had a stroke, can talk, and has lost bowel and bladder control B) Severely brain injured client on a ventilator who is receiving intravenous medications C) Client with Alzheimer's disease who is abusive, combative, and a threat to self and others D) Young child who recently had a spinal cord injury and is living with quadriplegia and needs to learn a new way of life

Answer: D Shortage of staff could mean less time and personnel to conduct and participate in research. Nursing teams that have teamwork skills can aid research. The desire to change is an incentive for research. Pressure from higher levels in the organization is also an incentive to research.

Which of the following could be a barrier to nursing research? A) Presence of teams in nursing B) Pressure from the administration C) Staff wishes to change a policy D) Shortage of professional nursing staff

a hospital refuses to allow a visitor with a seeing eye dog to enter the hospital. this violates what

americans with disabilities act

Answer: A Day care is an example of respite care because it allows the family to maintain normalcy while the client is under their care. A nursing home client receives 24-hour care in the facility. Home care is an intermittent service in which only certain tasks are performed. Nurse extenders may be hired to perform a specific task, such as bathing.

Which of the following is an example of respite care? A) Day care B) Home care C) Nursing home D) Nurse extender

Answer: C The federal government, which pays for the Medicare and Medicaid programs, is the biggest consumer of health care. The other options are incorrect.

Which of the following is the biggest consumer of health care? A) Hospitals B) Businesses C) Federal government D) Private insurance companies

Answer: A National League for Nursing (NLN) is the correct answer. The master of science in nursing (MSN) degree is earned through advanced educational preparation in nursing. Public Health Administration (PHA) is concerned with areas of public health. The National Institutes of Health (NIH) addresses health on a national level.

Which of the following professional organizations was created to address concerns of members in the nursing profession? A) NLN B) MSN C) PHA D) NIH

Answer: B, C, D Evidence-based practice helps nurses to solve dilemmas in the clinical setting because it combines scientific research with clinical expertise and local values. Evidence-based practice does require nurses to review and critique research and practice findings. Nurses are expected to always meet the standards of practice.

Which of the following statements is true about evidence-based practice? (Select all that apply.) Evidence-based practice: A) Is based only on the results of research B) Assists nurses in meeting standards of practice C) Helps nurses solve dilemmas in the clinical setting D) Requires nurses to review and critique research and practice findings

Answer: C The S2 (dub) sound is the second heart sound and indicates closure of the aortic and pulmonic valves. The closing of the mitral and tricuspid valves is the S1 sound.

While auscultating heart sounds, the nurse documents that S2 is best heard at the base. This sound (S2) correlates with closure of which of the following? A) Aortic and mitral valves B) Mitral and tricuspid valves C) Aortic and pulmonic valves D) Tricuspid and pulmonic valves

Answer: C Complaints of tenderness in the calf during palpation may indicate phlebitis. Other characteristics of phlebitis are swelling, warmth, redness, and sometimes a positive Homans' sign. Cyanosis, pallor, and brown pigmentation around the ankles as well as ulceration and reduced hair growth are indications of venous or arterial insufficiency, which would not cause tenderness on palpation. Venous distention may be indicative of varicosities, which also are not associated with tenderness.

While the nurse was palpating the calf muscles of the client's right leg, the client complained of tenderness. Further assessment by the nurse should include which of the following? A) Observation for reduced hair growth and ulceration B) Observation for venous distention while the client is standing C) Observation of the area for swelling, warmth, redness, and a positive Homans' sign D) Observation for cyanosis, pallor, and change in pigmentation around the ankles

Answer: D Florence Nightingale is the correct choice. Barton founded the Red Cross. Dix organized hospitals, nurses, and supply lines to support the troops of the Union Army. Wald opened the first community health service for the poor.

Who acted to decrease mortality by improving sanitation in the battlefields, which resulted in a decline in illness and infection? A) Dorothea Dix B) Lillian Wald C) Clara Barton D) Florence Nightingale

Fraud

Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to people or property

it is important to assess a patient's actual cultural belief's because

a patient may not adhere to the usual health beliefs of her culture

REM sleep

a recurring sleep state during which dreaming occurs

what describes health

a relative state of being

Guaiac Test

a test performed for occult (hidden) blood to detect gastrointestinal bleeding not visible to the eye

considering the chain of infection, a vector might be

a tick carrying lyme disease

When a patient you are admitting to the unit asks you why you are doing a history and exam since the doctor just did one, your best reply is: a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick." c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care. This information will help me develop a plan of care individualized to your unique needs." d. "We want to make sure that your responses are consistent and that all our data are accurate."

a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths."

Which of the following terms is defined as the sense of identification with a collective cultural group? a. ethnicity b. race c. cultural acquisition d. culture shock

a. Ethnicity is the sense of identification with a collective cultural group, largely based on the group's common heritage.

An obese client with an alteration in nutritional status is being seen in the clinic for poor wound healing. To gain a more comprehensive picture of this client's nutritional status, which of the following tools can the nurse ask the client to complete? a. Food frequency questionnaire b. Seven-day day food log c. CAGE assessment d. Three- day diet recall

a. Food frequency questionnaire Rationale: A food frequency questionnaire assesses intake of a variety of food groups on a daily, weekly, or longer basis.

Where do individuals learn their health beliefs and values? a. In the family b. In school c. From school nurses d. from peers

a. In the family (Healthcare activities, heal beliefs, and health values are learned within one's family)

A school nurse notices that Jill is losing weight and wants to perform a focused assessment on Jill's nutritional status, fearing that she might have an eating disorder. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention d. Request an order from the nutritionist since this is a collaborative intervention

a. Perform the focused assessment. This is an independent nurse-initiated intervention

Who are the largest group of healthcare providers in the United States? a. Registered Nurses b. Physicians c. Physical therapists d. Social Workers

a. Registered nurses are the largest group of healthcare providers in the United States

A patient complains about feeling nauseated after lunch. This is an example of what type of data? a. Subjective b. Objective c. Signs and symptoms d. Overt

a. Subjective

Which nursing organization was the first international organization of professional women? a. ICN b. ANA c. NLN d. NSNA

a. The ICN, founded in 1899, was the first international organization of professional women.

ALLEN'S TEST

done prior to ABGs to assess the patency of the radial artery. Ulnar ad radial is compressed, then ulnar is released and distal circulation is observed

Mr Price tells the nurse he fears becoming "hooked on drugs" and consequently waits until his pain becomes unbearable before requesting his prn analgesic. The nurse plans to be more attentive to Mr Price and to assess his needs for pain management more closely. Which of the following consequences of informal planning ought to be the major concern for this nurse? a. The lack of a coordinated plan known by everyone will result in uneven pain management. b. Faulty prioritization of patient needs c. Inability to evaluate the patient's responses to nursing care d. Lack of a record for reimbursement purposes

a. The lack of a coordinated plan known by everyone will result in uneven pain management.

From which of the following are outcomes derived? a. The problem statement of the nursing diagnosis b. The etiology of the problem of the nursing diagnosis c. The defining characteristics of the problem d. The evaluative statement

a. The problem statement of the nursing diagnosis (Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis in the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement)

Where do individuals learn their health beliefs and values? a. in the family b. in school c. from school nurses d. from peers

a. healthcare activities, health beliefs, and values are learned within one's family.

What group is the largest subculture of the healthcare system? a. nurses b. physicians c. social workers d. physical therapists

a. nurses are the largest subculture of the healthcare system

Fearful of attempting your first nursing history, you ask your instructor how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear: a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different." d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment for you must use."

b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."

A school nurse is teaching a class of junior-high students about the effects of smoking. This educational program will meet which of the aims of nursing? a. promoting health b. preventing illness c. restoring health d. facilitating coping with disability or death

b. Educational programs can reduce the risk of illness by teaching good health habits

for a patient to successfully win a malpractice claim what elements move be proven

duty breach of duty harm or damage cause and effect relationship

Your neighbor, Alan, asks you to come over because he has a high temperature, feels "awful," and did not go to work. What stage of illness behavior is Alan exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming the dependent role d. Achieving recovery and rehabilitation

b. Assuming the sick role (When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities)

Which of the following phrases best defines culture? a. A dominant group within a society b. A shared system of beliefs, values, and behaviors c. One's values are replaced by the values of the dominant culture d. Categories are based on specific physical characteristics

b. Culture may be defined as a shared system of beliefs, values, and behavioral expectations that provide social structure for daily living

Which of the following would you expect to find in the Nursing Interventions Classification Taxonomy? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions. b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings. c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention. d. A complete list of reimbursable charges for each nursing intervention.

b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

Practicing careful hand hygiene and using sterile techniques are ways in which nurses meet which basic human need? a. physiologic b. safety and security c. self esteem d. love and belonging

b. safety and security

Of the following statements, which one is true of self-actualization? a. Humans are born with fully developed self-actualization b. Self-actualization needs are met by having confidence and independence c. The self-actualization process continues throughout life d. Loneliness and isolation occur when self-actualization needs are unmet

c. The self-actualization process continues throughout life. (Self-actualization, or reaching one's full potential, is a process that continues through life.)

The best description of critical thinking indicators (CTIs) is which of the following: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice. b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice. c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice. d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice.

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice.

Which group is responsible for the promotion and organization of activities to continue the development, classification, and scientific testing of nursing diagnoses? a. American Nurses Association b. National Nursing Diagnosis Association c. North American Nursing Diagnosis Association d. Clearinghouse for Nursing Diagnoses

c. North American Nursing Diagnosis Association

What type of authority regulates the practice of nursing? a. International standards and codes b. Federal guidelines and regulations c. State nurse practice acts d. Institutional policies

c. Nurse practice act are established in each state to regulate the practice of nursing

When helping Mr Price turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of: a. Initial Planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning

You are asked to teach a group of preschool parents about poison control in the home. This activity is an example of what level of preventive care? a. Lowest b. Tertiary c. Primary d. Secondary

c. Primary (teaching poison control in the home is an example of primary preventive care)

Of the following terms, which would be defined as a disease? a. Excess fluid volume b. Risk for infection c. Rheumatoid arthritis d. Altered body image

c. Rheumatoid arthritis

A client in the clinic is complaining of developing "lots of blocked pores that look yellow" around his eyes. After inspecting these areas, the nurse realizes this client might be demonstrating: a. Signs of a low vitamin K level. b. Signs of a low vitamin C level. c. Signs of an elevated cholesterol level. d. Signs of an elevated blood glucose level.

c. Signs of an elevated cholesterol level.

You are a brand new RN. When you orient to a new nursing unit that is currently understaffed, you are told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response? a. Allow the UAPs to do the admission assessment and report the findings to you. b. Do your own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration. d. Contact your labor representative and complain.

c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration.

A client tells the nurse that she takes high volumes of multiple vitamins, various mineral supplements, and two additional herbs on a daily basis. Which of the following should the nurse include when instructing this client on her nutritional status? a. Review the role of iron. b. Be sure to include high doses of vitamin C. c. There are dangers associated with oversupplementation with herbs, vitamins, and minerals. d. High doses of fish oil would add to her supplementation regime.

c. There are dangers associated with oversupplementation with herbs, vitamins, and minerals.

To ensure a complete nutritional assessment, the nurse tells the client that laboratory tests will need to be done. Which of the following would be the most appropriate for this assessment? a. The client needs a complete blood count and cholesterol level drawn. b. The client needs a chest x-ray and ECG completed. c. There are no individual laboratory tests to assess nutritional status. This nurse is mistaken. d. The client needs a DEXA scan and cholesterol level drawn

c. There are no individual laboratory tests to assess nutritional status. This nurse is mistaken

You are surprised to detect and elevated temperature (102 F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. The first thing you do is to: a. Inform the charge nurse b. Inform the surgeon c. Validate your finding d. Document your finding.

c. Validate your finding

Minority groups living within a dominant culture may lose the cultural characteristics that made them different. What is this process called? a. cultural diversity b. cultural imposition c. cultural assimilation d. ethnocentrism

c. When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different

What historic event in the 20th century led to an increased emphasis on nursing and broadened the role of nurses? a. religious reform b. crimean war c. world war II d. Vietnam War

c. World War II

BILLROTH II PROCEDURE

client is at risk of dumping syndrome- NURSING INTERVENTIONS- lying down after eating, avoiding fluids with food, DIET- dry that is high in protein, moderate in fat, low in carbs. avoid concentrated sweets, eat several small meals

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? a.Report the fire. b. Extinguish the fire. c. Protect the clients. d. Contain the fire.

c.Protect the clients. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire

Which one of the following is an example of an affective outcome? a. within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/12, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/12, the patient's ulcer will begin to show signs of healing (eg, size shrinks form 3" to 2.5"). d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. (Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes describe increases in patient knowledge of intellectual behaviors; psychomotor outcomes describe the patient's achievement of new skills. )

A client asks the nurse if her weight would be considered a health risk. According to the height-weight table, the client is 10 pounds overweight. Which of the following would be an appropriate response for the nurse to make to this client? a. Yes, this weight puts you at risk for developing heart disease. b. No, 10 pounds are nothing to be concerned about. c. Yes, and you should diet to lose those 10 pounds as soon as possible. d. Let's measure your waist size and use the calipers before figuring that out.

d. Let's measure your waist size and use the calipers before figuring that out.

Jeanne is a college student who wants to lost 20 pounds. She meets with the student health nurse and develops a plan to increase her activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate her weight loss monthly. When Jeanne arrives for her first "weigh-in", the nurse discovers that instead of the projected weight loss of 5 pounds, Jeanne has only lost 1 pound. Which is the best nursing response? a. Congratulate Jeanne and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving Jeanne more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for Jeanne's partial success

d. Modify the plan of care after discussing possible reasons for Jeanne's partial success.

Of all the physiologic needs, which one is the most essential? a. Food b. Water c. Elimination d. Oxygen

d. Oxygen (Oxygen is the most essential of all needs because all body cells require oxygen for survival)

When you receive shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over body prominences. You should: a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment on skin integrity

d. Perform and document a focused assessment on skin integrity

A client comes into the clinic for a routine examination. The nurse measures this client's weight at 231 pounds. Previously this client weighed 247 pounds. Which of the following can the nurse accurately document about this assessment finding? a. Nothing. b. The client has lost 6.9 percent of his weight. c. The client has a health condition causing weight loss. d. The client has lost 6.5 percent of his weight.

d. The client has lost 6.5 percent of his weight.

Which of the following phrases describes one of the purposes of the ANA's nursing's social policy statement? a. to describe the nurse as a dependent caregiver b. To provide standards for nursing educational programs c. to regulate nursing research d. to describe nursing's values and social responsiblity

d. The nursing's social policy statement describes the values and social responsibility of nursing

Which of the following statements about the nursing process is most accurate? a. The nursing process is a four-step procedure for identifying and resolving patient problems. b. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process c. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept

d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept (a.The nursing process is a five-step process, b. The term nursing process was first used by Hall in 1955, c. Standards demand the use of the nursing process, so it is not optional.)

The nurse is reviewing the food pyramid with a client who avoids fruits and vegetables. Which category of the pyramid would address this client's issue? a. Personalization b. Proportionality c. Moderation d. Variety

d. Variety

A client who is 25 pounds underweight comes into the clinic with the new complaint of bruising and "bleeding marks" under the skin. The nurse realizes this client might be demonstrating signs of: a. Vitamin D deficiency b. Protein deficiency c. Vitamin B deficiency d. Vitamin C deficiency

d. Vitamin C deficiency

The terms diagnose and diagnosis have legal implications. they imply that there is a specific problem that requires management by a qualified expert. Which of the following statements is false? a. If you make a diagnosis, it means that you accept accountability for accurately naming and managing the problem b. If you treat a problem or allow a problem to persist without ensuring that the correct diagnosis has been made, you may cause harm and be accused of negligence. c. You are accountable for detecting, identifying, or recognizing signs and symptoms that may indicate problems beyond your expertise. d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

What is the best broad definition of a family? a. A father, a mother, and children b. Members are biologically related c. Includes aunts, uncles, and cousins d. A group of people who live together

d. a group of people who live together (Although all the responses may be true, the best definition is a group of people who live together.)

When you enter the patient's room to begin your nursing history, the patient's wife is there. You should: a. Introduce yourself to both and thank the wife for being present. b. Introduce yourself to both and ask the wife if she wants to remain. c. Introduce yourself and ask the wife to leave. d. Introduce yourself and ask the patient if the would like the wife to stay.

d. introduce yourself and ask the patient if he would like the wife to stay.

Of all physiologic needs, which one is the most essential? a. food b. water c. elimination d. oxygen

d. oxygen

A nurse states, that woman is 78 years old-too old to learn how to change a dressing. What is the nurse demonstrating? a. cultural imposition b. clustering c. cultural competency d. stereotyping

d. stereotyping is assuming that all members of a group are alike.

malignant hyperthermia

genetic disorder that can occur as a reaction to eneral anesthesia which triggers uncontrolled muscle contractions. . first sign would be sinus tachycardia, then elevated temp.

TURNERS SIGN

grayish discoloration of the flanks as seen in patients with acute pancreatis

S/S of urinary tract infections

hematuria, proteiuria, fever, pain, dysuria, costovertebral angle pain

which statement is NOT true regarding informed consent

informed consent is required for emergency life threatening procedures

TENSILON TEST

injection of tensilon (acetycholinesterase inhibitor) for the diagnosis of myastenia gravis (autoimmune disease causing general muscle weakness) - atropine sulfate is the antidote in case of complications such as ventircular fibrillation or cardiac arrest - if tensilon makes u weaker- then this indicates cholinergic crisis (too much acetycholinesterase inhibitor) - if tensiolon makes stornger (indicative of myastheic crisis) = need more acteycholinesterase inhibitor.

an advantage to the patient of a managed health care system is

paying lower health insurance costs and small copayments

an example of illness prevention activities would be

performing vision screenings

Factors affecting sleep

physical illness drugs and substances emotional stress environment lifestyle exercise and fatigue food and caloric intake sound

the correct actions when donning a pair of sterile gloves

picking up the first glove by grasping it on the fold of the cuff holding the glove with its fingers downward

Weber Test

place the base of the fork on the midline of the patients skull

Administration of intraocular disk

position convex side on fingertip place on conjuctival sac btw iris and lower lid gently pull eyelid over disk carefully pinch disk to remove from patient's eye

characteristics of postterm and preterm infant

preterm (prior to 37 weeks)- vernix and lanugo, smooth soles, Postterm (after 42 weeks) - dry peeling, wrinkly skin. major coplication would me meconium aspiration syndrome and respiratory distress.

A patient's age, gender,anxiety, culture, and __________ influence the pain experience

previous experience&meaning of pain

a basic premise of the American Nurses Association's nursing agenda for health care reform includes

primary health care services must play a very basic and prominent role in services delivery

transduction of pain

process that begins in the periphery when pain-producing stimulus send an impulse across a peripheral nerve fiber

inherent in any definition or philosophy of nursing are several core concepts

promoting wellness facilitating coping preventing illness restoring health

NSAIDs inhibit the synthesis of

prostaglandins

perception of pain

protects the body from damage, and is stimulated by extremes of pressure and temperature, as well as chemicals released from damaged tissues(physical component)

when placing the elderly patient in Fowler's position you must

refrain from raising the knees ore than 15 degrees

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________________.

risk for infection Rationale: Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.

dihiscence

rupture separion of one or more layers of a wound.

a common pressure point for a patient in the supine position is the

scapula

An example of community based approach to health care delivery is

school health sites offering primary care services

CHVOSTEKS sign-

seen in ttatny spam of facial muscles elicited by tapping the facial nerve in the region of parotid gland

lidocaine administration

should be diluted in 5% dextrose in water have resucitative equipment available

an unconscious patient begins vomiting in which position would the nurse place the patient

side lying

when caring for an unconscious client the nurse should

speak to the client in a normal voice

what is a collaborating practice

speaking to the social worker about the patients insurance problems

MANTOUX TEST

test for TB- low risk= positive result is induration more than 15mm High risk (immunodeficient)- positive result is more than 5 mm other high risk (drug users)- more than 10 mm

Brudzinski and Kernigs sign

tests for meningeal irritability

TROUSSEAU SIGN

tetany - in which carpa spasm an be eliceted by compressing the upper arm with blood pressure cuff.

Circadian Rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle

in which situation may the nurse legally use restraints

the critically ill client becomes violent and is removing IV lines and medical monitoring devices

while many factors can affect access to health care in the US, the most significant barrier is probably

the escalating cost of services

negligence is defined as

the failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance

when auscultating heart sounds S1 and S2

the fifth intercostal space at the midclavicular line with the diaphragm

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. True False

true

COMMON CARDIOVASCULAR EMERGENCY MEDS

vasodilators- nifedipine, nitroglycerin ACE Inhibitors- lisinopril BETA BLOCKERS- propanalol LIDOCAINE- ventircular dysrthmias AMIODARONE- restores normal sinus rhtyhm for atrial fibrillation

when a nurse is sued, the "reasonable person" standard asks

what a reasonable nurse would do in a similar situation

when is a nurse NOT obligated to follow the orders of a licensed physician

when the orders would result in harm to the client

the number of clients admitted to nursing homes is steadily growing

which statement is true regarding current trends for the delivery of health care services

when a negligence case is brought against a nurse, it is necessary to prove liability. which element is NOT essential for proof of liability

witnesses

evisceration

wound separation with protrusion of organs

closed wound

wound that involves underlying tissue without break in the skin

primary intention

wounds that heal under conditions of minimal tissue loss(partial thickness)