Intro to Nursing - Exam 3 Concepts - Modules 9, 10, 11, 12

An RN who usually works on the pediatric unit is floated to the GI medical-surgical unit. Which client is appropriate for the charge nurse to assign to the float nurse? A. 20-year-old with anorexia nervosa receiving total parenteral nutrition (TPN) through a central venous line B. 35-year-old who had a laparoscopic gastroplasty yesterday and is now taking sips of clear liquids C. 60-year-old with gastric cancer receiving elemental feedings through a jejunostomy tube D. 65-year-old with morbid obesity who requires a preoperative bariatric surgery assessment (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: A. A pediatric nurse would be familiar with the pathophysiology and collaborative treatment of the client with anorexia nervosa.

A malnourished client is being discharged on enteral nutrition products. Which suggestion from the registered dietitian does the nurse implement to make the enteral feeding experience more normal for the client? A. Administering the feeding product on a regular schedule B. Bringing the enteral product and napkin to the client on a tray C. Emphasizing the need to take iron medications before the feeding D. Once feeding is completed, putting equipment out of view (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. "Serving" the enteral product and napkin on a tray will help normalize the feeding experience for the client.

Which statement made by the patient indicates a need for further teaching on sleep hygiene? A. "I' m going to do my exercises before I eat dinner." B. "I'll have a glass of wine at bedtime to relax." C. "I set my alarm to get up at the same time every morning." D. "I moved my computer to the den to do my work." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: B. Drinking alcohol before bed in an effort to relax indicates a need for further teaching. Alcohol should be avoided before bed because it speeds onset of sleep, reduces REM sleep, awakens the person during the night, and causes difficulty returning to sleep.

A patient with left-sided weakness needs to be transferred to a wheelchair. On which side of the bed should the nurse place the wheelchair? A. On the patient's weak (affected) side. B. On the patient's strong (unaffected) side. C. Either side of the bed. D. Whichever side the patient prefers. (Evolve Online Course, Module 1: Safety)

Answer: B. During transfer, position the wheelchair on the same side of bed as patient's strong or unaffected side. This will best enable the patient to transfer safely and maximize their ability.

Which of the following patients would have the greatest potential for an alteration in respiration? A. A 15-year-old male with a migraine headache. B. A 44-year-old female with anemia. C. A 19-year-old female with diarrhea. D. A 32-year-old male with an ear ache. (Evolve Online Course, Module 8: Airway Management)

Answer: B. Hemoglobin carries about 97% of oxygen to the tissues. Anemia lowers the oxygen-carrying capacity of the blood and potentially leads to hypoxia.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum easily after nebulization C. Decreased independent ability to cough D. Lung sounds clear only after coughing (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: C. Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

A nurse is performing a health assessment on an obese client. The client states, "I have tried many diets in an effort to lose weight but have been unsuccessful!" How does the nurse assess whether the client's response to stress is related to the client's obesity? A. "Do you have a history of mental problems, especially depression?" B. "Do you usually use alcohol or drugs when you feel stressed?" C. "Tell me what you do to relieve stress in your daily life." D. "What is it about your obesity that causes you to feel uncomfortable?" (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. This is the only question that allows the client to verbalize stress-relieving mechanisms. It is also a question that cannot be answered with a simple "yes" or "no."

A nurse manager in a long-term care facility plans nutritional assessments of all residents. Which nutritional assessment activity does the nurse delegate to unlicensed assistive personnel (UAP) at the facility? A. Assessing residents' abilities to swallow B. Determining residents' functional status C. Measuring the daily food and fluid intake of residents D. Screening a portion of the residents with the Mini Nutritional Assessment (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. UAP education includes measurement of clients' oral intake; this skill does not require clinical judgment to be completed accurately.

The intensive care client with ketoacidosis (DKA) is receiving insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make? A. Urine output B. 12-lead electrocardiogram (ECG) C. Potassium level D. Rate of IV fluids (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential.

A patient is taking triazolam (Halcion). Which instructions about this drug are important for the nurse to include? A. It may be used as a barbiturate for only 4 weeks. B. Use as a nonbenzodiazepine to reduce anxiety. C. This drug does not lead to vivid dreams or nightmares. D. Avoid alcohol and smoking while taking this drug. (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: D.

Which nursing measure best promotes sleep in a school-age child? A. Encourage evening exercise B. Offer a glass of hot chocolate before bedtime C. Make sure that the room is dark and quiet D. Use quiet activities consistently before bedtime (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. A bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) used consistently helps young children avoid delaying sleep. Quiet activities such as reading stories, coloring, and allowing children to sit in a parent's lap while listening to music or a prayer are routines that are often associated with preparing for bed. Parents need to reinforce patterns of preparing for bedtime.

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll rest for 30 minutes before I eat my meal." C. "If I have trouble breathing at night, I'll use two to three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

A client who is receiving total enteral nutrition (TEN) exhibits acute confusion and shallow breathing and says, "I feel weak." As the client begins to have a generalized seizure, how does the nurse interpret this client's signs and symptoms? A. The enteral tube is misplaced or dislodged. B. Abdominal distention is present. C. A fluid and electrolyte imbalance is present. D. This is refeeding syndrome. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Symptoms of refeeding syndrome include shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency. Signs and symptoms of fluid and electrolyte problems resulting in circulatory overload can include peripheral edema, sudden weight gain, crackles, dyspnea, increased blood pressure, and bounding pulse, so C is incorrect.

The client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine? A. Day of discharge B. On admission C. When the client states readiness D. While performing the test in the hospital (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. Teaching the client about the operation of the machine while performing the test in the hospital is the best way for the client to learn. The teaching can be reinforced before discharge.

Which of the following patients would require repositioning? (Select all that apply.) A. A patient in correct body alignment who was turned 2 hours ago. B. A patient who has been sitting in a chair for 10 minutes watching television. C. A patient with paraplegia who has been sitting in a chair for 30 minutes but states she is comfortable. D. A patient who was repositioned for comfort 30 minutes ago after being moved up in bed. (Evolve Online Course, Module 1: Safety)

Answers: A, C. In general, patients should be repositioned as needed and at least every 2 hours if they are in bed and every 20 to 30 minutes if they are sitting in a chair to prevent the development of pressure ulcers. A patient with paraplegia would not be able to feel discomfort from pressure.

Exercise and activity are included in a cardiac rehabilitation program in order to (Select all that apply): A. Increase cardiac output. B. Increase serum lipids. C. Increase blood pressure. D. Increase blood flow to the arteries. E. Increase muscle mass. F. Increase flexibility. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answers: A, D, E, F. A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure.

For a patient with an endotracheal tube on mechanical ventilation, preoxygenation is unnecessary before suctioning because the ventilator will maintain the patient's oxygen levels. A. True B. False (Evolve Online Course, Module 8: Airway Management)

B. False. The ventilator should be set to deliver 100% oxygen before suctioning this patient.

A nurse is preparing to complete a fall risk assessment for a patient. Which factor places the patient at the highest risk for a fall? A. A previous fall B. Confusion C. Age greater than 65 years D. Impaired judgment (Lisa Ray Pre-Simulation)

Answer: A. A patient who has experienced a fall has an increased risk of recurrent falls. The remaining factors are of concern but are not the greatest indicator.

A patient is taking zolpidem (Ambien) for insomnia. The nurse prepares a care plan that includes monitoring of the patient for side effects/adverse reactions of this drug. Which is a side effect of zolpidem? A. Insomnia B. Headache C. Laryngospasm D. Blood dyscrasias (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: B.

Match the medication form with the method of preparation for administration through a feeding tube: Crush and then dissolve the powder in 15 to 30 mL warm water. A. Capsule B. Pill C. Gelatin capsule

Answer: B.

Match the type of restraint to its use: Mitten restraint. A. Immobilizes one or all extremities B. Prevents the use of fingers to scratch skin, remove dressings, or dislodge equipment C. Prevents a patient from reaching head and face to dislodge tubes or dressings D. Maintains a patient in a bed or stretcher (Evolve Online Course, Module 1: Safety)

Answer: B.

How does a nurse accurately calculate a client's body mass index (BMI)? A. BMI = weight (kg)/height (in meters)2 B. BMI = weight (lb)/height (in inches)2 C. BMI = weight (kg)/height (in meters) D. BMI = weight (lb)/height (in meters) (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: A.

Which of the following, if exhibited by the patient, is a late sign of hypoxia? A. Restlessness. B. Anxiety. C. Eupnea. D. Cyanosis. (Evolve Online Course, Module 8: Airway Management)

Answer: D. Restlessness and anxiety are early indicators of hypoxia. Cyanosis is a late indicator of hypoxia. Eupnea is normal respiration.

A hospitalized patient has repeatedly refused her meals. What should the nurse do? (Select all that apply.) A. Offer to feed patient. B. Administer vitamins with minerals to the patient. C. Determine the patient's food preferences. D. Apply more seasonings to foods. E. Determine whether the patient is in pain or has anxiety requiring treatment. (Evolve Online Course, Module 1: Safety)

Answers: C, E. The nurse should first try to identify and resolve possible problems while retaining the patient's independence. Determine whether the patient has other food preferences, cultural influences, or religious restrictions. Determine whether different times of the day are better. Determine whether discomfort or anxiety should be treated before eating. Determine whether the patient is mentally incapable of cooperating. If the problem cannot be resolved, the health care provider may be notified for further orders. Offering to feed the patient may be demeaning. The nurse may ask whether the patient would like seasonings added but should avoid adding them unless instructed. Administering vitamins with minerals would require a health care provider's order.

Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: A. Cause headaches and nausea. B. Be expensive and difficult to obtain. C. Cause severe depression and anxiety. D. Lead to sleep disruption. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Long-term use of sleeping medications in older adults can lead to sleep disruption. Because of slower metabolism and excretion of sleep medications, the potential for sleep impairment occurs. If sleep medications are needed, the lowest dose possible should be used short term.

_______ result in the greatest number of injuries to older adults. A. Falls Correct B. Medication errors C. Incidences of domestic violence D. Suicide attempts (Lisa Ray Pre-Simulation)

Answer: A. Falls, automobile accidents, and fires are the incidents that result in the greatest number of injuries to the older adult population.

Match the description to the category or causative factor: Chronic emphysema with long-term smoking. A. Increased restlessness, increases in secretions, and frequent coughing B. Chronic sonorous wheeze C. Decreased oxygen saturation after surgery (Evolve Online Course, Module 8: Airway Management)

Answer: B.

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. Upon arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient is at risk for airway occlusion. A. True B. False (Evolve Online Course, Module 8: Airway Management)

A. True. She must constantly be monitored for airway occlusion.

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. Upon arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. This patient's risk factors for respiratory problems include history of smoking, her illness, and her age. A. True B. False (Evolve Online Course, Module 8: Airway Management)

A. True. She was a smoker for many years, and her age and illness place her at greater risk for respiratory distress.

A 73-year-old patient was admitted with severe respiratory distress secondary to pneumonia. She has a long history of smoking, which she recently stopped. Upon arrival she was placed on continuous pulse oximetry, and an endotracheal tube was inserted for mechanical ventilation. She is heavily sedated. She is receiving an intravenous infusion at 100 mL per hour. Intravenous fluids may impact this patient's respiratory status. A. True B. False (Evolve Online Course, Module 8: Airway Management)

A. True. Too little fluid can cause thickened secretions and too much fluid may add stress to the heart. Monitor input and output closely. IV fluids can also help to keep her secretions thin and mobile.

A nurse is preparing a care plan for a patient. Which of the stated diagnoses from the nurse's plan of care is of the highest importance? A. Risk for imbalanced body temperature B. Risk for injury C. Deficient knowledge D. Disturbed thought processes (Lisa Ray Pre-Simulation)

Answer: B. Each of the nursing diagnoses is representative of an actual or potential problem. The patient's safety is of the greatest importance.

The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis? (Select all that apply.) A. Skin integrity and ROM. B. Pulse and temperature of restrained body part. C. Ability of patient to breathe without restriction. D. Readiness for discontinuation of restraint. E. Presence of visitors. F. Therapy (e.g., IV catheters, drainage tubes) remains uninterrupted. (Evolve Online Course, Module 1: Safety)

Answer: A, B, D, F. Evaluate the patient's condition for signs of injury every 15 minutes. Assess proper placement of restraint, including skin integrity, pulses, temperature, color, and sensation of the restrained body part. It is not necessary with an extremity restraint to assess patient's breathing. Use judgment and consider the patient's condition and the type of restraint when selecting physical assessment measures (e.g., circulation, nutrition and hydration, ROM in extremities, hygiene and elimination, physical and psychological status, and readiness for discontinuation). Observe IV catheters, urinary catheters, and drainage tubes to determine that they are positioned correctly and that therapy remains uninterrupted.

A nursing instructor asks what may cause orthostatic hypotension. The nursing student correctly replies: (Select all that apply.) A. Prolonged bed rest. B. Hypokalemia. C. Low body weight. D. Antihypertensives. E. Room temperature. (Evolve Online Course, Module 1: Safety)

Answer: A, B, D. Orthostatic hypotension may be related to bed rest, hypovolemia, hypokalemia, and certain medications such as sedatives, hypnotics, analgesics, antihypertensives, antiemetics, antihistamines, diuretics, and antianxiety agents. Body weight and room temperature are unrelated to the occurrence of orthostatic hypotension.

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A, C, D. Caution older adults to avoid grapefruit and grapefruit juice because these impair absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; thus older adults should be encouraged to ingest adequate fluids. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures.

Who may require a temporary restraint? (Select all that apply.) A. A patient who is at risk for falls when nonrestrictive measures have failed. B. A patient who is uncooperative. C. A confused patient who may interrupt prescribed therapy, such as a nasogastric tube. D. A patient who may be at risk to self or others. E. A patient who walks in his or her sleep. (Evolve Online Course, Module 1: Safety)

Answer: A, C, D. Patients needing temporary restraints include those at risk for falls and confused or combative patients at risk for injury or violence to self or others. In addition, restraints are used to prevent interruption of therapy such as an IV catheter, urinary or surgical drains, nasogastric tube, traction, or life support equipment. The least restrictive method should be used. Restraints should never be used as a punishment. Often, uncooperative patients can be managed with good communication skills. A bed alarm may be an appropriate safety measure for the patient who walks in his or her sleep. If alternative measures fail, then the health care provider may be contacted.

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.) A. Smoking is prohibited around oxygen. B. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. C. Do not use electrical equipment around oxygen. D. Special precautions may be required when traveling with oxygen (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

It is important for the nurse teaching the patient regarding secobarbital (Seconal) to include which information about the drug? A. It is a short-acting drug that may cause one to awaken early in the morning. B. It is an intermediate-acting drug that frequently causes REM rebound. C. It is an intermediate-acting drug that frequently causes a hangover effect. D. It is a long-acting drug that is frequently associated with dependence. (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: A.

Match the description to the category or causative factor: Pneumonia. A. Increased restlessness, increases in secretions, and frequent coughing B. Chronic sonorous wheeze C. Decreased oxygen saturation after surgery (Evolve Online Course, Module 8: Airway Management)

Answer: A.

Match the medication form with the method of preparation for administration through a feeding tube: Open and dissolve the powder in 15 to 30 mL warm water. A. Capsule B. Pill C. Gelatin capsule

Answer: A.

Match the type of restraint to its use: Extremity restraint. A. Immobilizes one or all extremities B. Prevents the use of fingers to scratch skin, remove dressings, or dislodge equipment C. Prevents a patient from reaching head and face to dislodge tubes or dressings D. Maintains a patient in a bed or stretcher (Evolve Online Course, Module 1: Safety)

Answer: A.

What is the purpose of a gait belt? A. It provides a means to steady a patient at the center of gravity or to transfer a patient safely without pulling on the patient's body. B. It keeps a patient from ambulating too fast. C. It measures the distance a patient has ambulated. D. It identifies patients who are at risk for a fall and who require a physical therapist to ambulate. E. It is a type of restraint. (Evolve Online Course, Module 1: Safety)

Answer: A. A gait belt is used to transfer a patient safely or as a safety measure to steady a patient who has poor balance. NAP or nurses may use a gait belt.

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A. Nasal cannula B. Venturi mask C. Simple face mask without inflated reservoir bag D. Plastic face mask with inflated reservoir bag (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. A nasal cannula delivers precise, high-flow rates of oxygen.

The patient is receiving a continuous enteral feeding. Which of the following assessment findings would require follow-up? A. Gastric residual of 275 mL B. Bowel sounds present in all 4 quadrants C. pH of gastric contents 5.0 D. Less than 10 mL of aspirate from NI tube (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: A. A residual of more than 250 mL is considered excessive. The nurse should stop the feeding, notify the physician, keep the patient in high-Fowler's position, and recheck residual in 1 hour. Normal residual is in the 10 mL or less range. Bowel sounds in all 4 quadrants and pH of 5.0 in gastric contents is normal for a patient who is receiving continuous enteral feeding.

The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? A. Raise head of bed to 90 degrees B. Turn patient to left lateral decubitus position C. Notify health care provider immediately D. Have patient perform the Valsalva maneuver (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Have the patient assume a left lateral decubitus position first. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down"). The increased venous pressure created by the maneuver prevents air from entering the bloodstream during catheter insertion. Maintaining integrity of the closed intravenous system also helps prevent air embolus.

Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? A. Placing an order for x-ray film examination to check position B. Confirming the distal mark on the feeding tube after taping C. Testing the pH of the gastric contents and observing the color D. Auscultating over the gastric area as air is injected into the tube (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. At present the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. The measurement of the pH of gastric secretions withdrawn from the feeding tube helps to determine the location of the tube. Auscultation has repeatedly been shown to be ineffective in detecting tubes accidentally placed in the lung. Further, it is not effective in distinguishing between gastric and intestinal placement for feeding tubes.

You have just received change-of-shift report on the endocrine unit. Which client should you see first? A. The type 1 diabetic client whose insulin pump is beeping "occlusion" B. The newly diagnosed type 1 diabetic client who is reporting thirst C. The type 2 diabetic client with a blood glucose of 150 mg/dL D. The type 2 diabetic client with a blood pressure of 150/90 (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. Because glucose levels will increase quickly in clients who use continuous insulin pumps, the nurse should assess this client and the insulin pump first to avoid DKA.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: A. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A. Record the amount and continue to monitor drainage B. Notify the health care provider C. Strip the chest tube starting at the chest D. Increase the suction by 10 mm Hg (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.

Which intervention is appropriate to include on a care plan for improving sleep in the older adult? A. Decrease fluids 2 to 4 hours before sleep B. Exercise in the evening to increase fatigue C. Allow the patient to sleep as late as possible D. Take a nap during the day to make up for lost sleep (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: A. Decreasing fluids 2 to 4 hours before sleep reduces the likelihood that the older adult's sleep will be disrupted during the night by the need to void.

A group of nursing students are studying together. They are discussing the differences between parenteral and enteral nutrition. Which statement, if made by one of the students, indicates further instruction is needed? A. "Parenteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube." B. "Enteral nutrition is preferred because it is less expensive than parenteral nutrition and maintains functioning of the gut." C. "An example of the parenteral route is subcutaneous or IM injections, or the IV route." D. "Gastric feedings may be given to patients with a low risk of aspiration. If there is a risk of aspiration, jejunal feeding is the preferred method. Parenteral nutrition is provided if the patient's GI tract is nonfunctional." (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: A. Enteral nutrition is the administration of nutrients directly into the GI tract by way of a feeding tube. Parenteral nutrition is a form of specialized nutrition support in which nutrients are provided intravenously.

A nurse is monitoring a client who is receiving an intravenous fat emulsion (IVFE) nutritional supplement. What action does the nurse take in the event that the client develops fever, increased triglycerides, and clotting problems? A. Discontinues the IVFE infusion B. Documents the findings and continues to monitor C. Slows the rate of flow of the IVFE infusion D. Switches the infusion to total parenteral nutrition (TPN) infusion (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: A. For clients receiving fat emulsions, monitor for manifestations of fat overload syndrome, especially in those who are critically ill. These manifestations include fever, increased triglycerides, clotting problems, and multi-system organ failure. Discontinue the IVFE infusion, and report any of these changes to the health care provider immediately if this complication is suspected.

The nurse is teaching the client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? A. "I should begin exercising for at least an hour a day." B. "I should monitor my diet." C. "If I lose weight, I may not need to use the insulin anymore." D. "Weight loss can be a sign of diabetic ketoacidosis." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? A. No observable respiratory difficulty or shortness of breath over the last 24 hours. B. A decrease in the amount of nasal drainage and sneezing. C. No sputum production, and a decrease in coughing episodes. D. Relief of an acute asthmatic attack. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: A. Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.

Which of the following is an appropriate nursing action to prevent a complication of NG tube feedings? A. Keep the head of the patient's bed elevated at least 30 degrees B. Leave the feeding tube unclamped and unplugged between feedings C. Allow the syringe to empty of feeding before adding more to the syringe D. Change the feeding tube bag and tubing every 72 hours for a continuous feeding (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: A. Head of bed elevation to a minimum of 30 degrees is a simple method to keep the risk for aspiration at a minimum. The nurse is instrumental in achieving this goal. To prevent air from entering stomach between feedings, clamp or plug end of tube when feeding is absent. The nurse should refill the syringe before it is completely empty until prescribed amount has been administered. Use a new administration set every 24 hours for an open system.

Which of the following would lead to an increase in oxygen demand? A. A fever. B. Sleep. C. Taking a narcotic. D. Postural drainage. (Evolve Online Course, Module 8: Airway Management)

Answer: A. Increased metabolic activity associated with a fever increases tissue oxygen demand. Postural drainage is an intervention used to mobilize secretions and maintain an open airway.

Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? A. Micrococcus B. Staphylococcus C. Corynebacterium D. Helicobacter pylori (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. Marshall and Warren first identified Helicobacter pylori in 1984. It is a bacteria that causes up to 85% of peptic ulcers and is confirmed by laboratory tests. It is treated with antibiotics that control the bacterial infection.

A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? A. "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." B. "If the patient's fluid status is sufficient, lubricating the catheter is unnecessary." C. "Petroleum jelly can be used to lubricate the catheter as long as the patient is not on oxygen via nasal cannula." D. "Applying water-soluble lubricant to the suction catheter ensures that it is working properly prior to oropharyngeal or nasotracheal suctioning." (Evolve Online Course, Module 8: Airway Management)

Answer: A. Oil-based lubricants increase the risk for aspiration and pneumonia. Water-soluble lubricant is applied to the catheter to ease insertion and prevent tissue trauma. It is unrelated to the patient's fluid status. Suctioning a small amount of sterile normal saline from the basin ensures that the suction system is working correctly. It is unnecessary to lubricate the end of the suction catheter when performing oropharyngeal suctioning.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: A. A safe environment promotes patient activity. B. Assessment focuses on environmental factors only. C. Teaching home safety is difficult to do in the hospital setting. D. Most accidents in the older adult are caused by lifestyle factors. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

The nurse caring for four diabetic clients has the following activities to perform. Which of these is appropriate to delegate to the nursing assistant? A. Perform hourly bedside blood glucose checks for a client with hyperglycemia. B. Verify the infusion rate on a continuous infusion insulin pump. C. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability. D. Check on a client who is reporting palpitations and anxiety. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. Performing bedside glucose monitoring is an activity that may be delegated because it does not require extensive clinical judgment to perform; the nurse follows up with the results.

A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. The nurse's best response is A. "Your father may be having ministrokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion." (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: A. Periods of confusion may be related to ministrokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified.

Why is controlling blood glucose levels important? A. High blood glucose levels increase the risk for heart disease, strokes, blindness, and kidney failure. B. High blood glucose levels increase the risk for seizure disorders, arthritis, osteoporosis, and bone fractures. C. Low blood glucose levels increase the risk for peripheral neuropathy, Alzheimer's disease, and premature aging. D. Low blood glucose levels increase the risk for obesity, pancreatitis, dehydration, and certain types of cancer. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. Persistent high blood glucose levels cause major changes in blood vessels that lead to organ damage, serious health problems, and early death. The long-term complications of diabetes include heart attacks, strokes, and kidney failure. In addition, diabetes is the main cause of foot and leg amputations and new-onset blindness. Reference: p. 1416, Physiological Integrity

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A. Raise the head of the bed to 45 degrees. B. Take his oxygen saturation with a pulse oximeter. C. Take his blood pressure and respiratory rate. D. Notify the health care provider of his shortness of breath. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

The nurse is providing discharge teaching to the client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching? A. "I can break in my shoes by wearing them all day." B. "I need to monitor my feet daily for blisters or skin breaks." C. "I should never go barefoot." D. "I should quit smoking." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. Shoes should be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering.

The nurse is performing routine assessments of the patients on the unit. The nurse notes audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can be delegated to competent NAP? A. Performing oral suctioning. B. Assessing the adequacy of respiratory functioning. C. Evaluating the outcome of oral suctioning. D. Performing nasotracheal suctioning. (Evolve Online Course, Module 8: Airway Management)

Answer: A. Since the patient is stable, the task of performing oral suctioning may be delegated to NAP. However, the responsibility for assessing the adequacy of respiratory functioning and evaluating the patient outcome of oral suctioning remains with you. Nasotracheal suctioning requires sterile technique and cannot be delegated to NAP.

Which is the best referral that the nurse can suggest to a client newly diagnosed with diabetes? A. American Diabetes Association B. Centers for Disease Control and Prevention C. Health care provider office D. Pharmaceutical representative

Answer: A. The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families.

The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? A. TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. B. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. C. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. D. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. The TPN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. Maintaining blood glucose within acceptable limits helps prevent complications from the TPN.

The NAP is reviewing with the nurse how to apply a belt restraint. Which statement, if made by the NAP, indicates further teaching is necessary? A. "I should place the belt restraint around the chest or abdomen." B. "A properly applied belt restraint allows the patient to turn onto his side." C. "I should apply the belt over the patient's gown or pajamas." D. "To apply the belt restraint, I should first have the patient sit up in bed." (Evolve Online Course, Module 1: Safety)

Answer: A. The belt restraint should be placed at the waist, not the chest or abdomen, as this restrains the center of gravity and prevents the patient from rolling off a stretcher or sitting up while on a stretcher, or from falling out of bed. Ventilation can be impaired if the belt restraint moves up over the abdomen or chest. The patient must be able to turn to a lateral position to prevent aspiration if the patient begins to vomit. The belt restraint is placed over the patient's clothes, gown, or pajamas. The NAP should remove wrinkles or creases in clothing. The patient first is in a sitting position as the belt restraint is applied.

Which morbidly obese client is not a candidate for bariatric surgery? A. 34-year-old woman experiencing mental confusion B. 44-year-old man with a history of hypertension C. 50-year-old woman with a history of sleep apnea D. 52-year-old man with a history of type 1 diabetes mellitus (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: A. The client who is experiencing mental confusion is not a good candidate for bariatric surgery because the client may have difficulty complying with the postoperative treatment regimen.

A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." These are the client's vital signs: T 98.4° F (36.9º C), P 112, R 38, BP 91/54, and O2 saturation 99% on room air. Which action should the nurse take first? A. Check the blood glucose. B. Administer oxygen. C. Offer reassurance. D. Attach a cardiac monitor. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: A. The client's clinical presentation is consistent with diabetic ketoacidosis, and the nurse should initially check the client's glucose level.

The nurse performs nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? A. Apply sterile gloves, pick up the suction catheter with dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. B. Wearing sterile gloves, suction a small amount of sterile normal saline from the basin and lightly coat 6 to 8 cm of the catheter with water-soluble lubricant. C. Using dominant hand, gently but quickly insert the catheter into the patient's nares and intermittently suction and rotate the catheter while withdrawing the catheter. D. Rinse the catheter and connecting tubing with normal saline and allow the patient to rest 1 to 2 minutes between catheter passes. Encourage the patient to cough, and when suctioning is complete, appropriately discard used equipment and perform oral care. (Evolve Online Course, Module 8: Airway Management)

Answer: A. The connecting tubing should be attached to the suction machine and turned on before applying sterile gloves.

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to restore essential services D. Evacuate patients per the disaster plan (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address organizational system exemplars, such as A. Care coordination. B. Communication. C. Diagnostic workup. D. Fall prevention. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: A. The most common safety issues at the blunt end include documentation/electronic records, team systems, environmental systems, error reporting/analysis systems, and regulatory systems. Each of the other options is classified as a point-of-care, sharp-end exemplar.

A patient with lung cancer has a feeding tube to help meet nutritional needs because of difficulty swallowing since radiation treatments. The patient requests some pain medication. The patient has an order for morphine, 5 mg IV push, every 2 hours as needed, or MS Contin (extended-release morphine tablet) PO 30 mg every 8 hours as needed. The nurse returns with the injectable form to be administered IV. The patient seems upset by this, stating, "I take a morphine pill for pain; why are you bringing me a shot?" What is the nurse's best response? A. "This is the same medication only in a form that I can administer through your IV line. The pill form you took at home should never be crushed, so I am unable to administer it through your feeding tube." B. "Your health care provider has ordered pain medication that may be administered either IV or through your feeding tube. It is easier to administer the pain medication through your IV." C. "This is the same medication you have taken at home only in a form that I can administer through your IV. It will take effect quicker than if I crushed your medication and administered it through your feeding tube." D. "I have brought you pain medication that can be administered through your IV, but if you prefer to have the pill form, I can go get it." (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: A. The nurse should never crush the tablet because crushing an extended-release tablet results in unpredictable absorption, metabolism, and effectiveness of the medication. The nurse should also avoid administering the medication orally because the patient has a risk for aspiration. The safest route for this patient's pain medication to be administered is the IV route.

The nurse is preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect? A. Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. B. Place the suction catheter in the container of water and apply suction. If the patient has an oxygen device, remove it, placing it near the patient's face. Insert the catheter gently into the mouth along the gingival border (gum line). C. Gently move the catheter around the patient's mouth until all of the secretions are cleared. Encourage the patient to cough. Replace the oxygen mask. Suction water from the basin through the catheter until the catheter is cleared of secretions. Reassess the patient's respiratory status and repeat the procedure if necessary. D. Turn off the suction source. Wipe the patient's face. Discard the water into an appropriate receptacle. Discard the Yankauer suction catheter or place it in a nonairtight container to ensure that it remains uncontaminated. Provide oral care. Remove the gloves and perform hand hygiene. Record the procedure. (Evolve Online Course, Module 8: Airway Management)

Answer: A. The nurse should place the patient in a Fowler's position, then perform hand hygiene, and finally set the suction control gauge according to manufacturer's directions. A high setting on the suction control gauge could cause damage to the oral mucosa. The other options are correct steps in the sequence for performing oropharyngeal suctioning.

What should the nurse do prior to administering physical restraints? A. Initially, provide a restraint-free environment. B. Warn the patient that restraints will be used if he or she does not cooperate. C. Move the patient to a room without a roommate and away from the nurses' station. D. Wait until the patient has actually fallen. (Evolve Online Course, Module 1: Safety)

Answer: A. The standard of care for institutionalized older adults is avoidance of mechanical restraints except as needed under exceptional circumstances and only after all other reasonable alternatives have been tried. Creating fear in the patient and stating restraints will be used as a punishment can be considered assault. The patient should be provided with the least restrictive environment, and close monitoring would be wise. Restraints are to be used only after all other reasonable alternatives have been tried. If the nurse waits until the patient has actually fallen, the patient could sustain an injury. Although restraints are to be used only after all other reasonable alternatives have been tried, it is unreasonable to wait until the patient sustains a fall.

The nurse manager is reviewing the use of restraints during an in service with the staff. Which of the following should NOT be included in the discussion? A. Physical restraints provide a safe and reliable method to prevent falls without serious complications. B. When all side rails are raised, this may be considered a form of physical restraint. C. Two fingers should be able to fit underneath the restraint. D. Attach the restraint to the movable part of the bed frame. (Evolve Online Course, Module 1: Safety)

Answer: A. The use of restraints is associated with serious complications, including pressure ulcers, constipation, urinary and fecal incontinence, and pneumonia. In some cases, restricted breathing or circulation has resulted in death. Loss of self-esteem and a sense of humiliation, fear, and anger are additional serious concerns. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. Check facility policy. Using two fingers to check the fit of a restraint guarantees safe application and prevents neurovascular compromise. Restraints should not be attached to the bedside rails, but should be attached to the portion of the bed frame that will move when the head of the bed is raised or lowered to prevent patient injury.

Which of the following patients is at greatest risk for experiencing a fall? A. A confused patient with a history of a previous fall. B. A patient who ambulates by holding onto furniture. C. A recently admitted patient. D. A patient who wears glasses to read. (Evolve Online Course, Module 1: Safety)

Answer: A. There are multiple factors that contribute to the risk of falls, including being in an unfamiliar environment (e.g., the recently admitted patient); difficulty communicating because of impaired vision, hearing, or speech; and impaired cognition. A patient who is confused and has a history of a fall is at greatest risk for experiencing a fall.

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A. I always feel tired when I wake up in the morning. B. I go to bed at the same time each night. C. It takes me about 15 minutes to fall asleep. D. Sometimes I have to get up during the night to urinate. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: A. This statement indicates that the patient is not experiencing quality sleep and should be followed up with more extensive questions and assessment of the problem. Patients are the best resource for describing sleep problems and how these problems are a change from their usual sleep and waking patterns. A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin you need to understand the nature of the sleep problem, its signs and symptoms, its onset and duration, its severity, any predisposing factors or causes, and the overall effect on the patient. Ask specific questions related to the sleep problem.

The nurse is getting a patient with right-sided weakness up in a chair. On what side of the bed should the nurse place the chair? A. On the patient's left side. B. On the patient's weak side. C. It doesn't matter, since you are assisting the patient. D. Whichever side the patient prefers. (Evolve Online Course, Module 1: Safety)

Answer: A. To facilitate balance and movement, the chair or wheelchair should be positioned so that the move will be toward the patient's stronger side.

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12. B. Vitamin C. C. Vitamin D. D. Omega-3 fatty acids. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answer: A. Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

A combative patient comes in to the emergency room and is swinging his fists at the nurses. With the assistance of security, the charge nurse places wrist restraints on the patient. What would be a priority action at this time? A. Notify the health care provider for follow-up evaluation. B. Tie the restraints to the bedside rail or frame of the wheelchair. C. Tie the restraint straps in a knot so the patient does not get loose. D. Assess, but avoid removing the restraints every 2 hours since the patient is violent. (Evolve Online Course, Module 1: Safety)

Answer: A. When a restraint is used for violent or self-destructive behavior, a licensed health care provider must evaluate the patient in person within 1 hour of the initiation of restraints and orders obtained. Restraints should be tied to the movable frame of the bed so if the position of the head of bed is changed, the patient's extremity will not be compromised. Restraints should never be tied to the side rail. Restraints should be secured with a quick-release tie in case of an emergency. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance.

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A. Fever increases metabolic demands, requiring increased oxygen need. B. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C. Carbon dioxide production increases as result of hyperventilation. D. Carbon dioxide production decreases as a result of hypoventilation. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A. Sharp pleuritic pain that worsens on inspiration B. Crackles over lung bases of affected lung C. Tracheal deviation toward the affected lung D. Increased diaphragmatic excursion on side of rib fractures (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

A nurse is teaching a patient about zolpidem. Which is important for the nurse to include in the teaching of this drug? A.The maximum dose is 20 mg/d. B.It may lead to psychological dependence. C.For older adults, the dose is 15 mg at bedtime. D.The drug should only be used for 21 days or less. (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: B.

A hospitalized elderly patient is disoriented to time and place, and the NAP reports the patient has been pulling at the indwelling catheter. The nurse just replaced the Foley catheter an hour ago after the patient pulled it out. After a focused assessment of the patient, the nurse determines the use of restraints is appropriate. What action should the nurse take next? A. Apply the restraints immediately. B. Have the NAP stay with the patient and call the health care provider. C. Call the patient's family and obtain consent. D. Have the NAP apply restraints and assess application 1 hour later. (Evolve Online Course, Module 1: Safety)

Answer: B. A health care provider's order is required for the use of restraints prior to application unless it is an emergency situation because of violent or aggressive behavior that presents immediate danger. The information from the nursing assessment is the foundation of the request for the health care provider's order. Restraint alternatives should be tried first, and if ineffective, restraints may be required. Although facility policy may indicate that family members should be notified, this would be done after the health care provider's order is obtained and the patient's safety secured. In long-term care, consent by the family is required for the application of restraints, but this patient was not in a long-term care setting.

The client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess before providing instruction about the disease and its management? A. Current lifestyle B. Educational and literacy level C. Sexual orientation D. Current energy level (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. A large amount of information must be synthesized; typically written instructions are given. This is essential information.

A hemoglobin level of _________ is needed to promote wound healing. A. 11 mg/dL B. 12 mg/dL C. 13 mg/dL D. 14 mg/dL (Lisa Ray Pre-Simulation)

Answer: B. A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia.

What nursing intervention is appropriate for the patient with a large amount of sputum? A. Perform nasotracheal suctioning every hour. B. Encourage the patient to cough every hour while awake. C. Place the patient on fluid restriction. D. Avoid all milk products. (Evolve Online Course, Module 8: Airway Management)

Answer: B. A patient with a large amount of sputum should be encouraged to cough every hour while awake. Adequate fluids should be maintained to help keep secretions thin and easier to expectorate. Although milk has a protein structure similar to sputum, it does not increase sputum production and plays an important role in nutrition. Suctioning should be performed on an as-needed basis.

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? A. Have patient follow hospital routines B. Avoid awakening patient for nonessential tasks C. Give prescribed sleeping medications at dinner D. Turn television on low to late-night programming. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: B. Avoiding awakening patient for nonessential tasks promotes sleep. Cluster activities and allow the patient time to sleep. Do not perform tasks such as laboratory draws and bathing during the night unless absolutely essential. Patients should try to follow home routines related to sleep habits. The other tasks do not promote sleep.

Which of the following should NOT be delegated to NAP? A. Oropharyngeal suctioning. B. Nasotracheal suctioning. C. Pulse oximetry. D. Oral care. (Evolve Online Course, Module 8: Airway Management)

Answer: B. Because sterile technique and critical thinking skills are required, it is inappropriate to delegate nasotracheal suctioning to NAP. The other tasks can be performed by NAP on stable patients.

Which statement made by the client during nutritional counseling indicates to the nurse that the client with diabetes type 1 correctly understands his or her nutritional needs? A. "If I completely eliminate carbohydrates from my diet, I will not need to take insulin." B. "I will make certain that I eat at least 130 g of carbohydrate each day regardless of my activity level." C. "My intake of protein in terms of grams and calories should be the same as my intake of carbohydrate." D. "My intake of unsaturated fats in terms of grams and calories should be the same as my intake of protein." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. Carbohydrates are the main fuel for the human cellular engine and the substance most commonly used to make ATP. Clients who have diabetes should never consume less than 130 g of carbohydrate per day (the percentage of total calories needed is determined for each client). Protein intake should range between 15% and 30% of total caloric intake per day. Reference: p. 1439, Health Promotion and Maintenance

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A. Stimulates hyperventilation, causing respiratory alkalosis B. Forms a strong bond with hemoglobin, creating a functional anemia. C. Stimulates hypoventilation, causing respiratory acidosis D. Causes alveoli to overinflate, leading to atelectasis (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: B. Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

A client has a primary problem of inadequate nutrition caused by the effects of chemotherapy. The client is receiving continuous enteral feedings through a nasogastric tube (NG) tube. What does the RN ask the LPN/LVN to do for this client? A. Assess nutritional parameters on the client every 3 days. B. Check the residual volume of the NG tube every 4 hours. C. Monitor the client for signs and symptoms of pneumonia. D. Teach the client about the purpose of enteral feedings. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. Checking the residual volume of the client's NG tube every 4 hours is within the scope of knowledge and practice for the LPN/LVN.

A client is receiving nutritional supplements to restore nutritional status. What does the nurse do to assess the effectiveness of the supplements for the client? A. Keeps an accurate and precise food and fluid intake record daily B. Makes certain the client is weighed daily at the same time C. Monitors vital signs every 4 hours and as needed D. Weekly assesses the client's skin for evidence(s) of breakdown (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. Daily weigh-ins will best show the effects of nutritional supplements by showing how much weight the client is regaining. Although it is important to identify any evidence of skin breakdown, this does not directly help in assessing the effects of nutritional supplements on the client.

The nurse is teaching the client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates correct understanding of hypoglycemia management? A. "I should drink a glass of water." B. "I should eat three graham crackers." C. "I should give myself 1 mg of glucagon." D. "I should sit down and rest." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. Eating three graham crackers is a correct management tactic for mild hypoglycemia.

The health care provider has ordered an enteral feeding tube for an elderly patient. Which statement if made by the patient's family member indicates further instruction is needed? A. "The enteral feedings will help provide additional calories." B. "The tube feedings are used to improve digestion." C. "This will help prevent her from getting pneumonia again from choking." D. "Tube feedings are less likely to cause infection than getting nutrients by IV infusion." (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: B. Enteral feedings will not improve digestion. Enteral feedings are used with patients who have adequate digestion and absorption, but cannot ingest, chew, or swallow food safely or in adequate amounts. Advantages of enteral feedings over parenteral feedings are that they are less expensive, maintain functioning of the gut and are less likely to cause infection.

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: B. Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.

The nurse is providing discharge teaching to the client with newly diagnosed diabetes. Which statement by the client indicates correct understanding about the need to wear a medical alert bracelet? A. "If I become hyperglycemic, it is a medical emergency." B. "If I become hypoglycemic, I could become unconscious." C. "Medical personnel may need confirmation of my insurance." D. "I may need to be admitted to the hospital suddenly." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. Hypoglycemia is the most common cause of medical emergency. A medical alert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care.

Why are most health care facilities no longer using vest (jacket) restraints? A. Because they are difficult to apply and remove. B. Because they have been associated with fatal injuries. C. Because they are less cost effective than other restraints. D. Because patients are able to get out of them more easily. (Evolve Online Course, Module 1: Safety)

Answer: B. Most patient deaths from use of restraints have resulted from strangulation from a vest or jacket restraint. For this reason, numerous facilities have stopped using vest restraints. Jacket or vest restraints are not difficult to apply or remove.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: B. Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A. A 55-year-old obese man recently diagnosed with diabetes mellitus B. A recently widowed 76-year-old woman recovering from a mild stroke C. A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery D. A 46-year-old man recovering at home following coronary artery bypass surgery (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently this group lives alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. This contributes to a risk for food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia.

The client with type 1 diabetes mellitus received regular insulin at 7 AM. The client should be monitored for hypoglycemia at which time? A. 7:30 AM B. 11 AM C. 2 PM D. 7:30 PM (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. Onset of regular insulin in ½ to 1 hour; peak is 2 to 4 hours. Therefore 11 AM is the anticipated onset time for regular insulin received at 7 AM.

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: A. Fastens the tube to the gown with tape. B. Places the patient supine while giving a bath. C. Performs oral care for the patient. D. Elevates the head of the bed 45 degrees. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated. Laying the patient supine increases the risk of aspiration of the feeding and should be avoided. This needs to be addressed to maintain patient safety.

A patient is questioning the nurse about circulation and perfusion. The nurse's best response to explain this concept is A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: B. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? A. Fat B Protein C. Vitamin D. Carbohydrate (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein.

A nurse is caring for a patient in a Posey restraint. The nurse recognizes the need to remove the Posey restraint at a minimum of every _____________ hour(s). A. 1 B. 2 C. 3 D. 4 (Lisa Ray Pre-Simulation)

Answer: B. Restraints should be removed at least every 2 hours. This allows for provision of hydration, toileting, and range of motion.

Which medication type is associated with an increased risk for a fall? A. Antibiotics B. Antidepressants C. Nonsteroidal anti-inflammatory drugs D. Hormone replacement (Lisa Ray Pre-Simulation)

Answer: B. Some medication types are associated with an increased risk for falls, including antidepressants, antihypotensive agents, diuretics, antihypertensive agents, and hypnotic agents.

The nurse is teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed? A. "It would be abnormal to obtain bloody secretions." B. "Because oral secretions are thick, suction settings should always be set on high." C. "I should be careful to avoid touching the back of the throat with the tip of the suction catheter." D. "I should encourage fluids to help keep secretions thin." (Evolve Online Course, Module 8: Airway Management)

Answer: B. Suction settings should be low to ensure that the oral tissue is uninjured during suctioning. Bloody secretions may be an indication of mucosal damage. The oropharynx should be assessed for any tissue injury, and the frequency of suctioning should be evaluated. Touching the back of the throat can stimulate the gag reflex. Unless contraindicated, fluids should be encouraged to reduce the viscosity of secretions.

The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and A. Accountability. B. Attitude. C. Education. D. Value. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: B. The Robert Wood Johnson Foundation funded the national initiative called Quality and Safety for Nurses (QSEN), which builds on the work of the Institute of Medicine (IOM), defines safety, and outlines the necessary elements of knowledge, skill, and attitude to demonstrate safety in one's practice. Accountability is a critical aspect of a culture of safety; recognizing and acknowledging one's actions is a trademark of professional behavior and is incorporated into, but not considered one of the three major elements, of QSEN.

The client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? A. Causes and treatment of hyperglycemia B. Causes and treatment of hypoglycemia C. Dietary control D. Insulin administration (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. The causes and treatment of hypoglycemia must be understood by the client and family to manage the client's diabetes effectively.

The client is an older adult with severe rheumatoid arthritis in the upper extremities. On assessment, the nurse determines that the client is malnourished. What does the nurse suspect as the cause for this client's malnutrition? A. A decrease in the client's appetite B. Decreasing ability to manipulate eating utensils C. Inadequate income to purchase sufficient food D. Metabolic requirements that are increased owing to immobility (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils.

Two nurses are assisting a patient to move up in bed with a lift sheet, and the patient is unable to assist. Which of the following actions is inappropriate? A. Remove pillow, lower the head of the bed to the lowest position the patient can tolerate, and lower the side rails. Have bed at working height. B. Place the pillow at the head of the bed. Roll the patient side to side and place a lift sheet under the patient that extends from the waist to the knees. C. With one nurse on each side of the patient, grasp the lift sheet firmly with hands near the patient's upper arms and hips, fanfolding the sheet close to the patient. Flex knees with body facing the direction of the move. D. Instruct the patient to rest the arms on the body and to lift the head on the count of three. Lift the patient toward the head of the bed on the count of three. Repeat the move if necessary. (Evolve Online Course, Module 1: Safety)

Answer: B. The lift sheet should extend from the patient's shoulders to the thighs to support the patient's weight and reduce friction during the move.

A nurse is teaching a group of adults in the community about the most recent Dietary Guidelines for Americans (2010). What does the nurse include with respect to the consumption of alcohol? A. Men should limit their drinking to 1 drink per day. B. Men may have 2 drinks every day. C. Older adults should have only 1 drink each week. D. Women should be limited to 2 drinks a day. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. The most recent guidelines (2010) emphasize the need to include preferences of specific racial/ethnic groups, vegetarians, and other populations when selecting foods to maintain a healthful diet that is balanced with moderation and variety. If alcohol is consumed, it should be limited to 1 drink per day for women and 2 drinks per day for men.

A nurse is caring for a patient. While assessing the patient, the nurse notes that the patient has a pressure ulcer. As a result of the assessment, the nurse includes Impaired skin integrity as a diagnosis in the plan of care for the patient. This nursing diagnosis can best be described as: A. a risk nursing diagnosis. B. an actual nursing diagnosis. C. a potential nursing diagnosis. D. a wellness nursing diagnosis. (Lisa Ray Pre-Simulation)

Answer: B. The patient in question has already experienced a skin breakdown, which was discovered upon assessment. Risk nursing diagnoses refer to health conditions or life processes that could possibly develop, and wellness nursing diagnoses refer to a patient's desire to increase well-being and actualize human health potential. Potential nursing diagnoses do not exist.

You have just taken change-of-shift report on a group of clients on the medical unit. Which client should you assess first? A. The client taking repaglinide (Prandin) who has nausea and back pain B. The client taking glyburide (Diabeta) who is dizzy and sweaty C. The client taking metformin (Glucophage) who has abdominal cramps D. The client taking pioglitazone (Actos) who has bilateral ankle swelling (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. This client has symptoms consistent with hypoglycemia and should be assessed first because he displays the most serious adverse effect of antidiabetic medications.

The nurse is teaching the client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? A. "I should go barefoot in my house so that my feet are exposed to air." B. "I must inspect my shoes for foreign objects before putting them on." C. "I will soak my feet in warm water to soften calluses before trying to remove them." D. "I must wear canvas shoes as much as possible to decrease pressure on my feet." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: B. To avoid injury or trauma to the feet, shoes should be inspected for foreign objects before they are put on.

What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age. B. Tobacco use. C. Drug overdose. D. Prolonged immobility. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use.

What is the priority assessment that should be performed before a patient is given food and fluids? A. Auscultating breath sounds B. Determining orientation C. Checking for bowel sounds D. Asking about food preferences (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Use simple orientation questions and single-step commands to determine the potential for both aspiration and safe oral intake before providing dysphagia screening.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. A Caucasian female who is breastfeeding. B. An African-American female who is breastfeeding. C. An Asian female diagnosed with hypoglycemia. D. A Hispanic female who has a BMI of 24.1. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answer: B. Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? A. Ratio of hemoglobin and hematocrit. B. Status of acid-base balance in arterial blood. C. Adequacy of oxygen transport. D. Presence of a pulmonary embolus. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus.

A patient received spinal anesthesia. Which is most important for the nurse to monitor? A.Loss of consciousness B.Hangover effects and dependence C.Hypotension and headaches D.Excitement or delirium (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: C.

A patient taking lorazepam (Ativan) asks the nurse how this drug works. The nurse should respond by stating that it is a benzodiazepine that acts by which mechanism? A.Depressing the central nervous system (CNS), leading to a loss of consciousness B.Depressing the CNS, including the motor and sensory activities C.Increasing the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to GABA receptors D.Creating an epidural block by placement of the local anesthetic in the outer covering of the spinal cord (Kee: Pharmacology, 8th Edition, Chapter 21)

Answer: C.

Match the description to the category or causative factor: Heavy sedation. A. Increased restlessness, increases in secretions, and frequent coughing B. Chronic sonorous wheeze C. Decreased oxygen saturation after surgery (Evolve Online Course, Module 8: Airway Management)

Answer: C.

Match the medication form with the method of preparation for administration through a feeding tube: Aspirate with a syringe, or dissolve in warm water over several minutes. After capsule dissolves, remove its gelatin outer layer. A. Capsule B. Pill C. Gelatin capsule

Answer: C.

Match the type of restraint to its use: Elbow restraint. A. Immobilizes one or all extremities B. Prevents the use of fingers to scratch skin, remove dressings, or dislodge equipment C. Prevents a patient from reaching head and face to dislodge tubes or dressings D. Maintains a patient in a bed or stretcher (Evolve Online Course, Module 1: Safety)

Answer: C.

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

Which of the following patients should be allowed to lie back down? A. A patient who was just transferred to a chair and states she was more comfortable in bed. Health care provider's orders are to be up in chair twice daily. B. A patient whose blood pressure was 120/80 prior to transfer, and is now 112/78. C. A patient who complains of feeling dizzy and slightly nauseous when dangling on the bedside. D. A patient whose blood pressure was 110/70 prior to transfer, and is now 125/80. (Evolve Online Course, Module 1: Safety)

Answer: C. A drop in blood pressure of approximately 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with symptoms of dizziness, pallor, or fainting indicates orthostatic hypotension. This patient's blood pressure changed within a normal range. A patient with orders to be up in chair needs to be encouraged to stay up in the chair in order to improve endurance.

Which of these clients with diabetes should the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? A. A 58-year-old with sensory neuropathy who needs teaching about foot care B. A 68-year-old with diabetic ketoacidosis who has an IV running at 250 mL/hr C. A 70-year-old who needs blood glucose monitoring and insulin before each meal D. A 76-year-old who was admitted with fatigue and shortness of breath (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit.

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A. Give the child milk. B. Give the child syrup of ipecac. C. Call the poison control center. D. Take the child to the emergency department. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

Which of the following patients is most likely to experience some difficulty with effective coughing? A. The elderly patient who had outpatient foot surgery. B. The middle-age man who is postoperative for knee arthroplasty. C. The patient who is postoperative for abdominal surgery. D. The patient who preoperatively practiced cascade coughing. (Evolve Online Course, Module 8: Airway Management)

Answer: C. Abdominal surgery causes pain and weakness of the abdominal muscles, both of which can result in ineffective airway clearance. Learning coughing techniques preoperatively will aid in postoperative performance of these skills.

The nurse is reading the health care provider's orders to increase the rate of the patient's NG feeding. Which of the following orders should the nurse question? A. Isocal 150 mL per feeding tube every 4 hours, increase by 50 mL per feeding per day until total volume is achieved to meet patient's caloric needs according to dietician's referral. B. Finger-stick blood glucose every 6 hours until maximum administration rate is achieved and maintained for 24 hours. C. Advance tube feeding rate by 100 mL/hr every 8 to 12 hours to target rate of 250 mL/hr over 12 hours. D. Weigh patient daily until maximum administration rate is reached and maintained for 24 hours, then weigh patient 3 times per week. (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: C. Advance rate slowly (e.g., 30 to 60 mL/hr) every 8 to 12 hours to target rate if tolerated. Begin feedings with no more than 150 to 250 mL at one time. Increase by 50 mL per feeding per day to achieve needed volume and calories in six to eight feedings. Weight gain is indicator of improved nutritional status; however, sudden gain of more than 2 pounds in 24 hours usually indicates fluid retention.

A nurse is teaching a class of older adults in the community about engaging in "regular" exercise. What does the nurse advise them? A. "1 to 2 hours of cardiovascular exercise every day is a good idea." B. "Joining a fitness program or gym will help greatly with your exercise." C. "Walking 20 minutes provides the same benefit as long periods of exercise." D. "You will benefit most if you get into a group that shares your exercise goals." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Although some people think that regular exercise has to include joining a fitness program or exercising for long periods of time, simple forms of exercise like walking 20 minutes provide the same type of benefit. Older adults can engage in this type of exercise. It does not cost money (like joining a program) and provides health benefits such as strengthening joints and improving cardiovascular health.

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A. Postural drainage B. Chest percussion C. Incentive spirometer D. Suctioning (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: C. An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

The diabetic client has a hemoglobin (Hb)A1c level of 9.4. What does the nurse say to the client regarding this finding? A. "Keep up the good work." B. "This is not good at all." C. "What are you doing differently?" D. "You need more insulin." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. Assessing the client's regimen or changes he may have made is the basis for formulating interventions to gain control of blood glucose.

The client newly diagnosed with type 1 diabetes asks why insulin is given only by injection and not as an oral drug. What is the nurse's best response? A. "Injected insulin works faster than oral drugs to lower blood glucose levels." B. "Oral insulin is so weak that it would require very high dosages to be effective." C. "Insulin is a small protein that is destroyed by stomach acids and intestinal enzymes." D. "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously. Reference: p. 1431, Health Promotion and Maintenance

A client has undergone bariatric surgery. Which nursing intervention is the highest priority in preventing dehydration in this client? A. Ambulating the client as quickly as possible after surgery B. Applying an abdominal binder daily when the client is out of bed C. Observing for tachycardia, nausea, diarrhea, and abdominal cramping D. Providing six small feedings daily; offering fluids frequently (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Small daily feedings and adequate fluids will prevent the development of dehydration in the client after bariatric surgery.

The client with type 2 diabetes has been admitted for surgery, and the physician has placed her on insulin. The client wants to know why she should have to take this. What is your best response? A. "Your diabetes is worse, so you will need to take insulin." B. "You can't take your metformin while in the hospital." C. "Your body is under more stress, so you will need to have insulin to support your medication." D. "You will have to take insulin from now on because the surgery will affect your diabetes." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. Because of the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for the client who uses oral agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.

The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem? A. Nocturia B. Hyperactivity C. Grogginess and feeling hung over D. Increased sleep time (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Benzodiazepines cause a hangover effect and rebound insomnia. The other sleep problems are not related to benzodiazepines.

The nurse is teaching the patient who is taking Coumadin about what foods to limit. Teaching has been effective when the patient avoids which of the following from the menu? A. Peas B. Artichokes C. Broccoli D. Cucumbers (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Broccoli should be avoided because vitamin K-rich foods (dark green leafy vegetables) interfere with the action of Coumadin (anticoagulant).(REF: p. 762)

Why is it important to have the tube feeding at room temperature? A. It is unnecessary to keep the tube feeding cold because it will be hanging at room temperature anyway. B. It aids the speed of digestion. C. Cold formula can cause gastric cramping. D. Cold formula may lower the patient's body temperature. (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: C. Cold formula can cause gastric cramping.

A client receiving total parenteral nutrition (TPN) exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing? A. Calcium imbalance B. Fluid volume deficit C. Fluid volume overload D. Potassium imbalance (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Congestive heart failure and pulmonary edema are symptoms of fluid overload.

The nurse's first action after discovering an electrical fire in a patient's room is to: A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. C. Remove all patients in immediate danger. D. Extinguish the fire by using the nearest fire extinguisher. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: C. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.

Which of the following would be a correct action of the NAP in regard to the application of restraints? A. The NAP removes the restraints every 24 hours for an hour. B. The NAP may apply restraints to patients if the NAP determines that it is necessary, as long as the NAP informs the nurse after doing so. C. The NAP removes one restraint at a time in a patient who is violent. D. The NAP may keep the patient's bed at a working height while the patient is in restraints. (Evolve Online Course, Module 1: Safety)

Answer: C. If the patient is violent or noncompliant, restraints should be removed one at a time, and/or staff assistance should be available while removing restraints. Restraints should be removed according to facility policy, but at least every 2 hours. An order is required for continuation of restraints every 24 hours. Application of restraints may be delegated to NAP. However, assessment of when restraints are needed and the appropriate type to use requires the critical thinking and knowledge application unique to the nurse and should never be delegated. The bed should be kept in the lowest position. If the patient falls when the bed is in the lowest position, this will reduce chance of injury.

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem A. Is disciplined according to established protocols. B. Must communicate the problem to the patient. C. Knows that near misses are used to improve care. D. Shares details to locate the individual at fault. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

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

Situation: An 87-year-old woman resident from an extended-care facility has not been eating for several days. She is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). She has developed a severe case of diarrhea. What is a possible cause? A. Digoxin (Lanoxin) B. Gastritis C. Potassium chloride (Kay Ciel) D. Ranitidine (Zantac) (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. In some cases, diarrhea may be the result of liquid medications such as elixirs and suspensions that have a very high osmolality.

The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? A. "The maximum duration to suction is 20 seconds." B. "The bacterial count in the nasotracheal pathway is higher, therefore suction the trachea through the mouth." C. "A 1- to 2- minute interval should be allowed between suctioning passes." D. "Intermittent suction is applied during insertion of the catheter." (Evolve Online Course, Module 8: Airway Management)

Answer: C. Intermittent suction up to 15 seconds safely removes pharyngeal secretions. The maximum time to suction the trachea is 10 seconds, with a 1- to 2-minute interval in between suctioning passes for reoxygenation. The mouth carries the highest bacterial count. Whenever possible, suction via the nasotracheal route. To avoid tissue damage, intermittent suction is applied as the catheter is being withdrawn.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse effectively plan nutritional care for this client? A. Calculates his body mass index (BMI) B. Keeps a 24-hour diary of his physical activities C. Maintains a 24-hour recall (diary) of his food intake D. Obtains his accurate height and weight measurements (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Maintaining a 24-hour recall of food intake will determine the client's food preferences and eating patterns so that they can be incorporated into the diet to the greatest extent possible.

A client with type 2 diabetes who also has heart failure is prescribed metformin extended-release (Glucophage XR) once daily. On assessment, the nurse finds that the client now has muscle aches, drowsiness, low blood pressure, and a slow, irregular heartbeat. What is the nurse's best action? A. Assess the client's blood glucose level and prepare to administer IV glucose. B. Reassure the client that these symptoms are normal effects of this drug. C. Hold the dose and notify the prescriber immediately. D. Administer the drug at bedtime to prevent falls. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. Muscle aches, drowsiness, low blood pressure, and a slow irregular heartbeat are symptoms of lactic acidosis, an adverse reaction to metformin. The drug should be stopped and the prescriber notified so steps can be taken to reduce the client's acidosis. Reference: p. 1430, Safe and Effective Care Environment

A female client is concerned that her inability to conceive a child is connected to her morbid obesity. How does the nurse respond? A. "Do you feel that your obesity is keeping you from getting pregnant?" B. "Have you considered adoption as an option?" C. "Tell me about changes, if any, in your menstrual cycle each month." D. "What has your health care provider told you about your problems in getting pregnant?" (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Obesity has been known to produce changes in the menstrual cycle, thus causing difficulties in getting pregnant.

Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? A. I need to stop eating red meat. B. I will increase the servings of fruit juice to four a day. C. I will make sure that I eat a balanced diet and exercise regularly. D. I will not eat so many dark green vegetables and eat more yellow vegetables. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Obesity is an epidemic in the United States. Proposed contributing factors are sedentary lifestyle and poor meal choices. Healthy eating and participation in exercise or other activities of healthy living promote good health.

The nurse is going to administer an intermittent tube feeding. Since the patient's feeding tube has been in place for 3 days, which action is best for the nurse to take at this time? A. Obtain an order for x-ray verification of tube location. B. Auscultate over the gastric area while instilling 30 mL of air into the feeding tube. C. Aspirate gastric contents and test on a pH strip. D. Verify the indelible ink mark on the tube is at the nares. (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: C. Ongoing verification of tube placement is made by pH testing of aspirate. Verification by x-ray is necessary upon feeding tube insertion and if tube migration is suspected. Auscultation is no longer considered a reliable method for determining feeding tube placement. The tube can migrate without moving at its externally taped location.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical). She asks the nurse how Xenical works. How does the nurse respond? A. "It decreases the amount of norepinephrine in your brain. This action will increase your feeling of being satisfied on less food." B. "It increases the amount of serotonin in your brain. This action will greatly increase your metabolic rate, and you will burn calories quicker." C. "It inhibits enzymes and changes the way your body digests fats. Because fats are only partially digested and absorbed, calorie intake is decreased." D. "It will alter the chemistry of your brain. Consequently, you will feel full before you overeat." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Orlistat inhibits lipase and leads to partial hydrolysis of triglycerides. Because fats are only partially digested and absorbed, calorie intake is decreased.

Which explanation best assists the client in differentiating type 1 diabetes from type 2 diabetes? A. Most clients with type 1 diabetes are born with it. B. People with type 1 diabetes are often obese. C. Those with type 2 diabetes make insulin, but in inadequate amounts. D. People with type 2 diabetes do not develop typical diabetic complications. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin.

When preparing a mixed insulin injection, which action does the nurse perform first? A. Draws up the longer-acting insulin B. Draws up the short-acting insulin C. Puts air in the longer-acting insulin vial D. Puts air in the shorter-acting insulin vial Rationale (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. Putting air in the longer-acting insulin vial is the first step in preparing a mixed insulin injection.

Which of the following manifestations would be an early sign of silent aspiration? A. Heart rate: 129 B. Blood pressure: 90/60 C. Respiratory rate: 30 D. Temperature: 38.2° C (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Tachypnea (respirations above 26) is an early sign of silent aspiration. (REF: p. 769)

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? A. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." B. "Sleep medicines won't cause any sleep problems once I stop taking them." C. "I'll talk to my health care provider before I use an over the- counter sleep medication." D. "I'll contact my health care provider if I feel extreme sleepy in the mornings." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Talking to a health care provider before using an over-the-counter sleep medication shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption, even when they initially seemed to be effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action, which can cause confusion, constipation, urinary retention, and increased risk of falls.

A nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" about what the BMI number means. Which client statement indicates a need for further instruction? A. "If I could get my BMI below 25, my risk for malnutrition would decrease." B. "I realize that this means that I have some increased health risks." C. "My goal should be to get my BMI below 18.5." D. "This means that I have an increased amount of total fat stored in my body." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. The least risk for malnutrition is actually seen in adult clients whose BMI is between 18.5 and 25.

The client newly diagnosed with diabetes asks why he is always so thirsty. What is the nurse's best response? A. "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." B. "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." C. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." D. "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. The movement of glucose into cells is impaired, and the resulting high blood glucose levels increase the osmolarity of the blood. This increased osmolarity stimulates the osmoreceptors in the hypothalamus, triggering the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity. Reference: p. 1413, Health Promotion and Maintenance

The nurse is going to irrigate the patient's established feeding tube with 30 mL of tap water before instilling the tube feeding. The nurse attempts to do so without success. What should action should the nurse take? A. Notify the health care provider. B. Irrigate the tubing with soda, such as Coca-Cola. C. Reposition the patient. D. Use a smaller-sized syringe with the plunger to push the fluid through the feeding tube. (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: C. The nurse should first reposition the patient on the left side and try again. The tip of the tube may be lying against the stomach wall. Changing the patient's position may move the tip away from the stomach wall. The nurse may attempt to flush the tubing with a large-bore syringe and warm water. If still unable to clear the feeding tube, the health care provider should be notified. Baking soda or cola should never be used because they could cause further complications if aspirated.

Situation: An 87-year-old woman resident from an extended-care facility has not been eating for several days. She is admitted to the hospital with a diagnosis of malnutrition. She has an enteral feeding tube placed in her left nostril. Her medications include digoxin (Lanoxin), ranitidine (Zantac), and potassium chloride elixir (Kay Ciel). The nurse who is responsible for checking the gastric pH of the feeding tube tests it and obtains a value of 6.0. This finding may indicate that the feeding tube is in the client's lungs. Is there another possible explanation for the nurse to consider? A. No. The feeding tube must be removed. B. No. The potassium effect will prevent the pH from reaching 6.0. C. Yes. The client is taking Zantac. D. Yes. The pH paper has expired and is giving a false reading. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. The pH may be as high as 6.0 if the client takes certain medications, such as H2 blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]).

A client is placed on orlistat (Xenical) as part of a treatment regimen for morbid obesity. What side effects does the nurse tell the client to expect from using this drug? A. Dry mouth, constipation, and insomnia B. Insomnia, dry mouth, and blurred vision C. Loose stools, abdominal cramps, and nausea D. Palpitations, constipation, and restlessness (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. These are side effects unique to orlistat (Xenical).

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching? A. "I won't put the baby to bed with a bottle." B. "For the first few weeks we're putting the cradle in our room." C. "My grandmother told me that babies sleep better on their stomachs." D. "I know I'll have to get up during the night to feed the baby when he wakes up." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Thinking that babies will sleep better on their stomachs indicates that the mother needs further teaching. She needs to be educated on the "back to bed" concept for infant sleeping. Infants' beds need to be safe. Parents should place infants on their back to prevent suffocation and decrease the risk of sudden infant death syndrome (SIDS).

The client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? A. "It is overwhelming, isn't it?" B. "Let's see how much you can learn today, so you are less nervous." C. "Let's tackle it piece by piece. What is most scary to you?" D. "Other people do it just fine." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: C. This approach will allow the client to have a sense of mastery with acceptance.

Match the type of restraint to its use: Belt restraint. A. Immobilizes one or all extremities B. Prevents the use of fingers to scratch skin, remove dressings, or dislodge equipment C. Prevents a patient from reaching head and face to dislodge tubes or dressings D. Maintains a patient in a bed or stretcher (Evolve Online Course, Module 1: Safety)

Answer: D.

Which complication of diabetes should the nurse report to the provider? The nurse receives report on a 52-year-old client with type 2 diabetes. CHART EXHIBIT Assessment: Lungs clear, Right great toe mottled Diagnostics: Glucose 179, Hemoglobin A1C 6.9 Prescriptions: Regular insulin 8 units if blood glucose 250 to 275 and cold to touch. Regular insulin 10 units if glucose 275 to 300 Client states wears eyeglasses to read. A. Poor glucose control B. Visual changes C. Respiratory distress D. Peripheral tissue perfusion (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. A cold, mottled toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization; this must be reported to avoid potential gangrene and amputation.

Which serum albumin level does the nurse expect to see in the healthy, ambulatory older adult client? A. 3.3 g/dL B. 3.7 g/dL C. 3.9 g/dL D. 4.3 g/dL (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. A level of 4.3 g/dL would be expected for this client.

The nurse is developing a plan of care for a patient experiencing narcolepsy. Which intervention is appropriate to include on the plan? A. Instruct the patient to increase carbohydrates in the diet B. Have patient limit fluid intake 2 hours before bedtime C. Preserve energy by limiting exercise to morning hours D. Encourage patient to take one or two 20-minute naps during the day (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. A person with narcolepsy has the problem of falling asleep uncontrollably at inappropriate times. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timing daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol; heavy meals; exhausting activities; long-distance driving; and long periods of sitting in hot, stuffy rooms).

Which of the following accurately describes the greatest risk related to having a feeding tube? A. Electrolyte imbalance B. Fluid volume overload C. Infection D. Aspiration (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: D. Although the risk of aspiration is lessened with a jejunal feeding tube, once a feeding tube is placed, all patients remain at risk for aspiration and need careful nursing management to avoid this complication.

An RN receives the change-of-shift report about these clients. Which client does the nurse assess first? A. 30-year-old admitted 2 hours ago with malnutrition that is associated with malabsorption syndrome B. 45-year-old who had gastric bypass surgery and is reporting severe incisional pain C. 50-year-old receiving total parenteral nutrition (TPN) with a blood glucose (BG) level of 300 mg/dL D. 75-year-old with dementia who is receiving nasogastric feedings and has a respiratory rate of 38 breaths/min (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Aspiration is a major complication in clients receiving tube feedings, especially in clients with an altered level of consciousness. This client needs respiratory assessment and interventions immediately.

Which of these nursing actions can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? A. Assist the client's spouse in choosing appropriate dietary items. B. Evaluate the client's use of a home blood glucose monitor. C. Inspect the extremities for evidence of poor circulation. D. Assist the client with washing his feet and applying moisturizing lotion. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. Assisting with personal hygiene is included in the role of home health aides. Assisting with dietary choices, evaluating the effectiveness of teaching, and performing assessments are complex actions that should be implemented by licensed nurses.

Which of the following patients should be assessed for a worsening clinical situation? A. The chronic obstructive pulmonary disease (COPD) patient whose pulse oximetry remains the same after oropharyngeal suctioning. B. The patient with absence of adventitious lung sounds on inspiration and expiration. C. The patient who demonstrates less drooling after being suctioned. D. The patient with presence of blood in the secretions. (Evolve Online Course, Module 8: Airway Management)

Answer: D. Bloody secretions are an unexpected outcome. The cause should be investigated. The removal of secretions helps to improve the oxygen saturation level. In patients with chronic pulmonary diseases such as COPD, the pulse oximetry value may remain the same. The absence of adventitious sounds is an expected finding. An expected outcome of oropharyngeal suctioning is lessened or absence of drooling.

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A. Sonorous wheezes in the left lower lung B. Rhonchi midsternum C. Crackles only in apex of lungs D. Inspiratory crackles in lung bases (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.

The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? A. Gastric pH of 4.0 during placement check B. Weight gain of 1 pound over the course of a week C. Active bowel sounds in the four abdominal quadrants D. Gastric residual aspirate of 350 mL for the second consecutive time (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: D. Delayed gastric emptying is a concern if 250 mL or more remains in the patient's stomach on each of two consecutive assessments. The North American Summit on Aspiration in the Critically Ill Patient made the following recommendations regarding gastric residual volumes (GRVs): (1) stop feedings immediately if aspiration occurs; (2) withhold feedings and reassess patient tolerance to feedings if GRV is over 500 mL for two successive measurements; and (3) routinely evaluate the patient for aspiration and use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL.

Which nursing care activity for a malnourished client does the nurse safely delegate to unlicensed assistive personnel (UAP)? A. Completing the Mini Nutritional Assessment B. Determining body mass index (BMI) C. Estimating body fat using skin-fold measurements D. Measuring current height and weight (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Determining height and weight is the only activity that can be safely delegated to UAP.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

Which action by the nursing assistant at bedtime requires the nurse to intervene? A. Giving the patient a back rub B. Turning on quiet music C. Dimming the lights in the patient's room D. Giving a patient a cup of coffee (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. Encourage patients not to drink or ingest caffeine before bedtime. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

The student nurse is preparing to administer medication through a feeding tube. Which of the following statements if made by the student nurse indicates correct understanding? A. "I will perform hand hygiene. Gloves are only necessary for tube insertion, not medication administration." B. "The head of the bed should be kept flat during medication administration." C. "I will aspirate gastric contents to check placement of the feeding tube and residual volume and then I will dispose of the aspirate properly." D. "I will flush with 10 mL of tap water after each medicine and with 30-60 mL of water after the last medication." (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: D. If a problem develops during medication administration (e.g., spillage, coughing), the nurse can tell which medications have been lost and which are still available for later administration. Following the last medication with 30 to 60 mL of water avoids clogging of the tube with medication and ensures the medication enters the stomach, where it can be absorbed. Gloves should be worn for protection from potential exposure to body fluids. Elevate head of bed to high-Fowler's position, at least 30 degrees, as keeping head above stomach reduces risk of aspiration. Gastric contents should be returned to the patient's stomach to avoid fluid and electrolyte imbalance.

Which statement made by a patient of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 4 months. D. I'm going to alternate formula with whole milk starting next month. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: D. Infants should not have regular cow's milk during the first year of life. It causes gastrointestinal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels the infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein.

Which client on a medical-surgical unit does the charge nurse assign to the LPN/LVN? A. 28-year-old with morbid obesity who had bariatric surgery today B. 30-year-old recently admitted with severe diarrhea and Clostridium difficile infection C. 36-year-old whose family needs instruction about how to use a gastric feeding tube D. 39-year-old with a jejunal feeding tube who needs elemental feedings administered (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. LPN/LVN education includes administration of tube feedings and associated client care and monitoring.

In reviewing the physician admission requests for the client admitted with hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis? A. 20 mEq KCl for each liter of IV fluid B. IV regular insulin at 2 units/hr C. IV normal saline at 100 mL/hr D. 1 ampule NaHCO3 IV now (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis.

A nurse obtains assessment data on a client who had bariatric surgery today. Which finding does the nurse report to the surgeon immediately? A. Bowel sounds are not audible in all quadrants. B. Client's skin under the panniculus is excoriated. C. The client reports pain when being repositioned. D. Urine output total is 15 mL for the past 2 hours. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Oliguria may indicate severe postoperative complications such as anastomotic leaks or acute kidney failure.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: D. Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

An older adult client needs additional dietary protein but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? A. Administering the liquid supplement with routine medications B. Giving a glucose polymer modular supplement C. Keeping a food and fluid intake diary for at least 3 days D. Providing protein modular supplements in the form of puddings (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Providing protein modular supplements in the form of puddings would increase the client's protein intake in an alternate format, other than a liquid supplement.

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A. "Suctioning the patient requires sterile technique." B. "I'll apply suction while rotating and withdrawing the suction catheter." C. "I'll suction the mouth after I suction the endotracheal tube." D. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction? A. The NAP inserted two fingers under the secured restraint. B. The NAP used a quick-release tie. C. The NAP placed the patient in functional alignment. D. The NAP attached the restraint to the side rail of the bed. (Evolve Online Course, Module 1: Safety)

Answer: D. The NAP should be able to insert two fingers under the secured restraint to make sure it is not too tight that it would interfere with circulation and cause neurovascular injury. Using a quick-release tie is an appropriate action of the NAP because it allows for quick release of the restraint in an emergency. The patient should be placed in functional alignment to prevent strain of joints and discomfort. The patient could be injured if the restraint is secured to the side rail and it is lowered. Restraints should be attached to the bed frame, which moves when the head of the bed is raised or lowered, so that the straps will remain at the correct tension without restricting circulation.

Based on nutritional screening findings and assessments, which client will be most successful with surgical treatment for obesity? A. Man with a BMI of 40, weight 75% above ideal body weight B. Man with a BMI of 41, weight 80% above ideal body weight C. Woman with a BMI of 38, weight 50% above ideal body weight D. Woman with a BMI of 42, weight 100% above ideal body weight (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. The best candidate for surgical intervention is the one with a BMI of 40 or more and a weight 100% above the ideal body weight.

The client newly diagnosed with type 2 diabetes asks how diabetes type 1 and diabetes type 2 are different. What is the nurse's best response? A. "Diabetes type 1 develops in people younger than 40 years and diabetes type 2 develops only in older people." B. "Diabetes type 2 develops in people younger than 40 years and diabetes type 1 develops only in older people." C. "Patients with type 1 diabetes are at higher risk for obesity and heart disease, whereas patients with type 2 diabetes are at higher risk for strokes." D. "Patients with type 1 diabetes produce no insulin and patients with type 2 diabetes produce insulin but their insulin receptors are not very sensitive to it." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. The main problem with type 1 diabetes is that the person can no longer make insulin. Without insulin, the client's blood glucose level becomes very high, but glucose cannot enter many cells. Clients with type 1 diabetes must use insulin daily for the rest of their lives or receive a pancreas transplant. With type 2 diabetes, the person still has beta cells that make some insulin. In fact, some people with type 2 diabetes have normal levels of insulin; however, the insulin receptors are not very sensitive to it. As a result, insulin does not bind as tightly to its receptors as it should, and less glucose moves from the blood into the cells. Reference: p. 1418, Health Promotion and Maintenance

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C. Encourage coughing and deep breathing to clear the airway. D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: D. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

A student nurse receives an order for Valium to be given intravenously. Valium tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? A. Communication error. B. Diagnostic error. C. Preventive error. D. Treatment error. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

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

The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase? A. REM sleep B. Stage 1 NREM sleep C. Stage 4 NREM sleep D. Transition period from NREM to REM sleep (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A. Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe they are functionally important to learning, memory processing, and adaptation to stress.

The patient begins to cough and choke while the nurse is feeding him. What should the nurse do? A. Notify the health care provider immediately. B. Give the patient some water. C. Allow the patient to rest. D. Suction the airway as necessary. (Evolve Online Course, Module 1: Safety)

Answer: D. The nurse should first use suction equipment if necessary to clear food from the airway and position the patient in the high-Fowler's position or, if unable to do so, position the patient on the patient's side. If choking occurs repeatedly, stop feeding the patient and notify the health care provider. Provide oxygen if the patient's color has failed to return to normal. Offering the patient water may only increase choking, because thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. As a preventive measure, the nurse should allow the patient to rest throughout feeding.

A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1c) is 8.2%. Which action will the nurse plan to take next? A. Instruct the client to continue with the current diet and Glucophage use. B. Discuss the need to check blood glucose several times every day. C. Talk about the possibility of adding rapid-acting insulin to the regimen. D. Ask the client about current dietary intake and medication use. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 67)

Answer: D. The nurse's first action should be to assess whether the client is adherent to the currently prescribed diet and medications. The client's current diet and medication use have not been successful in keeping glucose in the desired range. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical) 60 mg orally three times a day. She has been taking this medication for 4 weeks and has lost only 10 pounds. What does the nurse anticipate the health care provider will do for this client? A. Change her medication to phendimetrazine (Bontril). B. Decrease the amount of her medication. C. Encourage her to decrease her activity level. D. Increase the dosage of her medication. (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. The usual dosage can be 120 mg three times a day, depending on the client's response.

The nurse is going to administer a bolus enteral tube feeding of 240 mL. The nurse has obtained a pH of 4 and 50 mL of gastric aspirate. Based on these findings, what action should the nurse take? A. Stop the feeding and recheck the residual in one hour. B. Reposition the feeding tube under fluoroscopy. C. Discard the aspirate and continue with the bolus feeding as prescribed. D. Return the aspirate to the patient's stomach and administer the feeding. (Evolve Online Course, Module 15: Enteral Nutrition)

Answer: D. These are normal findings. The nurse should return the gastric aspirate to the patient's stomach to prevent an alteration in electrolyte balance and administer the tube feeding as prescribed.

A client is discharged home with an enteral feeding tube. What does the home health nurse do to determine the patency of the client's enteral tube? A. Arranges for the client to have an x-ray performed periodically B. Auscultates the client's abdomen for bowel sounds before each feeding C. Instills air into the tube to check for placement and patency before each feeding D. Tests aspirated tube contents for pH level before each feeding (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. This is considered to be the most accurate method for confirming enteral tube placement. The presence of bowel sounds does not indicate that the enteral tube is in place.

The nurse desires to suction the patient's left main stem bronchus. In what position should the patient be placed? A. Keep the patient's head in a neutral position and rotate the catheter counter-clockwise upon insertion. B. Keep the patient's head in a neutral position and rotate the catheter clockwise upon insertion. C. Turn the patient's head to the left. D. Turn the patient's head to the right. (Evolve Online Course, Module 8: Airway Management)

Answer: D. To effectively suction the left main stem bronchus, turn the patient's head to the right.

A bariatric client is recuperating after injury. Which nursing intervention most effectively prevents injury to the client who is being repositioned postoperatively? A. Administering pain medication B. Making sure to not move the client's nasogastric (NG) tube C. Monitoring skin-fold areas and keeping them clean and dry D. Using a weight-rated extra-wide bed for the client (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Using a special bed will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Monitoring skin-fold areas will prevent the development of skin breakdown but will not prevent injury to the client that might occur during repositioning.

The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. Open a window to let fresh air into the room. B. Use nasal strips to assist with breathing. C. Sleep in a side-lying position. D. Use pillows to prop yourself up while sleeping. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: D. Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat.

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A. A patient with asthma and severe shortness of breath. B. A patient undergoing a bronchoscopy for a biopsy. C. A patient with a pleural effusion requiring fluid removal. D. A patient experiencing a problem with a pneumothorax. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: D. When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.

The nurse is caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, the nurse completes a respiratory assessment. Which assessment parameters indicate the need for oral suction? (Select all that apply.) A. Unusual restlessness. B. Gagging. C. Gurgling and adventitious lung sounds. D. Evidence of emesis in the mouth. E. Persistent coughing that fails to clear airway. F. Persistent complaints of pain. G. Weakness and lethargy accompanied by drooling. (Evolve Online Course, Module 8: Airway Management)

Answers: A, B, C, D, E, G. The following signs indicate the need for oropharyngeal suctioning: (1) restlessness, especially if it is new or unusual for the patient; (2) obvious, excessive oral secretions as evidenced by drooling and/or gagging; (3) gurgling and/or audible crackles and wheezes that occur on inspiration and/or expiration; (4) evidence of gastric contents and/or emesis in the mouth; (5) persistent coughing that fails to clear the upper airway; and (6) weakness and lethargy accompanied by drooling and gagging. Persistent complaints of pain are more likely related to the surgery.

You are reviewing the signs, symptoms, and prevention of hypoxia with the family of a patient who requires frequent suctioning at home. Choose the information that you should cover. (Select all that apply.) A. Restlessness and anxiety are indications of hypoxia. B. Confusion, disorientation, and altered consciousness are indications of hypoxia. C. Increases in pulse, respiration, and blood pressure are indications of hypoxia. D. Having difficulty breathing and looking blue are indications of hypoxia. E. Infection and fever are indications of hypoxia. F. Bronchitis and chronic obstructive pulmonary disease are indications of hypoxia. (Evolve Online Course, Module 8: Airway Management)

Answers: A, B, C, D. Indications of hypoxia include restlessness, anxiety, confusion, disorientation, altered consciousness as well as increases in pulse rate, respiration rate, and blood pressure. Feeling out of breathe and looking blue also indicate hypoxia.

The nurse walking down the hospital corridor glances into the patient's room and sees the patient's feet and legs sticking out from the bathroom entrance. The nurse immediately goes into the room and determines that the patient has fallen. What actions should be taken? (Select all that apply.) A. Call for assistance. B. Assess for injury. C. Notify the health care provider. D. Avoid moving the patient until the health care provider arrives. E. Assess the situation for precipitous factors (e.g., hypotension, slippery footwear, etc.). F. Apply a restraint after returning the patient to bed. G. Fill out an incident report. (Evolve Online Course, Module 1: Safety)

Answers: A, B, C, E, G. The nurse should first call for assistance and assess the patient for injury. The nurse should stay with the patient until assistance arrives to help lift the patient to the bed or to a wheelchair. The health care provider should be notified. The patient may be moved to a bed or wheelchair before the health care provider arrives. The nurse should note pertinent events related to the fall and resultant treatment in the patient's medical record. The facility's incident reporting policy should be followed. The nurse will reassess the patient and environment to determine if the fall could have been prevented. The nurse may then reinforce identified risks with the patient and review safety measures needed to prevent a fall. The use of restraints requires a health care provider's order.

Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.) A. A patient who had maxillofacial surgery. B. A patient who had trauma to the mouth. C. A patient with impaired swallowing from neurologic injury. D. A patient who has been diagnosed with lung cancer. E. A patient with an artificial airway who requires oral hygiene. F. A patient who has a nasogastric feeding tube. G. A patient with pneumonia. (Evolve Online Course, Module 8: Airway Management)

Answers: A, B, C, E. The Yankauer suction device is useful in the removal of secretions from the mouth in patients after oral and maxillofacial surgery, trauma to the mouth, neurovascular injury and/or cerebrovascular accident causing hemiparesis and drooling, or impaired swallowing. Patients with artificial airways and impaired swallowing ability may require use of the Yankauer suction device to promote oral hygiene. Patients with lung cancer or pneumonia may be able to cough up or swallow secretions on their own.

The patient is presently receiving intermittent tube feedings of 120 mL every 6 hours. The health care provider's orders state: Jevity formula feeding 240 mL every 6 hours per feeding tube, increase per patient tolerance. Which of the following assessment data indicate patient intolerance of the tube feeding and therefore inability of the rate to be increased? (Select all that apply.) A. Diarrhea B. Abdominal distention and discomfort C. Nausea D. Flatulence E. Thirst F. Residual volume greater than 250 mL (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: A, B, C, F. If the patient develops diarrhea three or more times in 24 hours, this indicates intolerance. Notify the health care provider and confer with the dietitian to determine the need to modify the type of formula, concentration, or rate of infusion. Tolerance is indicated by absence of nausea and diarrhea and by low gastric residuals. Residual volume indicates whether gastric emptying is delayed; 250 mL or more remaining in the patient's stomach may reflect delayed gastric emptying. Abdominal discomfort and distention may indicate intolerance to the tube feeding, possible from too rapid an infusion. Flatulence and thirst do not indicate an intolerance to tube feeding.

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A. SpO2 levels B. Amount of sputum production C. Change in respiratory rate and pattern D. Pain in lower calf area (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answers: A, B, C.

How does the nurse support a culture of safety? (Select all that apply.) A. Completing incident reports when appropriate B. Completing incident reports for a near miss C. Communicating product concerns to an immediate supervisor D. Identifying the person responsible for an incident (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: A, B, C. Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

A nursing student has been assigned to care for a patient who is confused and has repeatedly tried to get out of bed. The student is concerned that the patient will be injured. Which of the student's planned interventions are not appropriate for this patient? (Select all that apply.) A. Raising the bed to deter the patient from attempting to get out of bed B. Encouraging the patient to stay in bed by putting up all the side rails C. Blocking the patient's exit from the bed by using the over-bed table D. Sitting with the patient for extended periods of time (Lisa Ray Pre-Simulation)

Answers: A, B, C. Raising the bed constitutes a safety hazard and would put the patient at risk. The bed should be kept in the lowest possible position. Using full side rails would be considered a restraint and is not permissible. Blocking the bed with the table is considered imprisoning and presents a possible source of injury and therefore cannot be done. Sitting with the patient is the only intervention that would be appropriate in this situation. Sitting with the patient may increase their level of orientation and reduce fears, thus reducing attempts to ambulate alone.

Which of the following is a potential complication for a patient who is having nasotracheal suctioning? (Select all that apply.) A. A significant drop in oxygen concentration. B. A decrease in heart rate. C. Dysrythmias. D. Coughing during and after suctioning E. Less secretions in the airway. (Evolve Online Course, Module 8: Airway Management)

Answers: A, B, C. The patient is at risk for developing hypoxemia at any point from assessment of airway secretions to a short time after the suctioning procedure. The suctioning procedure itself removes oxygen from the airways. A patient may experience bradycardia as a result of vagal stimulation. Dysrhythmias are a potential complication of nasotracheal suctioning. Coughing is an expected outcome of nasotracheal suctioning and will aid in clearing the airways.

Before performing endotracheal suctioning, the nurse presses the sigh mechanism on the mechanical ventilator. Why does the nurse do this? The nurse is: (Select all that apply.) A. preoxygenating the patient. B. offsetting the volume of oxygen lost during the suction procedure. C. compensating for the interruption in mechanical ventilation. D. preventing the development of atelectasis. (Evolve Online Course, Module 8: Airway Management)

Answers: A, B, C. The purpose of preoxygenating the patient whether intubated or not, is to compensate for the loss of oxygen during the procedure.

The daughter of an elderly patient comes to visit her mother who was recently admitted to the hospital. The daughter notices a yellow band on her mother's wrist and asks what it is for. The nurse correctly responds that it is used to identify patients who are at risk for falling and provides additional information as to what makes a patient a fall risk. What information should the nurse include? (Select all that apply.) A. Age over 65. B. New and different environment. C. Continent of urine and bowel. D. History of a fall. E. Having an IV. F. Taking muscle relaxants. (Evolve Online Course, Module 1: Safety)

Answers: A, B, D, E, F. Age over 65, being in an unfamiliar environment, having a recent history of a fall are all risk factors for a fall. Incontinence or frequency/urgency are additional risk factors, as well as being attached to equipment. Polypharmacy and certain medications such as muscle relaxants increase one's risk for a fall.

Which of the following places the patient at risk for aspiration pneumonia? (Select all that apply.) A. Pocketing of food B. Fatigue C. Cough D. Distractions E. Poor oral hygiene (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answers: A, B, D, E. Pockets of food may be found inside the cheeks when the patient has difficulty moving food from the mouth into the pharynx. The patient is usually unaware of pocketing, which may lead to aspiration. Chewing and sitting up for feeding accelerate the onset of fatigue. Fatigue increases risk for aspiration, and eating may lead to aspiration. Poor oral hygiene can result in decayed teeth, plaque, and periodontal disease and can cause growth of bacteria that can be aspirated. Environmental distractions and conversations during mealtime increase the risk for aspiration. (REF: p. 771-772)

Which of the following are appropriate measures to help the patient with dysphagia to swallow and prevent aspiration? (Select all that apply.) A. Add thickener to thin liquids. B. Place food on the unaffected side of the mouth. C. Provide the patient with a lap protector. D. Place the patient in the high-Fowler's position. E. Provide verbal coaching. F. Talk about other matters while feeding the patient. (Evolve Online Course, Module 1: Safety)

Answers: A, B, D, E. Patients with dysphagia (impaired swallowing) require special precautions to prevent aspiration. Maintaining an upright position to enhance the effects of gravity is important. When feeding the patient, the nurse should place food on the unaffected side of the mouth (as in patients with hemiparesis) and observe the swallowing event closely for delays. Providing verbal coaching throughout the swallowing process can greatly help the patient swallow more effectively. Food that is the consistency of mashed potatoes is easiest for patients with dysphagia to swallow. Liquids and solids are more likely to pose a threat. In some cases, thickeners may be added to food or fluids to increase the consistency and thus allow the patient more control of the volume in the mouth. Distractions should be reduced, and therefore it is more important to keep the patient focused on swallowing when talking. The nurse may provide encouragement to increase the patient's confidence in the ability to swallow. Although a lap protector may be used, it will not influence the ability to reduce aspiration. Instead have suction equipment available.

The nurse checks the patient's extremity restraints hourly. What is the nurse looking for related to this type of restraint? (Select all that apply.) A. Distal pulses. B. Temperature of the skin distal to the restraint. C. Whether the patient wants the restraints released. D. Proper placement of the restraint. E. The character of respirations. F. Sensation of the distal part of the extremity. G. The patient's blood pressure. H. Color of skin distal to the restraint. (Evolve Online Course, Module 1: Safety)

Answers: A, B, D, F, H. The restraint should be checked at least every hour or according to facility policy for proper placement, and the patient should be evaluated for pulse, temperature, color, and sensation of the distal part of the extremities. The restraints should be released every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance. With regard to extremity restraints, routine assessment of the patient's blood pressure or character of respirations is unnecessary unless the patient's condition indicates otherwise.

Which of the following patients may benefit from enteral nutrition? (Select all that apply.) A. A patient who has a brain injury B. A patient with oral cancer C. A patient with paralytic ileus D. A patient with burns of the lower extremities (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: A, B, D. Patients with brain injury or an altered or reduced level of consciousness and patients with neuromuscular diseases who have a high incidence of aspiration may benefit from long-term enteral therapy. Patients with head or neck cancer may be candidates for enteral nutrition. A patient with paralytic ileus has a nonfunctional GI tract, and enteral nutrition is inappropriate. Some patients have an increased metabolism as a result of sepsis or burns and are unable to ingest enough calories to meet their bodies' metabolic needs. These patients may also benefit from enteral nutrition.

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply): A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. C. Avoid discussion of the patient's favorite foods. D. Remind the patient that a lot of damage has already occurred. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: A, B, E, F. Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

A patient is admitted to a medical unit with pneumonia. She is able to ambulate on her own to the bathroom. What safety precautions should be taken for this patient? (Select all that apply.) A. Explain the use of the call light. B. Keep the bed in the low, locked position. C. Keep all side rails up when patient is in bed. D. Place a bedside commode near bed. E. Ensure that the pathway to the bathroom is clear. F. Keep patient's personal items (e.g., book, reading glasses, watch, comb) on the over-bed table. (Evolve Online Course, Module 1: Safety)

Answers: A, B, E, F. To promote safety for a recently admitted patient who is able to ambulate, the nurse should explain the use of the call light keeping it in an accessible location for the patient. Keep the bed in a low, locked position. Keep the pathway clear to reduce the likelihood of the patient falling over objects or bumping into them. Side rails may be considered a restraint device when used to prevent the ambulatory patient from getting out of bed. The nurse may ask the patient if she would like to have one side rail up. The patient is ambulatory; therefore, offering a bedside commode would be unnecessary. Necessary items such as eyeglasses should be placed within the patient's easy reach, such as on the over-bed table. This facilitates independence and self-care and prevents falls that occur when a patient reaches too far.

The nurse is providing an in-service on patient safety and reducing the risk of patient falls. What information should the nurse include in this discussion? (Select all that apply.) A. Organize a predictable daily routine that alternates activity and rest for the patient. B. Respond promptly to a patient's call light. C. Discourage family from staying with the patient at night. D. Push the wheelchair in a forward direction out of the elevator. E. Keep the bed in a low locked position. (Evolve Online Course, Module 1: Safety)

Answers: A, B, E. Reducing the risk of falls includes measures of providing a restraint free environment, such as keeping the patient's daily routine predictable with alternate periods of activity and rest, teaching the patient how to use the call light and responding to it promptly, and encouraging family members or a sitter to stay with the patient, especially at night. Other safety measures include backing a wheelchair in and out of the elevator and keeping the bed in a low, locked position.

An elderly woman is hospitalized with pneumonia and anemia, and has a history of heart failure. She is weak and has a poor cough effort. Her current vital signs are temperature 100.2 ˚F (37.9 ˚C), pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.) A. Anemia B. Tachycardia C. Increased secretions with weak cough. D. Impaired cardiac function. E. Shortness of breath. F. Pneumonia (Evolve Online Course, Module 8: Airway Management)

Answers: A, C, D, F. Hypoxia results when there is inadequate tissue oxygenation at the cellular level. Lowered oxygen-carrying capacity from anemia can lead to hypoxia. A diminished concentration of inspired oxygen, such as with an obstructed airway from secretions, results in lowered oxygen saturation. Impaired cardiac function results in poor tissue perfusion with oxygenated blood. With pneumonia there is decreased diffusion of oxygen from the alveoli to the blood, leading to inadequate tissue oxygenation. An increase in pulse rate is an adaptive response to meet the body's oxygen demand. Shortness of breath (dyspnea) is a symptom of decreased oxygenation.

An older client admitted to the hospital from the nursing home refuses to eat anything on her meal tray. What instructions will the nurse give to the nursing assistant who is attempting to feed the client? Select all that apply. A. "Feed her the soft food because she has no teeth." B. "Place the fork in her hand and leave the room." C. "Sit at her level so that she can feel more comfortable." D. "Take your time feeding her and don't rush her." E. "Offer her the Ensure supplement instead of feeding her." F. "Ask the client what foods she likes and dislikes." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answers: A, C, D, F. The client does not have any teeth to chew food, so to prevent choking, the nursing assistant should feed her only soft food that does not require chewing. Sitting face to face with or at the same level of the client can help make her feel comfortable during mealtimes, thus providing more support and possibly resulting in the client choosing to eat. The nursing assistant should also take her time while feeding the client for safety reasons and to support the client. Individuals are more likely to eat when given a choice in food selections that consider their likes and dislikes. A client who refuses to eat will not likely eat when left alone. Also, if the client is confused or disoriented, a fork may be dangerous. A balanced nutrition meal should be encouraged before using supplements. Reference: p. 1344, Health Promotion and Maintenance

If a patient has dysphagia (difficulty swallowing), which of the following foods found on the patient's tray may be cause for concern or require further intervention? (Select all that apply.) A. Grape juice. B. Oatmeal. C. Sausage patty. D. Toast with butter. E. Scrambled eggs. (Evolve Online Course, Module 1: Safety)

Answers: A, C, D. A patient with dysphagia should have thickener added to thin liquids such as grape juice to create the consistency of mashed potatoes. Thin liquids such as water and fruit juice are difficult to control in the mouth and are more easily aspirated. A patient with dysphagia should have foods that require little chewing (i.e., pureed foods), and if this is tolerated, then the patient may advance to foods that require more chewing and to thinner liquids.

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? (Select all that apply.) A. Do not study in your bed. B. Go to sleep each night whenever you feel tired. C. Turn off your cell phone at bedtime. D. Avoid drinking coffee or soda before bedtime. E. Turn on the television to help you fall asleep. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A, C, D. Adolescents need to practice good sleep hygiene practices. Beds should be used for sleeping only. Activities other than sleep should not be done in bed. A person should try to go to bed at the same time each night. Create an environment that is quiet and free of distractions. Turning off cell phones prevents sleep disruptions. Coffee or soda contains caffeine. Caffeine acts as a stimulant, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.

Enteral feedings may be administered by: (Select all that apply.) A. Continuous feeding pump B. Through a large vein C. Intermittent gravity drip D. Large-bore syringe (bolus) E. Through a central vascular access device (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: A, C, D. Enteral feedings may be administered continuously using a feeding pump, intermittently by gravity drip, or by bolus through a large-bore syringe. Enteral feedings should never be administered intravenously. Parenteral nutrition is administered through a large vein as with a central vascular access device.

A patient has been recently admitted to the hospital. What indications, if observed, may suggest that the patient has dysphagia (difficulty swallowing)? (Select all that apply.) A. Persistent drooling. B. Drowsiness. C. Change in voice after swallowing. D. Wet, gurgly voice. E. Loss of appetite (Evolve Online Course, Module 1: Safety)

Answers: A, C, D. The nurse should assess the patient for difficulty swallowing. The presence of drooling; problems with speech; and a wet, gurgly voice indicate difficulty with muscle control and may put the patient at risk for aspiration. Loss of appetite does not indicate difficulty swallowing. Although the nurse should ensure that the patient is fully awake before feeding, drowsiness does not indicate dysphagia.

The nurse is gathering a sleep history from a patient who is being evaluated for obstructive sleep apnea. Which common symptoms does the patient most likely report? (Select all that apply.) A. Headache B. Early wakening C. Excessive daytime sleepiness D. Difficulty falling asleep E. Snoring (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A, C, E. Common symptoms for obstructive sleep apnea include headache, snoring, and excessive daytime sleepiness caused by poor sleep during the night. The other symptoms are not related to obstructive sleep apnea.

The nurse is attempting to administer medication through a feeding tube but is unable to do so because of a blockage in the tube. What action(s) should the nurse take? (Select all that apply.) A. For a newly inserted tube, notify health care provider and obtain x-ray confirmation of positioning. B. Clamp the tube and try again at a later time. C. For an established tube, attempt to flush tube with large-bore syringe and warm water. D. Soak the end of the tube in warm water. E. If unable to flush, contact health care provider for replacement of tube and potential need to reroute medication. F. Have the patient place the chin to the chest and swallow. (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: A, C, E. If the patient is unable to receive medication because of blockage in the tube, for a newly inserted tube, the nurse should notify the health care provider and obtain x-ray confirmation of positioning. The nurse should attempt to flush tube with large-bore syringe and warm water to clear clog. (The nurse should avoid using a small-bore syringe because this exerts large amounts of pressure and may rupture tube.) If unable to flush clog, the nurse should contact the health care provider for replacement of tube and potential need to reroute medication if dose cannot be skipped or delayed. Clamping the tube and waiting until later would only delay medication administration. A clog in the tube should not cause respiratory symptoms. Soaking the tube in warm water is inappropriate and will not clear a blockage. Having the patient flex the chin to the chest and swallow will not resolve a clogged feeding tube.

The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) A. Sit the patient upright in a chair. B. Give liquids at the end of the meal. C. Place food in the strong side of the mouth. D. Provide thin foods to make it easier to swallow. E. Feed the patient slowly, allowing time to chew and swallow. F. Encourage patient to lie down to rest for 30 minutes after eating. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answers: A, C, E. Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. Feed the patient with dysphagia slowly, providing smaller-size bites, and allow the patient to chew thoroughly and swallow the bite before taking another. Position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. If the patient has unilateral weakness, teach him or her and caregiver to place food in the stronger side of the mouth. Additional interventions include providing a 30-minute rest period before eating. Have the patient slightly flex the head to a chin-down position to help prevent aspiration. Determine the viscosity of foods that the patient tolerates best through the use of trials of different consistencies of foods and fluids. Thicker fluids are generally easier to swallow. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient’s readiness. If the patient begins to cough or choke, remove the food immediately.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing the following laboratory results: (Select all that apply): A. Body mass index (BMI) of 17. B. Waist-to-hip ratio of 1.0. C. Weight loss of 6% since last month's visit. D. Prealbumin level of 16 mg/dL. E. Hematocrit level of 50%. F. Hemoglobin level of 8.2 g/dL. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: A, C, F. A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.

A patient is to receive conscious sedation for a minor surgical procedure. Which drug administration should the nurse expect? (Select all that apply.) A.Propofol (Diprivan) to sustain natural sleep B.Lidocaine (Xylocaine) to provide local anesthesia C.Midazolam (Versed) to promote sedation and following of commands D.Ketamine (Ketalar) for rapid induction and prolonged duration of action E.Phenobarbital (Luminal) for short-acting duration of sleep (Kee: Pharmacology, 8th Edition, Chapter 21)

Answers: A, C.

A patient has severe rheumatoid arthritis affecting her hands. What measures can be taken to facilitate optimum nutrition? (Select all that apply.) A. Determine the patient's food preferences. B. Provide the patient with finger foods such as raisins, nuts, grapes, and cheese cubes. C. Identify the food location on the plate as if it were a clock. D. Provide adaptive utensils (e.g., large handles). E. Attach a plate guard to the plate. (Evolve Online Course, Module 1: Safety)

Answers: A, D, E. Determining the patient's food preferences promotes the patient's appetite, regardless of physical ability. Providing adaptive utensils can enable the patient to remain independent in eating. Large-handled utensils facilitate a patient with a poor grasp. A plate guard enables a patient to push the food up against the plate guard so as to fill the fork or spoon. Finger foods that are small may be more difficult for a patient with a poor hand grasp to obtain. A patient with visual impairment may benefit from having the location of food identified on the plate as if it were a clock.

Which of the following are appropriate safety measures for the use of a wheelchair? (Select all that apply.) A. Brakes on both wheels are locked when the patient is being transferred into the wheelchair. B. Brakes on the side nearest the bed are locked when the patient is being transferred into the wheelchair. C. Keep footplates lowered for transfer into the wheelchair. D. Back the wheelchair into and out of an elevator. E. Stand behind the wheelchair when going down a ramp or incline. F. Seat the patient in the wheelchair with buttocks against the back of the seat. (Evolve Online Course, Module 1: Safety)

Answers: A, D, F. To keep the chair steady and secure, the brakes on both wheels must be locked securely when a patient is transferred into or out of a wheelchair. The footplates should be raised before the transfer so that they are not a trip hazard and should be lowered, placing the patient's feet on them, after the patient is seated so that the patient's feet will be supported with movement of the wheelchair. The wheelchair should be backed into and out of an elevator, with rear large wheels first. This makes a smoother ride and prevents smaller wheels from catching in the crack between the elevator and the floor. When navigating on a ramp or incline, the nurse turns so that the chair pushes against the nurse's body, which is between the chair and the bottom of the ramp. This prevents a runaway wheelchair that can pull away and roll faster down the ramp than intended. The patient should be seated with buttocks well back in the seat, and a seat belt or wedge cushion may be used if available to protect the patient from sliding out of the chair.

For safe administration of oral medications through a feeding tube, specific attention must be paid to: (Select all that apply.) A. Proper placement of the tube B. The patient's weight C. Whether the medication can be crushed for administration through the tube D. The patient's electrolyte status (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: A, D. For safe administration of oral medications through a feeding tube, specific attention must be paid to proper placement of the tube and whether the medication can be crushed for administration through the tube. The patient's weight and electrolyte status do not require specific attention regarding medication administration through a feeding tube.

Which of the following can be delegated? (Select all that apply.) A. Transfer from bed to chair. B. Determining a dependent patient's risk for aspiration. C. Completing a fall risk assessment tool. D. Applying restraints. E. Moving a patient with an acute spinal cord injury up in bed. (Evolve Online Course, Module 1: Safety)

Answers: A, D. The skills of safe and effective transfer from bed to chair can be delegated to NAP who have successfully demonstrated good body mechanics and safe transfer techniques for patients involved. The assessment of a patient's risk for aspiration and determination of positioning cannot be delegated. Assessment for risk of fall or injury requires the critical thinking and knowledge application unique to the nurse and should never be delegated. Application of restraints may be delegated to NAP. However, assessment of when restraints are needed and the appropriate type to use requires the critical thinking and knowledge application unique to the nurse and should never be delegated. The nurse should assist and supervise when moving patients who are transferred for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma.

The nurse is caring for an elderly person who has suffered a stroke and now has left side weakness and dysphagia. The nurse is being very careful to prevent the patient from aspirating by taking which of the following measures? (Select all that apply.) A. Having the patient maintain an upright position for 30 to 60 minutes after eating. B. Placing the food on the patient's left side of the mouth. C. Placing the food in the middle of the tongue toward the back of the mouth. D. Having the patient tilt her head forward slightly when swallowing. E. Placing 1 tablespoon of food in the patient's mouth and following it with liquid. (Evolve Online Course, Module 1: Safety)

Answers: A, D. To help avoid aspiration or regurgitation, a patient with dysphagia should be maintained in an upright position for 30 to 60 minutes after eating. One-half to one teaspoon of food should be placed on the unaffected side (in this case, the right side) of the mouth, and the patient's head should be flexed slightly forward.

Which of the following concepts would a nurse think has the strongest link to safety? (Select all that apply): A. Cognition. B. Communication. C. Quality. D. Regulation. E. Teamwork. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answers: B, C, D, E. Communication, quality, regulation, and teamwork are the concepts with the strongest links to safety and include processes that are essential for the nurse to consider related to safety. Safety refers to the prevention of injuries or freedom from accidents. Quality and safety are interrelated, overlapping concepts, and it is difficult to achieve outcomes in one without working on the other. Regulation refers to the mandates that have been credited with many of the improvements in health care systems, such as those from the Joint Commission, and to the oversight for the safety of the public provided by state boards of nursing. Teamwork and the ability of health care professionals to work together account for as much as 70% of health care errors. Cognition dependent on an optimally functioning brain could affect vigilance but would not be considered a concept that has one of the strongest links to safety.

A nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. A. "Begin a weight-training program for building muscle mass." B. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." C. "Eat a variety of foods, especially grain products, vegetables, and fruits." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." F. "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answers: B, C, D, E. Consuming a diet that is moderate in salt and sugar and low in fats and cholesterol is a smart strategy for a person who wants to lose weight.

Situation: A 45-year-old obese woman with a body mass index (BMI) of 30 has high blood pressure. After a complete physical examination, her health care provider places her on a diuretic and also prescribes orlistat (Xenical) 60 mg orally three times a day. She takes this medication for 4 weeks, losing only 10 pounds. The health care provider doubles the amount of Xenical and recommends behavioral changes. A nurse is teaching the client appropriate behavioral changes. What is included in the teaching plan? Select all that apply. A. Cognitive restructuring to learn negative coping statements B. Keeping a daily food diary C. Identifying emotional and situational factors that stimulate eating D. Increasing exercise E. Seeking behaviors in others that one can model (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answers: B, C, D. Cognitive restructuring involves modifying negative beliefs by learning positive coping self-statements.

Which of the following statements regarding nasotracheal suctioning are true? (Select all that apply.) A. This procedure can be delegated to NAP. B. Sterile technique is required. C. Suction should be applied intermittently as the catheter is removed. D. The suction catheter should be rotated as it is withdrawn. E. Clean technique may be used. (Evolve Online Course, Module 8: Airway Management)

Answers: B, C, D. Sterile technique is required for nastotracheal suctioning to prevent introducing microorganisms into the trachea. Suction is applied intermittently and the catheter is rotated as it is removed to prevent adherence of the mucosa to the suction catheter and to facilitate removal of secretions. Nasotracheal suctioning should not be delegated to NAP. NAP may perform oropharygeal suctioning where clean technique is used.

An elderly patient was recently admitted to a medical unit with severe fluid and electrolyte imbalance. His family states that he has periods of confusion. What are some practical precautions the nurse can take to ensure the patient's safety without having to use restraints? (Select all that apply.) A. Use a security camera to monitor when the patient tries to get out of bed. B. Use a battery-operated alarm attached to the patient's leg. C. Use a weight-sensitive alarm placed under the patient in a chair or in bed. D. Use a tether alarm attached to a chair, bed, or doorway and clipped to the patient's garment. E. Increase infusion of IV fluids to reverse fluid imbalance. (Evolve Online Course, Module 1: Safety)

Answers: B, C, D. You may use a bed or chair alarm such as a battery-operated alarm attached to the patient's leg; a weight-sensitive alarm placed in the patient's chair or bed; or a tether alarm attached to a chair, bed, or doorway and clipped to the patient's garment. Each of these alarms would alert the staff to the patient getting up without assistance. Although some health care facilities may have rooms equipped with security cameras and have the staff to monitor them, it is unlikely in most settings. The infusion of fluids is determined by a health care provider and will not necessarily reverse confusion quickly.

The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following actions would indicate a break in sterile technique? (Select all that apply.) A. The nurse applies a sterile glove to the dominant hand and a nonsterile glove to the nondominant hand. B. As the nurse places the sterile basin on the bedside table, the nurse touches the inside of the basin with the nonsterile glove. C. The nurse uses the same suction catheter to suction the oral cavity followed by the endotracheal tube and then discards the suction catheter inside the gloves into an appropriate receptacle. D. The nurse picks up the catheter with the dominant hand, then picks up the connecting tubing with the nondominant hand and secures the catheter to the tubing. (Evolve Online Course, Module 8: Airway Management)

Answers: B, C. The nurse should avoid touching the inside of the sterile basin with the nonsterile glove as this would contaminate the sterile basin. The nurse should not use the same suction catheter to suction the mouth and then the trachea as this would introduce microorganisms into the trachea. The nurse may suction the trachea first, followed by the oral route using the same catheter.

An person of Northern heritage is at an increased risk for which of the following: (Select all that apply): A. Vitamin C deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. hypertension F. metabolic syndrome (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: B, C. Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, Hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

What are some examples of "verbal coaching" that can be used when feeding the adult dependent patient who has difficulty swallowing? (Select all that apply.) A. "Green beans are very nutritious." B. "Open your mouth." C. "Let's turn on the television and see what's cooking on the Food Network." D. "Raise your tongue to the roof of your mouth." E. "Close your mouth and swallow." (Evolve Online Course, Module 1: Safety)

Answers: B, D, E. Verbal coaching may consist of something like the following: "Open your mouth. Feel the food in your mouth. Chew and taste the food. Raise your tongue to the roof of your mouth. Think about swallowing. Close your mouth and swallow. Swallow again. Cough to clear the airway." It is important to respect the patient's dignity and to keep the patient focused on the task at hand. Distractions should be minimized.

The nurse is providing health teaching for a patient using herbal compounds such as melatonin for sleep. Which points need to be included? (Select all that apply.) A. Can cause urinary retention B. Should not be used indefinitely C. May cause diarrhea and anxiety D. May interfere with prescribed medications E. Can lead to further sleep problems over time F. Are not regulated by the U.S. Food and Drug Administration (FDA) (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: B, D, F. Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and promote sleep. Short-term use of melatonin has been found to be safe, with mild side effects of nausea, headache, and dizziness occurring infrequently. Caution patients about the dosage and use of herbal compounds because the FDA does not regulate them. Herbal compounds may create interactions with prescribed medication, and patients need to avoid using these together.

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

Which of the following medications should never be given through a feeding tube? (Select all that apply.) A. Liquid medications B. Elixirs C. Sublingual tablets D. Enteric-coated (EC) E. Sustained release (SR) F. Extended release (XR) G. Long acting (LA) H. Large tablets or pills (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: C, D, E, F, G. Liquid medication and elixirs are the best choice to administer through a feeding tube, but some medicines only come in tablet form. Most tablets may be crushed; however, those that are sublingual, enteric-coated, sustained release, extended release, or long acting should never be given by tube because their absorption, metabolism, and effectiveness will be unpredictable. As long as large tablets or pills are capable of being crushed, they may be administered through a feeding tube.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: C, D, E, F, G. Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

In the change of shift report, the nurse was told a patient requires "minimal assistance with meals." What should the nurse expect to do for the patient at mealtime? (Select all that apply.) A. Place the meal tray in the room, leave the room, and return in 30 minutes to remove the tray. B. Feed the patient. C. Open packages and cartons. D. Assist the patient to an upright position. E. Ask the patient if he or she needs the nurse to cut up the food or butter the bread. F. Document the intake. (Evolve Online Course, Module 1: Safety)

Answers: C, D, E, F. The patient requires some assistance but is able to feed himself or herself. The nurse should position the patient appropriately for safe eating and assist the patient with setting up the meal tray: open packages, cut up food, apply seasonings/condiments, butter bread, and place a napkin. If appropriate, the nurse may place adaptive utensils on the tray and instruct the patient in their use. The patient should be encouraged to remain as independent as possible in self-feeding. A patient who is able to eat without assistance may have the correct tray left to be picked up when the patient is finished. Whether the patient is independent or requires assistance, the nurse should document the intake.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives with the family that are appropriate for this patient. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

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

A patient is receiving a continuous enteral feeding by infusion pump. The nurse enters the patient's room to verify tube placement and measure residual. The nurse notices the patient's respirations are shallow and rapid and that the patient's color is ashen. The nurse notes rhonchi upon auscultation, and the patient appears to be coughing up sputum of a color similar to the formula feeding. What action(s) should the nurse take? (Select all that apply.) A. Ask if the patient feels short of breath. B. Administer oxygen. C. Turn off the tube feeding. D. Have the patient deep breathe and cough. E. Position the patient in Fowler's position and suction the patient. F. Position patient on the left side and suction the patient. G. Notify the health care provider. H. Prepare for chest x-ray examination. (Evolve Online Course, Module 15: Enteral Nutrition)

Answers: C, E, G, H. The patient has aspirated formula. The nurse should turn off the tube feeding immediately, position the patient in Fowler's position, suction, and notify the health care provider immediately. The nurse may prepare the patient for chest x-ray examination. It is unnecessary to ask the patient about feeling short of breath because it is apparent. Having the patient deep breathe and cough will fail to help at this time. Placing the patient on the side will fail to improve respiratory status. A health care provider's order is required before administering oxygen (follow facility policy; some facilities may allow the nurse to initiate oxygen).

Which of the following should be avoided for the patient consuming a dysphagia mechanically altered diet? A. Moist cake B. Canned peaches C. Peanut butter D. Spaghetti (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

The basis of the dysphagia mechanically altered diet is that foods are moist and easily form a bolus to facilitate swallowing. Canned fruit and soft noodles are allowed. Sticky foods such as peanut butter are not allowed because it is difficult for the patient to form a bolus that can be easily swallowed.(REF: p. 769-770)