Nursing 1 Final Part 3

Which treatment modality would be ideal for a patient who wishes to try CAM to relieve stress but has limited financial resources? A. Herbal therapy B. Chiropractic manipulation C. Homeopathy D. Meditation

D. Meditation Rationale: Meditation is an intervention that would acknowledge the connection between mind and body. It does not cost anything and can be done independently.

Rectal medications are sometimes administered into a colostomy stoma in certain patient situations.

True Rationale: Absorption of medication can still occur in the segment of the colon that is brought to the abdominal wall.

A goal of administering albumin intravenously is to increase oncotic pressure in the vascular space.

True Rationale: Albumin is a large serum protein that draws fluid into the vascular space.

It is important for nurses to accept patients' beliefs about complementary and alternative medicines.

True Rationale: Although a nurse may not agree with the therapy, a nurse's goal is to maintain a therapeutic dialogue with the client.

It is important for the nurse to assess the results of the serum blood urea nitrogen and serum creatinine lab tests for the patient receiving certain chemotherapy agents.

True Rationale: Chemotherapy agents can also be nephrotoxic.

Inadvertently administering an insulin injection into the deltoid would alter a pharmacokinetic process in relationship to that drug.

True Rationale: Correct administration of insulin is via the subcutaneous route. Administration of insulin into a muscle would increase the pharmacokinetic process of absorption because of the increased blood supply in that area.

A thorough assessment of the patient's educational needs and learning-style preferences should be conducted before beginning any patient teaching session.

True Rationale: For health teaching to be effective, the nurse needs to know what the patient needs and wants to learn. If the teaching is not geared toward mutually defined goals, it will not be useful to the patient. Knowing the way a person best takes in and retains information is the best way to plan a teaching session.

A meconium stool in a 1-day-old infant is a normal finding.

True Rationale: Meconium is green-black, tarry, and sticky and odorless. It is formed by swallowed mucus, hair, and amniotic fluid. It has no odor. Stools transition to a yellow-green color over the next few days.

Certain medical conditions may prevent the use of imagery.

True Rationale: Patients who are cognitively impaired may not be able to use this therapy.

When applying an Ace wrap (roller bandage) to a limb, it is important to begin at the most distal point and wrap toward the body.

True Rationale: This prevents blood and fluid from becoming trapped in the most distal area.

Deeper level tissue damage, known as undermining, may be present in a stage IV pressure ulcer.

True. Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. Undermining and sinus tracts (blind tracts underneath the epidermis) are common. Exposed bone/tendon is visible or directly palpable. Slough or eschar may be present.

Piggyback

Used for intermittent IV medication delivery

Filter needle

Used for medication in an ampule

The nursing diagnosis Disturbed Sleep Pattern would be appropriate in the case of a patient who must be awakened every 2 hours for blood glucose monitoring.

True

When present in a limited amount, anxiety can be a positive factor in learning.

True

In determining the location, size, and density of the liver, the nurse uses the assessment skills of auscultation. True False

False Rationale: The assessment skill the nurse uses would be percussion.

The RN may delegate the collection of nutritional history information to the NAP.

False Rationale: The nurse aide may obtain height, weight, and document intake and output. The nurse must collect information related to the nutrition history.

The recommended daily intake of fiber is 10 to 15 grams.

False Rationale: The recommended intake is 25 to 30 grams a day.

Which core issue of spirituality includes a patient's basic human need for achievement? 1) Hope 2) Faith 3) Love 4) Forgiveness

1) Hope Rationale: Hope includes the basic human needs to achieve, create, and make something of one's life. Faith addresses our ongoing effort to make sense of our life and our purpose for being. With the aspect of love, we extend our love to others with hope of receiving love. Forgiveness is not a core issue of spirituality

During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teaching strategy? 1) Some people might have difficulty with an interactive approach when there is conflict among participants. 2) Nurses might rehearse responses that are not effective for resolving interpersonal conflict. 3) Nurses don't use the rehearsal technique because it's an inefficient use of time for participants. 4) This type of interactive teaching strategy is not as effective as dispersing information verbally or in print.

1) Rationale: The teaching strategy described is role-playing. Role-playing may cause participants to feel self-conscious; to be effective, participants must be willing to participate as an observer or role player, particularly in a situation in which there is conflict among those involved in the exercise. With role-playing, the participant may be unaware that teaching is occurring. The strategy can therefore be a productive use of time while modeling effective responses and desired behavior. Rehearsing real-life situations common to family dynamics is typically more effective for conflict resolution than reading about the topic or discussing approaches for effective communication.

After a patient dies of ovarian cancer, her daughter says to the nurse, "You'll probably think I'm terrible, but I'm glad she can finally rest peacefully." Which response by the nurse is best? 1) "Your feelings are a normal response to watching your loved one suffer." 2) "It's unusual for family members to be grateful that a loved one has died." 3) "Your mother's death has been very hard on you; you should seek counseling." 4) "I don't understand what you mean by this comment."

1) "Your feelings are a normal response to watching your loved one suffer." Rationale: The nurse should reassure the patient's daughter that her feelings are normal; there is no need for the daughter to seek counseling based on the information provided in this situation. Keep in mind that people can grieve in a dysfunctional manner for which they would benefit from counseling or other mental health support services. By responding, "It's unusual for family members to be grateful that a loved one has died," the nurse is being judgmental. The nurse who states she doesn't understand the family member's comment should at least seek clarification and prompt further exploration of the person's feelings. A comment of this nature can be a discussion starter for the daughter to release feelings and begin the grieving process.

Which of the following is considered a first-line intravenous solution for a patient with hypovolemia? 1) 0.9% NaCl (normal saline) 2) 0.45% NaCl (½ normal saline) 3) Dextran (a plasma expander) 4) D5W (5% dextrose in water)

1) 0.9% NaCl (normal saline) Rationale: Hypovolemia occurs when there is a proportional loss of water and electrolytes from the extracellular fluid. Normal saline is an isotonic fluid that remains inside the intravascular space, thus increasing volume. Solutions of 0.45% NaCl and D5W are hypotonic fluids and therefore would pull body water from the intravascular compartment into the interstitial fluid compartment, leading to cellular death. Dextran is a hypertonic fluid that pulls fluid and electrolytes from the intercellular and interstitial compartments into the intravascular compartment and can be used in cases of hypovolemia but is not considered as a first choice.

A patient who underwent surgery for removal of a pituitary tumor develops a condition in which the kidneys are unable to conserve water and the quantity of urine voided increases. Which urine specific gravity would the nurse expect to find in the patient with this disorder? 1) 1.001 2) 1.010 3) 1.025 4) 1.030

1) 1.001 Rationale: The patient with diabetes insipidus would have a low specific gravity, such as 1.001. This indicates dilute urine that results from poor concentrating ability of the kidneys. Normal urine specific gravity ranges from 1.010 to 1.025. A specific gravity of 1.030 indicates concentrated urine or deficient fluid volume (dehydration).

A patient is hospitalized with severe depression after her divorce is finalized. Which type of loss is the patient experiencing? 1) Actual 2) Perceived 3) Physical 4) External

1) Actual Rationale: The loss of a relationship is an actual loss. An actual loss is a reality that can be identified by others, not just by the person experiencing it. Perceived loss is internal; it can only be identified by the person experiencing the loss. Physical loss includes injuries, removal of an organ or body part, or loss of function. An external loss is an actual loss of an object.

The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patient's religion, for which religious practice should she expect to notify the hospital chaplain? 1) Anointing of Sick 2) Baptism 3) Eucharist 4) Sacrament of Reconciliation

1) Anointing of Sick Rationale: The sacrament of anointing of the sick is commonly referred to as last rites. It is performed on a seriously ill person and can be repeated if the person recovers and becomes ill later. The sacrament of the Eucharist is communion bread, Reconciliation is confession, and Baptism is the immersion in water practices as a symbol of being re-born and cleansed into Christ.

The head of the bed of a patient who is receiving enteral feedings is elevated to 45 degrees. Which complication associated with enteral feedings does this intervention help prevent? 1) Aspiration 2) Diarrhea 3) Infection 4) Electrolyte imbalance

1) Aspiration Rationale: The head of the bed (HOB) should be elevated to at least 30 to 45 degrees during enteral feeding administration to prevent regurgitation and aspiration. Maintaining an elevated HOB aids in digestion by helping the transit of feeding through the GI tract. Diarrhea, infection, and electrolyte imbalance are all complications associated with enteral feeding, but cannot be prevented by elevating the head of the bed.

What is the role of a nursing informatics specialist? Select all that apply. 1) Assists with planning for workflow changes with implementation of computer systems 2) Serves as a liaison between clinicians and information technologists 3) Analyzes a variety of types of data for clinical research 4) Identifies programming errors in information technology systems 5) Teaches healthcare team how to use the electronic health record system

1) Assists with planning for workflow changes with implementation of computer systems 2) Serves as a liaison between clinicians and information technologists 3) Analyzes a variety of types of data for clinical research 5) Teaches healthcare team how to use the electronic health record system Rationale: The nursing informatics specialist (NIS) works with informatics technicians and others to provide clinical information and data analysis for effective patient care. The nursing informatics specialist works closely with others on the healthcare care team, including physicians, technicians, and other specialty and general nurses and serves as a liaison with information technologists (ITs). NISs act as the translator between end-users and IT experts. In addition, the nursing informatics specialist works with computers, data analysis systems, and nursing knowledge and experience to be sure the best possible care is provided. Data collection, analysis of different types of data, information sharing, and research dissemination are functions of the NIS. In sum, the NIS uses nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice. Nursing informatics specialists' role in education and professional development ranges from teaching the end-user to use a device or software application for electronic health records. A computer technician [information technologist (IT)] supports computer hardware, software, networks, and programming within an institution.

A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth

1) Bathing water Rationale: Prior to prayer, Muslims participate in Wudhu, which includes ritualistic washing of the hands, feet, hair, mouth, nose, and ears. Cleanliness prior to prayer is a sign of respect to the Creator. Roman Catholics may want to hold their rosary beads while praying. Although rosary beads are commonly associated with Catholicism, many religions may use prayer beads or cloths a symbol of their religion. The mala is the Buddhist rosary beads. Some Buddhists and Hindus meditate with a set of beads, called a mala. The prayer cloth or "handkerchief" is used among several religions associated with Christianity. Others may use a prayer cloth or other religious items.

The home health nurse is reviewing several cases referred from a local physician's office. She must assess which services are eligible for home health coverage. Which one of the following will she select? 1) Care for a new wound that requires assessment and monitoring in a bed-bound patient 2) Assessment of a central venous access device in a patient who is able to drive 3) Patient teaching about diabetes and its management for an employed person 4) Homemaker services for a healthy, homebound older woman who tires easily

1) Care for a new wound that requires assessment and monitoring in a bed-bound patient Rationale: Only skilled services are eligible for coverage and reimbursement by most insurance policies. In addition, home care is provided only to homebound clients for care that the client or family is unable to provide. An ambulatory client is not homebound even though he may have a central venous access device. An employed person, too, would not be considered homebound. Homemaker services are available to clients only if the principal reason for home care is a skilled service, which would be unlikely for a healthy older woman who tires easily.

A patient asks about accessing informative and reliable patient education resources on the Internet. What resources would the nurse recommend? Select all that apply. 1) Centers for Disease Control and Prevention 2) National Institutes of Health 3) American Heart Association 4) Wikipedia 5) Healthcare blogs

1) Centers for Disease Control and Prevention 2) National Institutes of Health 3) American Heart Association Rationale: The American Heart Association, Centers for Disease Control and Prevention, and the National Institutes of Health are all credible Internet resources. Wikipedia and blogs are not considered to be an authority source for reliable health information. It is an open access Internet resource that submitted or modified by anyone.

What should the nurse do to maintain infection control in the home? Select all that apply. 1) Cleanse hands with antibacterial cleanser before and after patient care. 2) Use soap and water if your hands become grossly soiled. 3) If the home isn't clean, leave your home care bag in your car and take in only the supplies that you need. 4) Double bag all contaminated dressings and take them with you to your car. 5) Disinfect hard plastic items in a bag in the microwave, wrapped in moist paper towel.

1) Cleanse hands with antibacterial cleanser before and after patient care. 2) Use soap and water if your hands become grossly soiled. 3) If the home isn't clean, leave your home care bag in your car and take in only the supplies that you need. 5) Disinfect hard plastic items in a bag in the microwave, wrapped in moist paper towel. Rationale: Good handwashing is key to infection prevention. You should use antibacterial cleanser before and after patient care. You should use soap and water if your hands are grossly soiled. If they are not grossly soiled, antibacterial cleanser is preferred. If the home isn't clean, you should take in only the supplies you will need and leave your nursing bag in the car. You should not take soiled dressings from the home. They should be left in the home, secured in a biohazard bag, for disposal in the client's trash. To disinfect hard plastic items, you can use the microwave to destroy microbes. Wrap items in a wet paper towel and place in a zippered plastic bag. Microwave the entire bag on high for up to10 minutes, depending on the items.

What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

1) Decreased glomerular filtration rate Rationale: Glomerular filtration rate is the amount of filtrate formed by the kidneys in 1 minute. Renal blood flow progressively decreases with aging primarily because of reduced blood supply through the micro-blood vessels of the kidney. A decrease in glomerular filtration is the most important functional deficit caused by aging. Urate crystals are somewhat common in the newborn period. They might indicate that the infant is dehydrated. In older people, they result from too much uric acid in the blood, although this is not related to aging. Renal mass (weight) decreases over time, starting around age 30 to 40.

Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A lifelong journey involving accumulation of experience and understanding 4) Codes of conduct that integrate beliefs and values

1) Discussions and theories related to God and His relation to the world Rationale: Theology is best described as discussions and theories related to God and His relation to the world. Eschatology includes doctrines about the human soul and its relation to death, judgment, and eternal life. Spirituality is considered a lifelong journey. Religion provides codes of conduct that integrate beliefs and values.

One hour after receiving a dose of lispro insulin (Humalog), a patient begins sweating and develops tremors and dizziness. His blood glucose level signals hypoglycemia (low blood glucose). Which type of adverse reaction to insulin is this patient most likely experiencing? 1) Dose-related 2) Patient sensitivity 3) Allergic 4) Anaphylactic

1) Dose-related Rationale: Dose-related adverse effects occur when undesired effects result from known pharmacological effects of medication, such as those that occur as a result of the patient's insulin dose. Patient sensitivity occurs when a patient is unusually susceptible to the effects of the drug. In allergic reactions, the immune system identifies a medication as a foreign substance that should be neutralized or destroyed. An anaphylactic reaction is a life-threatening allergic reaction.

The community health nurse is evaluating the effectiveness of a program informing college females about the need for HPV vaccination. This nurse is functioning in what role? 1) Educator 2) Client advocate 3) Collaborator 4) Counselor

1) Educator Rationale: Because community nursing focuses on wellness and disease prevention, much of what the nurse does involves client education—of individuals, aggregates at risk of disease, politicians, or a community at large. Part of the role of educator is evaluating the effectiveness of teaching. As client advocate, the effective community health nurse consistently supports the identified or expressed concerns of the client and/or community. Advocating for the health needs affecting a community often requires political involvement at the local, state, or national level. In the role of collaborator, the community health nurse effectively addresses common concerns among different communities. As a counselor, the community health nurse establishes rapport with a group and consults about a variety of concerns, whether or not they are related to health. This program is about program evaluation and the effectiveness of teaching.

The ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making is known as which of the following? 1) Ethical agency 2) Attitudes 3) Belief 4) Value neutrality

1) Ethical agency Rationale: Ethical agency is the ability of nurses to base their practice on professional standards of ethical conduct and to participate in ethical decision making. Attitudes are mental dispositions or feelings toward a person, object, or idea. A belief is something that one accepts as true. Value neutrality occurs when we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgmental when providing care to clients.

A pregnant adolescent is in hypertensive crisis, and will likely die unless the obstetrician performs surgery to deliver the baby immediately. However, the baby is not mature enough to survive outside the uterus. The obstetrician believes that there is no good choice: either he risks harm to the mother or harm to the baby. This situation describes which of the following? 1) Ethical dilemma 2) Moral distress 3) Whistleblowing 4) Values conflict

1) Ethical dilemma Rationale: An ethical dilemma is a situation in which a choice must be made between two equally undesirable actions. There is no clearly right or wrong option. Moral distress occurs when a person makes but is unable to carry out a moral decision—no decision has been made in this scenario. A whistleblower is specifically defined as a person who identifies an incompetent, unethical, or illegal situation, or actions of others, in the workplace and reports it to someone who may have the power to stop the wrong. There is no values conflict because the value that the obstetrician is struggling with (probably sanctity of life) applies to both the mother and the baby.

When evaluating health information Internet sites, the nurse should do which of the following. Select all that apply. 1) Evaluate credibility of authorship. 2) Determine who the sponsor is. 3) Check links to original sources. 4) Examine currency of the content. 5) Note the target audience.

1) Evaluate credibility of authorship. 2) Determine who the sponsor is. 4) Examine currency of the content. 5) Note the target audience. Rationale: Not all Internet sites are created equal. There is no regulation on the quality of information posted on the Internet. Some sites are extremely useful sources of evidence-based information. For instance, many government-based sources provide sound information. Others do not. It is the responsibility of the reader to evaluate the credibility of the source of information. Sponsored Internet sites have the potential for commercial promotion and bias. Health information changes over time. It is important to realize the currency of content before making practice decisions or conducting patient teaching. Content is written at a level suited to the target audience.

When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the penis with an antiseptic wash. Which step should she take next? 1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. 2) Ask the patient to bear down as though trying to void. 3) Slowly insert the end of the catheter into the urinary meatus. 4) Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.

1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant. Rationale: The steps of the procedure for inserting an indwelling urinary catheter are as follows: The nurse should gently insert the tip of the prefilled syringe into the urethra and instill the lubricant. Then the nurse should ask the patient to bear down as though trying to void, as she slowly inserts the end of the catheter into the meatus. She should continue to insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows. When urine appears, she should advance the catheter 1 to 2 inches (2.5 to 5 cm) more. She should hold the catheter securely with her dominant hand while the urine flows. After urine flows, she should stabilize the catheter's position in the urethra and use the other hand to pick up the saline-filled syringe and inflate the catheter balloon.

A patient is admitted to the hospital with severe diarrhea. The patient should be monitored for which complication associated with diarrhea? 1) Hypokalemia 2) Hypocalcemia 3) Hyperglycemia 4) Thrombocytopenia

1) Hypokalemia Rationale: Diarrhea causes fluid loss and hypokalemia, not hypocalcemia, hyperglycemia, or thrombocytopenia.

A patient is brought to the emergency department (ED) by paramedics after a bystander saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP, 138/84 mm Hg; pulse, 135 beats/min, regular and strong; respiratory rate, 22 breaths/min; temperature, 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect? 1) Hypomagnesemia 2) Hyypocalcemia 3) Hyperkalemia 4) Hypernatremia

1) Hypomagnesemia Rationale: Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany. Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias. Hypernatremia, a high sodium level, produces extreme thirst and agitation.

Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incision site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue

1) Infection at the incision site Rationale: Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. A hematoma is a collection of blood that forms under the skin. It is usually tender or painful to the touch, and usually swollen. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. It is beefy red in appearance but would not be warm or tender to the touch.

Review the following: 38 years old; growth in height to 5′2″; female gender; weight gain of 15 pounds. This list can be referred to as which of the following? 1) Information 2) Knowledge 3) Data 4) Patient record

1) Information Rationale: The segments are grouped into a meaningful, structured form and are considered together as information. However, 38, 5′2″, female, 15 standing along would be examples of raw, unprocessed numbers, symbols, or words that have no meaning by themselves and therefore would be data.

The nurse administers a scheduled dose of heparin 5,000 units subcutaneously at 2100 and documents in the medication administration record that the dose was administered. What other information is important for the nurse document on the MAR? 1) Injection site 2) Previous site of administration 3) Patient response to medication 4) Heart rate prior to administration

1) Injection site Rationale: After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5,000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from previous dose and would not be noted in the entry for the current dose. The patient's response to medication is recorded in the nurse's narrative note in the traditional paper for electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician's order. Heparin does not affect heart rate.

Which body fluid lies in the spaces between the body cells? 1) Interstitial 2) Intracellular 3) Intravascular 4) Transcellular

1) Interstitial Rationale: Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial, intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells. Intracellular fluid is contained within the cells. Intravascular fluid is the plasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; and digestive juices.

As a home care nurse, you prepare for your visit to ensure your safety. Which of the following safety tips should you implement before or during your visit? Select all that apply. 1) Maintain your car in good repair. 2) Check your surroundings before you leave your car. 3) Allow the client's dog to sit next to you. 4) Try to interrupt the violent domestic argument, if possible. 5) Sit with the client where there is privacy.

1) Keep your car in good repair. 2) Check your surroundings before you leave your car. Rationale: As a home care nurse, you should prepare for you safety by making sure your car is in good repair and always being aware of your surroundings before leaving your car. You should ask the client to remove the pets from the area during your visit, if possible. You should leave the home if there is a domestic argument; do not attempt to intervene. Sit where you have access to an exit, just in case a situation would arrive where your safety is threatened. Your safety is the highest priority.

A patient is admitted with pyelonephritis. Which anatomic structure is affected by this disorder? 1) Kidneys 2) Bladder 3) Urethra 4) Prostate gland

1) Kidneys Rationale: Pyelonephritis is an infection of the kidneys. Cystitis is an infection involving the bladder. An infection of the urethra is known as urethritis. Prostatitis is an infection involving the prostate gland.

The student nurse is reviewing a patient's laboratory reports. Which of the following results should be reported to the primary care provider? 1) Na+ = 126 mEq/L 2) K+ = 3.8 mEq/L 3) Ca2+ = 9.2 mg/dL 4) Mg2+ = 1.8 mg/dL

1) Na+ = 126 mEq/L Rationale: Serum sodium of 126 mEq/L indicates significant hyponatremia. The student nurse should report the findings to the nurse with whom she is working (or the primary care provider, depending on agency policy) who will report the findings to the primary care provider. The other laboratory results are all within normal limits.

What are the barriers to nurses' access to online, evidence-based resources at the bedside? Select all that apply. 1) Time shortage 2) Demands of patient care 3) Nurses' motivation 4) Connectivity 5) Resistance of healthcare team for change

1) Time shortage 2) Demands of patient care 4) Connectivity 5) Resistance of healthcare team for change Rationale: League and colleagues (2012) studied nurses' use of evidence-based resources via the Internet. Although the nurse may be motivated to seek evidence-based support for nursing actions, barriers include insufficient time; demands of patient care; and access to the Internet on site. Seeking evidence-based support for clinical practice can lead to change in the implementation in care. Some people are slow to adopt change, and therefore, might resist seeking resources that could lead to new practices.

The patient's medical record contains the following documentation: 06/05/15 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge intravenous catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.———Ann Davids, RN Which type of charting has the nurse used? 1) Narrative 2) Focus 3) SOAP 4) PIE

1) Narrative Rationale: The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

Which of the following terms refers to the ethical questions that arise out of nursing practice? 1) Nursing ethics 2) Bioethics 3) Ethical dilemma 4) Moral distress

1) Nursing ethics Rationale: Nursing ethics refers to ethical questions that arise out of nursing practice. Bioethics is a broader field that refers to the application of ethics to healthcare. An ethical dilemma occurs when a choice must be made between two equally undesirable actions, and there is no clearly right or wrong option. Moral distress occurs when someone is unable to carry out his or her moral decision.

A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.

1) Palpating the bladder height. 3) Performing a bladder scan. 4) Asking the patient about his recent voiding history. Rationale: The nurse should palpate the bladder for distention. A bladder scan will yield a more accurate measurement of the postvoid residual urine. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care. A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection. Cranberry juice is sometimes used to in an effort to prevent urinary tract infection, although there is conflicting research to support this action. Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder and is usually unnecessary if the nurse has access to a portable bladder scanner.

Which of the following resources might the nurse use to update the hospital's diabetes patient education resources? Select all that apply. 1) Peer-reviewed nursing journals published within the past 3 years 2) Popular magazines published within the past 6 months 3) The American Diabetes Association Web site 4) An Internet blog that discusses innovative care for diabetes 5) Local medical center protocols for diabetes management

1) Peer-reviewed nursing journals published within the past 3 years 3) The American Diabetes Association Web site Rationale: Recently published scholarly nursing journals and the American Diabetes Association Web site are credible resources for patient education materials. Popular magazines and Internet blogs are not evidence-based resources. Clinical protocols of a local hospital might not relevant to the patient population in your institution. Plus, committees within the institution establish clinical protocols, which may or may not be adequately supported with evidence-based, authority sources. Documentation of evidence-based resources could be unclear.

When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which phase of wound healing? 1) Proliferative 2) Maturation 3) Aggregation 4) Inflammatory

1) Proliferative phase Rationale: The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. Granulation tissue forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.

According to William Worden, which task in the grieving process takes longest to achieve? 1) Realizing that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy

1) Realizing that the loved one is gone. Rationale: Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.

An agnostic nurse is caring for a devoutly religious patient. The client says, "I am so frightened. Please say a prayer with me." The patient begins praying aloud. What should the nurse do? 1) Remain quietly beside the bed until the client finishes the prayer. 2) Walk quietly from the room while the client is praying. 3) Stop the client and say, "I am not comfortable with prayer. I will get someone to join you." 4) Stay during the prayer and say "Amen" at pauses and when the prayer is finished.

1) Remain quietly beside the bed until the client finishes the prayer. Rationale: The nurse might choose to pray or not to; but the nurse must respect the client's dignity and provide spiritual support. Remaining at the bedside during prayer provides support for the client without compromising the nurse's beliefs. The nurse does not need to pray but merely should remain quiet and respectful while the client prays. Only if the client asks should the nurse say she is uncomfortable praying. Secretly exiting the room while the patient is praying is neither respectful nor honest. Participating in the prayer by interjecting and closing with "Amen" is also dishonest because the agnostic nurse does not believe in prayer.

What is the American Nurses Association's reason for recommending that home health nurses hold a baccalaureate degree? Home health nursing requires 1) a high level of autonomy and independence. 2) the ability to perform home safety assessments. 3) the collection of OASIS data for Medicare purposes. 4) careful attention to infection control matters.

1) a high level of autonomy and independence. Rationale: All of the options are true of home health nursing. However, American Nurses Association prefers a baccalaureate degree because home health nursing practice requires a high level of autonomy and independence.

As a home care nurse, after assessing your client's home for potential fall risk factors, you provide client teaching. Your education will include which the following? Select all that apply. 1) Request that the client remove all throw rugs. 2) Encourage the client to improve lighting along stairs. 3) Instruct which medications may cause dizziness. 4) Emphasize the need to wear shoes that fit properly. 5) Hold on to railing when using stairs while light-headed.

1) Request that the client remove all throw rugs; 2) Encourage the client to improve lighting along stairs; 3) Instruct which medications may cause dizziness; 4) Emphasize the need to wear shoes that fit properly. Rationale: All of these situations could create a fall risk for the client. Throw rugs on the floor can easily move and cause the client to slip and fall. Visual acuity in older adults is often compromised, particularly if cataracts are present. Good lighting can help to prevent stumbling on stair treads. Poor balance and gait instability are fairly common problems in older adults. Medications that cause dizziness aggravate an already compromised situation. The home health nurse can prevent a fall by informing the client which medications can lead to dizziness. Shoes that are too tight cause blisters, bunions, and corns, all of which cause pain and gait alterations. Shoes that are too loose slip around and can cause a person to trip and fall. Well-fitting shoes are essential in preventing falls in the home and elsewhere. Clients who are light-headed or dizzy should not use stairs. The risk for falling is too great even if using a railing.

A provider's prescription reads "diltiazem (Cardiazem) 5 mg IV now." Which type of prescription did the provider write? 1) STAT 2) single 3) prn 4) standing

1) STAT Rationale: "Diltiazem (Cardiazem) 5 mg IV now" is an example of a STAT prescription; a single dose of the medication is to be administered immediately. A single prescription indicates that the medication is to be given only once at a specified time, but not necessarily STAT. A prn prescription indicates that a drug can be administered whenever the patient requires; however, the medication cannot be given any more frequently than prescribed.

Which of the following groups represent(s) a vulnerable population? Select all that apply. 1) School-age children 2) Pregnant teens 3) Middle-aged adults with diabetes 4) Active seniors 5) Persons with mental illness

1) School-age children 3) Middle-aged adults with diabetes 5) Persons with mental illness Rationale: Vulnerable populations include those with limited economic or social resources, the very young and the very old, those with chronic disease, women who are pregnant, and those who have experienced abuse or trauma. Persons with mental illness are considered vulnerable because of social isolation, and comprised ability to deal with the demands of daily living.

A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed? 1) Seek clarification from the surgeon about the medication prescription. 2) Clamp the NG tube while administering the dose by mouth. 3) Instill the medication through the NG tube. 4) Withhold the oral potassium chloride elixir.

1) Seek clarification from the surgeon about the medication prescription. Rationale: The nurse should seek clarification from the surgeon about the medication prescribed via the oral route. If the patient has a nasogastric tube in place to release gastric drainage, any medication given by mouth would be lost into the drainage collection unit and, therefore, be unavailable to the patient for therapeutic use. The nurse does not have authority to electively withhold or alter the route of prescribed treatment without seeking clarification and resolving any discrepancy in the route by which the medication would be administered.

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? 1) Sims' 2) Supine 3) Dorsal recumbent 4) Semi-Fowler's

1) Sims' Rationale: Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery. The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler's position without causing harm to the joint. Supine position is lying on the back, facing upward. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? 1) Sitting upright 2) Lying flat on the back with knees flexed 3) Lying flat on the back with arms and legs fully extended 4) Side-lying with the knees flexed

1) Sitting upright Rationale: If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. In addition, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on their back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient's physical condition restricts the comfort or ability of the patient to sit upright.

A physician has requested privileges to admit and monitor patients at the community hospital. A license check by the hospital administrator reveals that there have been four successful lawsuits against the physician for unsafe medical practice. The hospital ethics committee will meet to discuss granting privileges to him. Which of the following models will the ethics committee most likely follow as they review the physician's case? 1) Social justice 2) Patient benefit 3) Autonomy 4) Privilege to practice

1) Social justice Rationale: The social justice model focuses more on broad social issues involving the entire institution than it does on a single patient issue. The autonomy model is useful when a patient is competent to decide; it emphasizes patient autonomy and choice as the highest value. The patient benefit model assists in decision making for the incompetent patient by using substituted judgment. There is no privilege to practice model.

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient's nails? 1) Soft, boggy nails 2) Brittle nails 3) Thickened nails 4) Thick nail with yellowing

1) Soft, boggy nails Rationale: Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis.

The nurse is working on a unit that uses nursing assessment flowsheets. Which statement best describes this form of charting? Nursing assessment flowsheets: 1) are comprehensive charting forms that integrate assessments and nursing actions. 2) contain only graphic information, such as I&O, vital signs, and medication administration. 3) are used to record routine aspects of care, but do not contain assessment data. 4) contain vital data collected upon admission, which can be compared with newly collected data.

1) are comprehensive charting forms that integrate assessments and nursing actions Rationale: Nursing assessment flowsheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information.

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating 1) beef. 2) milk. 3) eggs. 4) oatmeal.

1) beef. Rationale: The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.

The nurse should assess skin temperature by using the: 1) dorsum of the hand. 2) pad of the fingertip. 3) palm of the hand. 4) dorsum of the wrist.

1) dorsum of the hand Rationale: The dorsum of the hand should be used to assess skin temperature. The nurse should compare the temperature of the hands with that of the feet and compare the right side of the body with the left.

An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is to: 1) elevate the right heel off the surface of the bed. 2) request a surgical consult for debridement of the area. 3) apply a hydrocolloid to promote autolytic debridement of the wound. 4) request an order for an enzymatic debridement medication.

1) elevate the right heel off the surface of the bed. Rationale: A black wound (eschar) requires debridement of the necrotic tissue except at the heel. The Agency for Healthcare Research and Research (AHRQ) does not recommend debridement of this site. Therefore, your best treatment choice would be elevation of the heel off of the bed. A heel suspension device might be used to relieve pressure to the affected area.

The nurse is teaching a patient newly diagnosed with type 1 diabetes mellitus about how to best manage his blood sugar. Which outcome in the patient's plan of care is associated with the cognitive domain of learning? The patient: 1) identifies signs and symptoms of hypoglycemia. 2) nods affirmatively with direct eye contact. 3) demonstrates fingerstick glucose monitoring. 4) independently self-administers insulin.

1) identifies signs and symptoms of hypoglycemia. Rationale: Cognitive behavior includes recall and comprehension, which is demonstrated by stating information, such as indicators of hypoglycemia. Nodding with eye contact is an action that signals that the listener is dealing with the information with emotion (respect), which shows affective domain. Affective learning is the manner in which we deal with things emotionally, such as feelings, values, appreciation, enthusiasms, motivations, and attitudes. Willingness to hear and showing attention falls within the affective domain. Demonstration of skills depicts the psychomotor domain, such as performing a test to check blood sugar level or injecting insulin.

The nurse has taught a client how to manage constipation. Which action by the client would provide evidence of learning? (Select all that apply.) The patient: 1) increases his intake of high-fiber foods. 2) drinks at least four 8-ounce glasses of water a day. 3) goes to the bathroom to evacuate after meals. 4) takes a daily laxative.

1) increases his intake of high-fiber foods. 3) goes to the bathroom to evacuate after meals. Rationale: The urge to defecate typically comes after eating; the nurse can help manage the patient's constipation by assisting the patient to the bathroom after meals. The nurse should also encourage the patient to increase his intake of high-fiber food and drink at least eight glasses of water a day (not four). Laxatives should be administered or taken only when absolutely necessary.

The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE: 1) reduces the time nurses spend charting. 2) addresses the patient's concerns holistically. 3) establishes an ongoing care plan from admission. 4) is most useful when constructing a timeline of events.

1) reduces the time nurses spend charting Rationale: An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient's concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: 1) separates the health record according to discipline. 2) organizes documentation around the patient's problems. 3) highlights the patient's concerns, problems, and strengths. 4) is designed to streamline documentation.

1) separates the health record according to discipline Rationale: In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient's problems. Focus® charting highlights the patient's concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation.

To obtain the most accurate culture information of a chronic wound, the nurse would recommend: 1) tissue biopsy. 2) swab culture. 3) sterile culture. 4) needle aspiration culture.

1) tissue biopsy. Rationale: A tissue biopsy, in which a piece of tissue is removed from the wound bed and analyzed, provides the most definitive information about infection status of a chronic wound. Chronic wounds are frequently colonized with bacteria; therefore, surface culture (swab) would not be accurate.

What are some ways that the nurse may reinforce patient teaching? Select all that apply. 1) Respond by saying, "What questions do you have?" 2) Ask, "Do you understand the instructions?" 3) Say, "Show me how you would change your ostomy bag." 4) Verbally repeat steps the patient has questions about. 5) Provide a printed pamphlet for the patient to take home.

1), 3), 5) Rationale: The nurse may reinforce material taught by asking, "What questions do you have?" However, when asking, "Do you understand?" some patients are likely to answer "yes" out of embarrassment or a need to cooperate. A patient's lack of questions does not necessarily mean that she understands what's been taught; it could in fact mean the opposite (Dickens & Piano, 2013). Open-ended questions engage the patient more and prompt active learning. Finding out what the patient needs and wants to know is more efficient than discussing an array of topics. Demonstration with return demonstration, also known as "teach back and show back," is a highly effective approach to teaching and evaluating whether learning has occurred. In addition, the nurse can correct poor technique and address specific and targeted issues using a hands-on approach. A printed phamplet is often useful as a reinforcement for the information the nurse teaches, particularly when the patient is receiving a lot of information at once, is not feeling well, or is in pain.

Enuresis

If a child is experiencing involuntary urination after the age of 5 or 6, he may have a condition known as

A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patient's condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? 1) "I'll call your physician right away so he can discuss this with you." 2) "You have the right to change your decision about treatment at any time." 3) "Are you sure you want to change your decision?" 4) "We must follow whatever is written in your living will."

2) "You have the right to change your decision about treatment at any time." Rationale: The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patient's decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patient's decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.

The nurse is caring for a patient who is terminally ill with lung cancer. Recently, the patient's blood pressure has been decreasing and heart rate increasing. He is experiencing temperature fluctuations and perspires profusely with limited movement. Based on these findings, the patient will most likely die within which time period? 1) 1 to 3 months 2) 1 to 2 weeks 3) Days to hours 4) Moments

2) 1 to 2 weeks Rationale: One to 2 weeks before death, patients typically exhibit decreased blood pressure, increased heart rate, increased perspiration, and temperature fluctuations; 1 to 3 months before death, the patient withdraws from the world: sleep increases and appetite decreases. Days to hours before death, the patient may experience a surge in energy. Very near the time of death, the dying patient is typically not responsive to touch or sound.

The nurse must administer a medication by subcutaneous injection. She has a ⅝-inch needle available. For an average patient, at which angle should the nurse administer the injection? 1) 30° 2) 45° 3) 60° 4) 90°

2) 45° Rationale: As a rule, a 5/8-inch needle should be injected at a 45-degree angle; a 3/8-inch needle should be injected at a 90-degree angle.

How should the nurse modify an examination for a 7-year-old child? 1) Ask the parents to leave the room before the examination. 2) Demonstrate equipment before using it. 3) Allow the child to help with the examination. 4) Perform invasive procedures (e.g., otoscopic) last.

2) Demonstrate equipment before using it. Rationale: The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examination of an adolescent, but they usually help younger children feel more secure. The nurse should allow a preschooler to help with the examination when possible, but not usually a school-age child. Toddlers are often fearful of invasive procedures, so those should be performed last in this age group. It is best to perform invasive procedures last for all age groups; therefore, this does not represent a modification.

The nurse working in a hospital with a diverse population strives to offer culturally sensitive care. What nursing action would be most appropriate? 1) Act as if familiar with cultural practices or values even if uncertain. 2) Allow patient to include cultural practices in plan of care unless harmful. 3) Use common slang phrases, as they are familiar to many people. 4) Incorporate humor into interactions with patients to put them at ease.

2) Allow patient to include cultural practices in plan of care unless harmful. Rationale: Find ways to incorporate the client's current healthcare practices and beliefs into the plan of care unless there is potential for harm. When the nurse is unfamiliar with the patient and family's cultural practices, she should admit lack of knowledge, seek clarification, and express willingness to learn. She should not fake it. The nurse should avoid using slang expressions because they can take on different meanings in different cultures, especially if language proficiency is limited. Slang can lead to miscommunication and offensive messages. Avoid using humor; jokes often do not translate well because of subtleties and double-meaning.

For which of the following clients will Medicare most likely reimburse for home care? 1) A homebound young adult needing skilled care, who has no private insurance 2) An older adult whose vision is severely limited and who has complex teaching needs 3) A homebound older adult, confined to bed, who cannot bathe or feed herself 4) A middle-aged client who is homebound, needs skilled care, and has private insurance

2) An older adult whose vision is severely limited and who has complex teaching needs Rationale: To receive Medicare, a person must be over age 65, disabled, or have end-stage renal disease. Medicare reimburses for home care if the client needs skilled care, is homebound, and requires only part-time, intermittent care. Young and middle-aged clients, unless they are disabled, do not qualify to receive Medicare. A homebound older adult who cannot accomplish the activities of daily living would not qualify for Medicare home care unless skilled care was needed, no matter how helpless that person may be. Teaching is considered skilled care.

During the admission assessment, a patient tells the nurse that he does not believe there is a God. The nurse should document his religious affiliation as: 1) Agnostic 2) Atheist 3) Christian Scientist 4) Rastafarianism

2) Atheist Rationale: Those who actively deny the existence of God are known as atheists. Agnostics believe it is not possible to know whether or not God actually exists. Christian Scientists believe in the presence of God, who is the basis of their health and healing. Rastafarians follow the Old and New Testaments of the Bible and emphasize a deep love of God.

A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is alert and oriented and, after giving it much thought, has decided that he wants to be removed from the ventilator. The nurse believes the patient intends suicide, but supports his final decision. When the ventilator is removed, the nurse remains with the patient to support him. The nurse's action demonstrates respect for what moral principle? 1) Nonmaleficence 2) Autonomy 3) Beneficence 4) Fidelity

2) Autonomy Rationale: Autonomy refers to a person's right to choose and his ability to act on that choice. In this case, the nurse respects the patient's right to choose to die. Nonmaleficence is the twofold principle of doing no harm and preventing harm. Beneficence is the duty to do or promote good. Fidelity is the obligation to keep promises.

According to the Uniform Determination of Death Act, which bodily function must be lost to declare death? 1) Consciousness 2) Brainstem function 3) Cephalic reflexes 4) Spontaneous respirations

2) Brainstem function Rationale: According to the Uniform Determination of Death Act, death can be declared when there is a loss of brainstem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.

When a patient with heartburn takes antacids, for which problem is he especially at risk? 1) Diarrhea 2) Constipation 3) Stomach ulceration 4) Flatulence

2) Constipation Rationale: Antacids slow peristalsis, placing the patient at risk for constipation. Antibiotics increase the risk for diarrhea. Stomach ulceration is an adverse effect associated with NSAIDs. Iron supplementation may cause flatulence.

Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) E 4) K

2) D Rationale: The body can synthesize vitamin D from a cholesterol compound in the skin when exposed to adequate sunlight. People at risk for vitamin D deficiency are those who spend little time outdoors; older people; and people who live in an institution (e.g., a nursing home). The deficiency can also occur in the winter at northern and southern latitudes, in people who keep their bodies covered (e.g., traditional Muslim women), and in those who use sunscreen. Also, because breast milk contains only small amounts of vitamin D, breastfed infants who are not exposed to enough sunlight are at risk of the deficiency and rickets. There is no seasonal tie to deficiencies in the other fat-soluble vitamins, A, E, and K.

The healthcare team meets with the family of a man with documented brain death. They discuss discontinuing advanced life support, including mechanical ventilation. For several days, the wife of the patient has been agonizing over this decision. She says, "I don't know what to do. I know there is no hope for him, and it would be kind to let him go; but I just don't see how I can say goodbye forever." Which of the following nursing diagnoses should be used? 1) Moral Distress 2) Decisional Conflict 3) Death Anxiety 4) Spiritual Distress

2) Decisional Conflict Rationale: Decisional Conflict should be used when the patient is uncertain about which course of action to take. The person may verbalize distress and uncertainty and may delay decision making. This woman has not made a moral decision, so she cannot be experiencing Moral Distress, which occurs when the person has made a moral decision but is unable to carry out the chosen action. The woman cannot be experiencing Death Anxiety, because she is not the one who is about to die. Spiritual Distress is the impaired ability to experience and integrate meaning and purpose in life through a connectedness with self, others, music, literature, nature, and/or a power greater than oneself. This woman did not express concerns of a spiritual nature.

A patient is in respiratory distress. The provider has ordered arterial blood gases (ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How should the nurse interpret the ABGs? 1) Respiratory acidosis 2) Respiratory alkalosis 3) Metabolic acidosis 4) Metabolic alkalosis

2) Respiratory alkalosis Rationale: The ABGs are consistent with respiratory alkalosis. The pH is elevated, indicating alkalosis. The PCO2 is decreased, which is also consistent with alkalosis. The HCO3 is within normal range.

A nurse strives to teach a spouse how to monitor a patient's blood pressure. Which teaching method is best? 1) Provide the patient and spouse with written instruction about how to obtain a blood pressure reading. 2) Demonstrate the technique for taking a blood pressure reading, and then request a return demonstration. 3) Schedule the spouse for a class about high blood pressure, including monitoring technique. 4) Provide the spouse with a patient education brochure about blood pressure monitoring.

2) Demonstrate the technique for taking a blood pressure reading, and then request a return demonstration. Rationale: The best way to teach a psychomotor skill, such as obtaining a blood pressure reading, is through demonstration and return demonstration as many learning styles are involved (auditory, visual, kinesthetic). Cognitive learning, which includes storage and recall of information, is most often taught through lecture and print and audiovisual materials.

The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis is: 1) Anxiety related to colostomy. 2) Disturbed Body Image related to colostomy. 3) Disturbed Body Image related to incontinence of stool. 4) Impaired Skin Integrity related to fecal drainage.

2) Disturbed Body Image related to colostomy. Rationale: The patient is having difficulty adjusting to her colostomy. The colostomy is covered by a collection device, so there is no incontinence. There is no evidence of either anxiety or actual skin impairment.

A patient calls the nurse because he is having incision pain and wants a dose of analgesic medication. When the nurse checks the patient's medication administration record, she notes that he is prescribed the narcotic hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drug for administration? 1) Cabinet in the patient's room 2) Double-locked medication drawer 3) Stock supply cabinet 4) Portable medication cart

2) Double-locked medication drawer Rationale: Hydromorphone (Dilaudid) is a controlled substance and must be kept in a double-locked medication drawer for control of inventory. Frequently used Schedule II medications, such as ibuprofen, are stored in the stock supply. Other prescribed medications may be stored in a locked cabinet in the patient's room or in the medication cart.

Which action should the nurse take after administering a dose of medication through a percutaneous endoscopic gastrostomy (PEG) tube? 1) Continue the enteral feeding. 2) Flush the tube with 30 mL of water. 3) Wait 2 hours before resuming the feeding. 4) Check residual volume.

2) Flush the tube with 30 mL of water. Rationale: The nurse should flush the PEG tube with 30 mL of water before and after administering a medication through the tube. The tube feeding should be held for 1 hour before and 1 hour after administering some medications, such as phenytoin (Dilantin). It is not necessary to hold the feeding for 2 hours. Residual volume should not be checked immediately after administering medications.

Which medication will the primary care provider will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

2) Furosemide Rationale: Furosemide (Lasix) is a loop diuretic that increases urine elimination. It works by limiting the reabsorption of water in the renal tubules. Digoxin (Lanoxin) increases the force of contraction by the heart. It is also prescribed for treatment of heart failure. Lovastatin (Mevacor) is a cholesterol-lowering agent. Atorvastatin (Lipitor) is a cholesterol-lowering drug. Although high cholesterol is a leading factor for heart disease, the medication is used to reduce cholesterol in the blood—not to promote diuresis to reduce the demand on the heart and backflow into the lungs.

The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees

2) Left side-lying position Rationale: The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowler's, supine with the bed lowered flat, and the supine position with the head of bed elevated to 30 degrees are not appropriate positions for colostomy irrigation.

Which form would the home care nurse complete to assist Medicare in determining the effectiveness of care and monitor the patient's outcomes? 1) Health Assessment Form 2) OASIS—Outcome and Assessment Information Set 3) Medication Reconciliation Form 4) Clinical Care Classification form

2) OASIS—Outcome and Assessment Information Set Rationale: Medicare requires home health agencies to collect specific information for all Medicare clients they serve. The OASIS data must be collected at the start of care, with each recertification (every 60 days), and at termination of care. Medicare uses these data to determine the effectiveness of care and to monitor client outcomes.

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas

2) Oranges, raisins, and strawberries Rationale: Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium.

Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 15 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration

2) Patient's dentures lost after transfer Rationale: You would need to complete an occurrence report if you suspect your patient's personal items to be lost or stolen. A medication can be administered within a half hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider's order is missing information; an occurrence report is not necessary.

Which information source generally yields the best results when searching for best practice guidance? 1) General interest periodical 2) Peer-reviewed, scholarly journal 3) Popular periodical 4) Worldwide Web

2) Peer-reviewed, scholarly journal Rationale: Peer-reviewed, scholarly journals are examined closely by subject matter experts. Authors must provide citations to scientifically sound research. .

A community health nurse provides wound care to a client with type 2 diabetes mellitus. What type of nursing interventions does this nurse perform? 1) Primary intervention 2) Secondary intervention 3) Tertiary intervention 4) Primary and tertiary interventions

2) Secondary intervention Rationale: Primary interventions occur before disease appears. The goal of primary intervention is to promote health and prevent disease. Secondary intervention aims to reduce the impact of the disease process by early detection and treatment. Tertiary intervention aims to halt disease progression and restore client functioning.

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1) Dorsal recumbent 2) Semi-Fowler's 3) Lithotomy 4) Sims'

2) Semi-Fowler's Rationale: If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in Sims' position is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. Sims' position is used to examine the rectal area. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

During parenteral nutrition administration, a nurse breaks sterile technique. For which complication does this place the patient at risk? 1) Air embolism 2) Sepsis 3) Thrombosis 4) Pneumothorax

2) Sepsis Rationale: A break in sterile technique places the patient at risk for sepsis. Air embolism can occur when the intravenous tubing is disconnected from the catheter hub. Thrombosis occurs as a result of irritation of the vein from the central venous catheter. Pneumothorax is a complication of central venous catheter insertion.

A patient of Mormon faith is admitted to the hospital with new onset diabetes mellitus. Based on his religious affiliation, which item(s) should the nurse remove from the patient's dinner tray? Select all that apply. 1) Pork 2) Tea 3) Meat 4) Coffee

2) Tea 4) Coffee Rationale: Mormons follow a strict health code, known as the Word of Wisdom, which prohibits the consumption of tea, coffee, and alcohol. Conservative Jews avoid pork products. Most Hindus are lacto-vegetarians, which mean they consume milk but not eggs. Buddhists, Hindus, some Rastafarians, and some Christians (on Fridays during Lent) do not consume meat.

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. Why should the nurse question the order for digoxin 0.25 mg orally daily? 1) Based on the digoxin level, the dose may need to be increased. 2) The patient is at risk for an elevated digoxin level at this time. 3) Digoxin and furosemide should never be taken together. 4) The nurse should not be concerned about the order as written.

2) The patient is at risk for an elevated digoxin level at this time. Rationale: The hypokalemic patient on digoxin is at high risk for digoxin toxicity. The patient's serum digoxin level will need to be assessed as she receives potassium supplementation. Digoxin and furosemide can be taken together.

The nurse applying a bioocclusive, transparent dressing on the abdomen of an elderly frail women is concerned about damaging her fragile skin when removing the dressing at a later time. What action should the nurse take to safegaurd the skin? 1) Gently cleanse the skin with soap and water first. 2) Use a skin sealant before applying the dressing. 3) Remove hair from the site using scissors or clippers. 4) Change the dressing frequently to avoid excessive adhesion.

2) Use a skin sealant before applying the dressing. Rationale: The junction between the epidermis and dermis on the older adult is not as strong as it is in a younger person. Skin sealant preparations may be used under adhesives to reduce the pressure or tension needed to break those bonds and cause skin damage. Soap has a drying effect on skin and should not be used, particularly on fragile, dry skin of an elderly person. Typically, an elderly woman's abdomen would not have enough hair to warrant trimming. Removing the dressing can be traumatic, especially with the thin, fragile skin of a frail, older adult.

Which of the following consequentialist theories takes the position that the value of an action is determined by its usefulness? 1) Ethics of care 2) Utilitarianism 3) Deontology 4) Categorical imperative

2) Utilitarianism Rationale: Utilitarianism is a consequentialist theory that takes the position that the value of an action is determined by its usefulness. An ethics of care is a nursing philosophy that directs attention to the specific situations of individual patients viewed within the context of their life narrative. Deontology considers an action to be right or wrong independent of its consequences. A categorical imperative is a principle, established by Immanuel Kant, that states that one should act only if the action is based on a principle that is universal.

There has been an accident involving two busloads of school children. The accident victims have been transported to the local emergency department (ED). The ED nurse is triaging the children to determine who will receive treatment first. Which ethical framework does this process illustrate? 1) Teleology 2) Utilitarianism 3) Deontology 4) Categorical imperative

2) Utilitarianism Rationale: Utilitarianism states that the value of an action is determined by its usefulness. When using this framework, the action that results in the most benefits for the greatest number of people involved is preferred. Teleology is a synonym for consequentialism. Deontology theory considers an action to be right or wrong independent of its consequences. The categorical imperative is a principle established by Immanuel Kant, which states that one should act only if the action is based on a principle that is universal.

Normal flora contained in the colon aid digestion and produce which nutrients? Select all that apply. 1) Vitamin A 2) Vitamin B 3) Vitamin C 4) Vitamin K 5) Iron 6) Zinc

2) Vitamin B 4) Vitamin K Rationale: The normal flora in the colon produce vitamin K and several of the B vitamins. They are not responsible for production of vitamins A and C, iron, and zinc.

Which of the following questions would provide information about "O" in a HOPE assessment and "S" in a SPIRIT assessment? 1) Do you have any dietary restrictions or needs on religious holidays? 2) What is your religion or what church do you go to? 3) How comfortable are you with discussing spirituality? 4) Do you have an advance directive?

2) What is your religion or what church do you go to? Rationale: In the HOPE assessment "O" represents "organized religion." In the SPIRIT tool, "S" represents "spiritual/religious belief system." Dietary needs provide information about ritualized practices and restrictions ("R" in the SPIRIT tool; "E" in the HOPE approach). Asking about the patient's comfort with discussing spirituality addresses personal spirituality ("P" in the SPIRIT tool; "P" in the HOPE approach). Advance directives address terminal events planning ("T" in the SPIRIT tool; "E" in the HOPE approach).

Which of the following groups represents a community? Select all that apply. 1) Residents within Saint Louis, Missouri 2) Youth group attending a local Baptist church 3) Adults with a valid driver's license 4) Older adults living in an active retirement village 5) Students with a grade point average of 3.8 or higher

2) Youth group attending a local Baptist church 4) Older adults living in an active retirement village Rationale: A community is a body of like-minded people or the inhabitants of a town who are connected in a relationship. Most members of a community share a common language, certain rituals, and special customs. Church youth group members share common beliefs. Adults in an active retirement village typically share a common lifestyle, including leisure and social activities, and are at a similar phase in life. A population is defined as all of the people inhabiting a specified area. All residents in a particular county, township, or large metropolitan area are considered a population of that particular geographical area. Adults with a valid driver's license and students with a high grade point average are not considered a community because they do not share common beliefs and interests and have no interrelationship.

A patient reports that he has been taking famotidine (Pepcid) for treatment of esophageal reflux disease. Pepcid is the _____________ name of the drug. 1) official 2) brand 3) chemical 4) generic

2) brand Rationale: Pepcid is the drug's brand name, which is the name given to the drug by the manufacturer. The official name or generic name is assigned by the United States Adopted Names Council. The official name of this drug is famotidine. The chemical name is the exact description of the drug's chemical composition.

During an admission assessment, the patient reports that he takes vitamin E supplements twice a day. The nurse should explain that taking vitamin E supplements twice a day 1) ensures healthy vision. 2) can lead to toxicity. 3) strengthens the immune system. 4) helps maintain body tissues.

2) can lead to toxicity. Rationale: Vitamins are critical in building and maintaining body tissues, supporting the immune system to fight infection, and ensuring healthy vision. However when fat-soluble vitamins, such as vitamins A, D, E, and K, are supplemented in large doses, toxicity may occur.

Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur: 1) moments before death 2) days to hours before death 3) 1 to 2 weeks before death 4) 1 to 3 months before death

2) days to hours before death Rationale: Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.

The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as: 1) stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 2) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 3) stage IV pressure ulcer with sinus tract from 12:00 to 3:00. 4) tage III pressure ulcer with sinus tract from 12:00 to 3:00.

2) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. Rationale: A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. Undermining is deeper-level damage of adjacent tissue. Sinus tracts are narrow, blind tracts underneath the epidermis.

Based on Gilligan's theory of moral development, compared with men, which of the following statements would a woman be more likely to use in ethical reasoning? "We shouldn't lie to the patient because 1) it is against agency policy." 2) the patient might lose trust in us." 3) lying disrespects the principle of veracity." 4) we might be sued by the patient."

2) the patient might lose trust in us." Rationale: In Gilligan's theory, females develop morally by paying attention to community and to relationships, whereas males tend to process dilemmas through more abstract ideals or principles. Concern about losing the patient's trust reflects that the person is paying attention more to the nurse-patient relationship than to rules and principles. Agency policy reflects a rule-following orientation, which is an early phase in Kohlberg's theory. Veracity is a moral principle, and is more reflective of male reasoning in Gilligan's theory. Fear of a lawsuit reflects a legal perspective rather than an ethical perspective.

A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip rate at? 1) 75 gtt/min 2) 100 gtt/min 3) 250 gtt/min 4) 500 gtt/min

3) 250 gtt/min Rationale: Calculate the drip rate by multiplying the hourly rate by the drop factor in drops/mL divided by 60 min. An infusion of 1,000 mL over 4 hours yields an hourly rate of 250 mL (1,000 mL/4 hours = 250 mL/hr). 250 ml (hourly rate) × 60 (gtt/mL) = 250 gtt/min 60 min

Serosanguineous drainage on a surgical dressing is an abnormal finding and should be reported to the physician immediately.

False Rationale: Serosanguineous drainage is a common finding during the immediate postoperative period.

A hospitalized patient's medical record contains the following medication prescription. The patient's name is stamped on the order sheet. Which prescription is complete? 1) Furosemide 40 mg IV daily 2) 5/26/14—digoxin 0.25 mg IV daily, G. Horowitz RN 3) 5/28/14—0930—K-lor 40 mEq PO now, James Carp MD 4) 5/29/14—metopropol 5 mg IV q 6 hours, Robert Young DO

3) 5/28/14—0930—K-lor 40 mEq PO now, James Carp MD Rationale: Medication prescription must contain the patient's full name, date and time the prescription was written, name of the medication, drug dosage, route of administration, and signature of the prescriber with credentials. Therefore, Dr. Carp's prescription is complete because it contains all of the elements required in a medication prescription. An MD and DO (Doctor of Osteopathy) can prescribe medication. An RN does not, unless licensed as an advanced practice nurse with prescriptive authority.

To import vital signs information directly into the patient's electronic health record (EHR), you would need to have access to which of the following? 1) Electronic mail 2) Decision support software 3) An interface between the EHR and the monitor 4) Computer processing

3) An interface between the EHR and the monitor Rationale: Interfaces are communication tools that support information exchange between two or more digital devices.

Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs

3) Antibiotic therapy Rationale: A key treatment for diverticulitis (an infected diverticulum) is antibiotic therapy; if antibiotic therapy is ineffective, surgery may be necessary. Antacids, antidiarrheal agents, and NSAIDs are not indicated for treatment of diverticulitis.

A client who cannot manage a patient-controlled analgesia pump is prescribed morphine 4 mg intravenously q 1 hour prn pain. When should the nurse administer the medication? 1) Every hour around the clock 2) Immediately after taking off the order 3) As needed, but not more than once per hour 4) 1 hour after the last administered dose

3) As needed, but not more than once per hour Rationale: The abbreviation for "as needed" is prn. The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

How might the nurse improve patients' health literacy when communicating with healthcare providers? 1) Ask patients simple yes or no questions. 2) Speak with passive voice instead of active. 3) Avoid medical jargon and technical terms. 4) Provide information printed in English.

3) Avoid medical jargon and technical terms. Rationale: Health literacy is the ability to understand basic health information and services needed to make appropriate healthcare decisions. A gap in health literacy results when a healthcare provider uses terminology that is unfamiliar or misunderstood by the patient, thus resulting in an unintended message or lack of meaningful information. Therefore, healthcare providers should avoid unnecessary medical jargon and technical terms. Speak using common words, short sentences, and structuring sentences with active rather than passive voice. To be sure the patient understands your questions clearly, ask questions that involve "how" and "what" rather than "yes" and "no." Patients with limited language proficiency might use words of agreement ("yes") or disagreement ("no") simply because of reduced vocabulary and poor understanding of the question. Do not assume that a client who smiles, nods, and says "yes" really understands what you are teaching. The client may be shy to ask questions or may feel that it will embarrass you. An interpreter might help communication when language is the barrier.

The nurse should use the diaphragm of the stethoscope to auscultate which of the following? 1) Heart murmurs 2) Jugular venous hums 3) Bowel sounds 4) Carotid bruits

3) Bowel sounds Rationale: The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.

A client just admitted with an acute myocardial infarction (heart attack) is prescribed heparin (an anticoagulant) 2,000 units IV now. Which action should the nurse take first before administering this medication? 1) Make sure the informed consent is signed. 2) Verify the prescription with the physician. 3) Check the laboratory results of coagulation studies. 4) Be sure a signed HIPPA form is on the chart.

3) Check the laboratory results of coagulation studies. Rationale: Heparin is an anticoagulant; therefore, coagulation studies should be checked before and during therapy. Informed consent is not necessary for heparin administration. The drug can be prescribed IV or subQ, so there is no need to verify the prescription with the physician unless the prescription is not clearly written. A signed HIPPA form is obtained at the time of admission and pertains to release of medical information. Although a signed HIPPA form needs to be on the chart, this is not relevant to the task of administering heparin to the patient.

A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication? 1) Inform the prescriber that she is not comfortable administering the drug. 2) Ask a nursing colleague for relevant information about the drug. 3) Consult the drug formulary accessible to staff at the patient care unit. 4) Trust that the prescriber wrote the correct dose and administer the drug as intended.

3) Consult the drug formulary accessible to staff at the patient care unit. Rationale: The nurse is responsible for every medication she administers. Therefore, the nurse must be familiar with the indications, routes of administration, dosages, contraindications, adverse reactions, drug interactions, and any special administration guidelines associated with each drug before administration. There are numerous ways to become more informed about medication, such as a drug formulary, Physicians' Desk Reference, or registered pharmacist before administration. The nurse should not rely on information from a colleague because as a secondary source of information, there is a risk for inaccuracy, which can be dangerous in a patient care situation.

The nurse is obtaining the history of a newly admitted patient. Which element in the history places the patient at risk for urinary tract infection? 1) Hypertension 2) Hypothyroidism 3) Diabetes mellitus 4) Hormonal contraceptive use

3) Diabetes mellitus Rationale: Diabetes mellitus places the patient at risk for urinary tract infection because glucose in the urine provides a medium favorable for bacterial growth. Hypertension, hypothyroidism, and hormonal contraceptive use are not directly related to an increased risk for urinary tract infection.

The nurse makes a mistake while documenting in the patient's health record. Which action should the nurse take? 1) Use an opaque white fluid to cover the documentation error. 2) Completely cover the documentation error with black ink. 3) Draw a line through the error and initial the change. 4) Use correction tape to make the documentation correct.

3) Draw a line through the error and initial the change. Rationale: The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words "error" or "mistaken entry" above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient's health record as though the error had not been made. Making note of the correction in documentation makes it clear to others what happened.

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1) Ongoing assessment 2) Comprehensive physical assessment 3) Focused physical assessment 4) Psychosocial assessment

3) Focused physical assessment Rationale: The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case, shortness of breath. An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.

An adult patient who is receiving a continuous enteral feeding at 80 ml/hr has a residual volume of 120 ml 6 hours after the last check. How should the nurse proceed? 1) Continue administering the enteral feeding. 2) Hold the enteral feeding and notify the provider immediately. 3) Hold the feeding for 1 hour, and recheck. 4) Hold the feeding for 2 hours, then resume the feeding.

3) Hold the feeding for 1 hour, and recheck Rationale: The nurse should check enteral feeding residual every 4 to 6 hours. If residual is 10% greater than the formula flow rate for 1 hour (or alternatively, a total of 150 mL), the nurse should hold the feeding for 1 hour and recheck. If residual is still not within normal limits, she should notify the provider.

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and diagnostic information are consistent with which of the following? 1) Hypocalcemia 2) Hypernatremia 3) Hypokalemia 4) Hypermagnesemia

3) Hypokalemia Rationale: The serum potassium level is low (norm = 3.5 to 5.0 mEq/L). PVCs related to cardiac irritability and a flat T wave on an ECG are also indicative of hypokalemia. The patient takes furosemide (Lasix), a diuretic that can induce hypokalemia.

The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours.

3) It improves interdisciplinary collaboration that improves efficiency in procedures. Rationale: The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client's record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.

When you enter a client's home for the first time, in what order would you complete the following tasks? 1) Identify yourself to the client by showing your identification and the agency's information. 2) Ask the patient to provide two identifiers: name and date of birth. 3) Knock or ring the doorbell and wait to be invited into the home. 4) Begin the home care assessment of the client and environment.

3) Knock or ring the doorbell and wait to be invited into the home. 1) Identify yourself to the client by showing your identification and the agency's information. 2) Ask the patient to provide two identifiers: name and date of birth. 4) Begin the home care assessment of the client and environment. Rationale: It is not safe to enter a client's home unless you are invited in. Next, you verify to the client who you are and the home care agency that you work for. Then you verify that you have the correct client by asking for the two client identifiers, as required by The Joint Commission. You then begin your assessment of the client and home environment.

Which food provides the only animal source of carbohydrate? 1) Beef 2) Eggs 3) Milk 4) Chicken

3) Milk Rationale: The only animal source of carbohydrate is lactose, the sugar contained in milk. Beef, eggs, and chicken do not provide a source of carbohydrate.

Which of the following is considered a religious denomination within the tradition of Christianity? 1) Buddhism 2) Rastafarianism 3) Mormonism 4) Islam

3) Mormon Rationale: Mormonism is a religious denomination within Christianity. Buddhism, Rastafarianism, and Islam are all religious traditions outside of Christianity.

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

3) NKA Rationale: The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no (known) drug allergies. NPO is an abbreviation that means nothing by mouth.

The patient's health record contains the following provider's order: furosemide (Lasix) 40 mg intravenously STAT. If the nurse later needed to know when the medication had been given and the patient's response to the medication, where would he look? 1) Progress notes 2) Graphic record 3) Narrative notes 4) MAR

3) Narrative notes Rationale: The nursing narrative note will contain documentation about the time the medication was administered and the patient's response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient's response. The physician's progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient's output.

The time it takes for drug concentration to reach a therapeutic level in the blood is known as: 1) peak action. 2) duration of action. 3) onset of action. 4) half-life.

3) Onset of action Rationale: The onset of action is the time needed for drug concentration to reach a high enough level in the blood for its effects to appear. Peak action occurs when the concentration of a medication is highest in the blood. Duration of action is that period when the medication has a pharmacological effect. Half-life is the amount of time required for half of the drug to be eliminated.

Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palms of the hands

3) Oral muscosa Rationale: In dark-skinned patients, look for color changes in the conjunctiva or oral mucosa. They should be pink and moist. In dark-skinned patients, skin color changes may not be apparent in nailbeds, palms of the hands, and other exposed areas.

When performing a spiritual assessment, who is the preferred source of information? 1) Durable power of attorney 2) Next of kin 3) Patient 4) Patient's clergyperson

3) Patient Rationale: The patient is always the best source of information. Patients who may not participate in an organized religion may be spiritual. Likewise, when confronted with an illness or other medical challenge, patients may reconsider their views and beliefs about religion and/or spirituality. A next of kin should only be used when the patient is unable to communicate for himself. The patient's clergyperson is a source of support for the patient; however, contacting the clergyman without the patient's permission is a breach of patient confidentiality. A durable power of attorney identifies the person who can make decisions for the patient.

The most appropriate nursing diagnosis for a patient with a draining wound would be: 1) Risk for Infection related to dehiscence of wound. 2) Body Image Disturbance related to nonhealing surgical wound. 3) Risk for Impaired Skin Integrity related to wound drainage. 4) Pain related to surgical incision.

3) Risk for Impaired Skin Integrity related to wound drainage. Rationale: The drainage from a wound places the patient at an increased risk for skin breakdown because of the dampness and presence of enzymes in the drainage. The risk of infection is present, but the data provided do not indicate this is a problem. There are no data indicating the patient is having a problem with body image or that he is in pain.

A nurse is caring for a dying patient who is nonresponsive. Which of the following is it important for the nurse to do? 1) Be alert to the patient's nonverbal cues. 2) Direct explanations about care to family members. 3) Tell the patient when the nurse is about to leave the room. 4) Sit by the head of the bed when speaking to the patient.

3) Tell the patient when the nurse is about to leave the room. Rationale: The nurse should continue to communicate with dying patients even if they are nonresponsive. Research indicates that patients continue to hear even though the level of consciousness is low, sometimes up to the moment of death. Nonverbal actions would not communicate meaning for a patient who is nonresponsive; nor would the patient be aware that the nurse is sitting instead of standing when speaking. The nurse should direct explanations of care to the patient, as always; nurses should not talk about the patient to others in the patient's presence, even when the patient is comatose.

The nurse is caring for a patient who has multiple fractures from a skiing accident. To best promote bone growth, the nurse should encourage the patient to eat foods high in calcium and vitamin D. Which food selection by the client indicates an understanding of foods that are high in calcium? 1) Orange juice from concentrate 2) Cottage cheese 3) Tofu 4) Brie cheese

3) Tofu Rationale: Firm tofu (½ cup serving) contains approximately 227 mg of calcium. This is an excellent dietary source of calcium. A ½ cup serving of orange juice from concentrate contains 27 mg of calcium. Brie cheese (1 oz) contains only 50 mg of calcium. A ½ cup serving of cottage cheese contains only 65 mg of calcium.

A 45-year-old patient is ventilator dependent after a high cervical neck injury. He is conscious and competent and has decided that he wants to be removed from the ventilator. His family and the multidisciplinary team agree. The nurse believes the patient intends suicide, and would prefer he choose differently, but says nothing. The nurse remains at the bedside holding the patient's hand. In this instance, the nurse is displaying which of the following? 1) Value set 2) Value system 3) Value neutrality 4) Value awareness

3) Value neutrality Rationale: Value neutrality occurs when we put aside our own values regarding an issue in order to provide nonjudgmental care to clients. A value set is your list of values. A value system is your value set with the values ranked on a continuum from most important to least important.

Which intervention should be included in the plan of care for a patient in the end-stage death process? 1) Encourage the patient to accept as much help as possible. 2) Avoid administering laxatives. 3) Wet the lips and mouth frequently. 4) Administer pain medication on a prn basis.

3) Wet the lips and mouth frequently. Rationale: If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.

How do the Langerhans cells protect the skin from injury? Langerhans cells: 1) contain protein that gives the skin strength and elasticity. 2) are able to filter out beta ultraviolet light waves. 3) are mobile to phagocytize foreign material. 4) are located in the dermal layer of the skin.

3) are mobile to phagocytize foreign material. Rationale: Langerhans cells are located in the epidermal layer of the skin. They are mobile to phagocytize (consume) foreign material and trigger an immune response. Keratinocytes are protein-containing cells that give the skin strength and elasticity. Melanocytes provide protection from ultraviolet light.

A patient is admitted to the emergency department with a stroke. After being stabilized, the patient's needs are best met if the nurse documents a care plan that provides for: 1) acute interventions. 2) patient teaching. 3) discharge needs. 4) family health data.

3) discharge needs. Rationale: The patient's potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient's hospitalization.

When a patient takes a medication by mouth, it is absorbed through the gastrointestinal (GI) tract and circulates through the liver before entering systemic circulation. Many medications are almost completely inactivated during this process. This process is known as: 1) absorption. 2) distribution. 3) first-pass effect. 4) excretion.

3) first-pass effect. Rationale: During first-pass effect, oral medications that are absorbed through the GI tract and circulated through the liver are almost completely inactivated. For this reason, oral medications are formulated with a higher concentration of the drug than are parenteral medications. Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver, and GI tract, lungs, and exocrine glands.

Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) milk and cheese. 2) bread and pasta. 3) fruits and vegetables. 4) lean meats.

3) fruits and vegetables. Rationale: The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

A 77-year-old woman with an inoperable brain tumor has been hospitalized for the past 5 days. Her daughter comes to visit her. The patient has asked that her daughter not be told her diagnosis. After visiting with her mother, the daughter asks to speak to the nurse. She says, "My mother claims she has pneumonia, but I know she is not telling me the truth." The daughter asks the nurse to tell her what is truly wrong with her mother. The nurse should tell her that: 1) her mother has an inoperable brain tumor, but does not wish anyone to know. 2) she needs to speak to the physician in charge of her mother's care. 3) her mother has requested that her case not be discussed with anyone, not even family. 4) her mother is very sick with a serious case of pneumonia that could lead to death.

3) her mother has requested that her case not be discussed with anyone, not even family. Rationale: The nurse's first allegiance is to the patient and her desire for confidentiality. Telling the daughter to speak to the physician would place the physician in the same position as the nurse. Telling her that her mother has pneumonia would be a lie. The nurse, of course, should inform the physician of the patient's wishes so that he will be prepared if the daughter questions him about her mother's health condition.

For a patient in respiratory distress, the first arterial blood gases (ABGs) were: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. The ABGs were repeated the next morning. The new results are the following: pH = 7.47; PCO2 = 26 mmol/L; HCO3 = 20 mEq/L. The nurse recognizes that the values have changed and that the patient is now experiencing 1) respiratory acidosis. 2) metabolic alkalosis. 3) partial compensation. 4) complete compensation.

3) partial compensation. Rationale: Although the pH remains alkalotic, the bicarbonate level has begun to fall to compensate for the low PCO2, which has not yet changed. The patient is in respiratory alkalosis and the compensation will be metabolic, so the HCO3 should decrease. Normal HCO3 is 22-26, with <22 being acidosis. Complete compensation occurs when the pH returns to normal.

The nurse providing discharge teaching to a patient whose primary language is not English would most likely use which teaching strategies? Select all that apply. 1. Present 10 to 12 short, simple instructions at a time. 2. Send forms home with the patient for family members to help complete. 3. Use drawings and photographs to illustrate the information. 4. Ask an interpreter to help translate the discharge instructions. 5. Use an active voice with simple words when speaking to the patient.

3), 4), 5) Rationale: Drawings and photographs are an effective way of conveying information with fewer words. An interpretor would accurately convey the information and be available to clarify as needed. The interpreter is bound by patient privacy and confidentiality. To promote health literacy, use simple words, short sentences, and active voice (rather than passive). Avoid medical jargon and abstract words, as well. To keep from overloading the patient with too much information as well as to promote retention of information, it is best to present topic in three to five "chunks" at a time. To protect the patient's privacy, health information should be collected in the healthcare setting. The patient's family members are not assured to have language competency that is better than the patients. Also, sending the forms home with the patient does not increase the likelihood of getting the information back to the patient's health record.

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following? 1) Osmosis 2) Filtration 3) Hydrostatic pressure 4) Diffusion

4) Diffusion Rationale: Diffusion is a passive process by which molecules move from an area of higher concentration to an area of lower concentration. Osmosis is the movement of water across a membrane from an area of a less concentrated solution to an area of more concentrated solution. Filtration is the movement of water and smaller particles from an area of high pressure to low pressure. Hydrostatic pressure is the force created by fluid within a closed system.

The parent of a 7-year-old son brings the child to the pediatric care provider to discuss her child's nighttime bedwetting. She reports he has never achieved consistent dryness at night. What is the nurse's best response to the mother's concern? 1) "We'll start medication right away to control it." 2) "Family history is not associated with bedwetting." 3) "We will look for a urinary tract infection." 4) "Wait it out. Your son will likely outgrow it."

4) "Wait it out. Your son will likely outgrow it." Rationale: Based on the history, the nurse understands the condition is nocturnal enuresis because the child has not yet achieved dryness at night at an age when continence would be expected. Nocturnal enuresis is most common among boys. Ninety-five percent of children outgrow it by age 10. Nighttime bedwetting runs in families. So if one parent experienced nocturnal enuresis as a child, then the chances that the child will also have trouble with achieving continence at night will be likely. Pharmacological intervention can be useful for older children, particularly when the child is not sleeping at home. However, prior to age 8 or 10, medication is not indicated. Frequency and urgency and burning are signs of a urinary tract infection. These symptoms are most noticeable during the day (not night). Nocturnal enuresis occurs without the person realizing that he emptied the bladder.

A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as: 1) trace edema. 2) +1 edema. 3) +2 edema. 4) +3 edema.

4) +3 edema Rationale: To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes; and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.

Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? 1) Cations, because they carry a positive charge 2) Cations, because they carry a negative charge 3) Anions, because they carry a positive charge 4) Anions, because they carry a negative charge

4) Anions, because they carry a negative charge Rationale: Anions are electrolytes that carry a negative charge; they include chloride, bicarbonate, phosphate, and sulfate. Electrolytes that carry a positive charge are called cations. Cations include sodium, potassium, calcium, and magnesium.

A patient has been in the dying process for about 10 days. His wife has left his side only for very short periods during that time, and she looks pale and exhausted. The nurse, realizing the wife has not eaten much, suggests that she take a break to eat and rest. The woman refuses, saying, "I don't want to leave him. I won't have him much longer, and I don't want him to go when I'm gone." What should the nurse do? 1) Explain that she will be of more help to her husband if she is rested and well. 2) Tell the wife that it is safe to leave her husband for an hour or two because he won't die that soon. 3) Call the primary care provider to come and try to persuade her to take physical care of herself. 4) Arrange for a cot for the wife at the bedside and arrange to have food brought to her.

4) Arrange for a cot for the wife at the bedside and arrange to have food brought to her. Rationale: The nurse was correct to suggest that the woman needs to eat and rest. However, this is primarily for the woman's well-being, not because she needs to be of more help to her husband. The nurse should not assure her that her husband will not die in an hour or two, because she does not know exactly when he will die. It would be inappropriate to ask anyone else to try to persuade her to change her mind; the nurse should support the wife's decisions in a therapeutic manner and not try to change them. The nurse should not rely on the physician to encourage basic care and comfort for the family. She should make the wife as comfortable as possible if she does not wish to leave the room. This would include arranging for her to rest in the patient's room and having food and drink brought to the room.

A patient remarks to the nurse, "What's the point of going through all these medical treatments? They make me feel so bad, and I will never be well anyway." What is the most helpful action for the nurse to take? 1) Explore with the patient what has triggered his emotions. 2) Treat the patient with dignity and respect. 3) Pray with the patient in a private setting. 4) Assist the patient to identify areas of hope in life.

4) Assist the patient to identify areas of hope in life. Rationale: The patient is demonstrating Hopelessness. All of the responses would be appropriate under certain circumstances, but helping the patient identify areas of hope in life most directly addresses Hopelessness. The nurse does not need to explore the trigger for the patient's emotions—he has said that it is the treatments and the lack of hope for returning to wellness. All patients should be treated with dignity and respect; however, this alone would not address Hopelessness. The nurse should pray with the patient only after first learning whether this would be helpful to the patient; in this scenario, that information is not available.

Which organ relies almost exclusively on glucose for energy? 1) Liver 2) Heart 3) Pancreas 4) Brain

4) Brain Rationale: The brain relies almost exclusively on glucose for energy. The heart and liver do not. The pancreas produces insulin for glucose utilization but does not use glucose.

Which blood level is commonly tested to help assess kidney function? 1) Hemoglobin 2) Potassium 3) Sodium 4) Creatinine

4) Creatinine Rationale: The nurse would examine laboratory results for blood urea nitrogen and creatinine to assess kidney function. Hemoglobin, potassium, and sodium levels can be affected by kidney disease, but they do not directly assess kidney function.

A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound: 1) Evisceration 2) Fistula 3) Hemorrhage 4) Dehiscence

4) Dehiscence Rationale: Wound dehiscence is a rupture of one or more layers of a wound and usually occurs in the inflammatory phase before large amounts of collagen have been deposited in the wound to strengthen it. Dehiscence is usually associated with abdominal wounds, and patients often report feeling a pop or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. Usually, there is an immediate increase in serosanguineous drainage. Patients with obesity are more likely to experience wound dehiscence because fatty tissue does not heal readily, and the patient's body mass increases the strain on the suture line.

When making a home health visit to a patient who lives alone, a nurse knocks on the door and rings the doorbell. No one answers. The nurse knocks and rings again, but after waiting for a total of 5 minutes, no one comes to the door. What should the nurse do? 1) Drive to the next visit and call at the end of the day to reschedule. 2) Try the door. If it is unlocked, open it slightly and call the patient's name. 3) Walk around the house, rap on the bedroom window, and call the patient's name. 4) Do not enter; using the nurse's cell phone, telephone the patient.

4) Do not enter; using the nurse's cell phone, telephone the patient. Rationale: The nurse should never go inside without being invited. The nurse should use the cell phone to call the patient, or return to a secure public pay phone and dial the patient. For safety reasons, it is not advisable to open an unlocked door, nor to walk around the house and rap on the window.

Which nursing action would the nurse implement to reduce medication errors? 1) Check to be sure pediatric medication is prescribed using dose per pound of body weight. 2) Administer prescribed medication if you note it is not documented on the MAR. 3) Administer medication before the patient goes to sleep when it is prescribed "at bedtime." 4) Draw up liquid suspension in an oral syringe with a bulb or plunger and no needle.

4) Draw up liquid suspension in an oral syringe with a bulb or plunger and no needle. Rationale: Oral medications should be drawn up into an oral syringe to avoid inadvertent IV administration. Pediatric medication should be prescribed using dose per kilogram of body weight, not pounds. The Joint Commission also advises nurses to weigh patients in kilograms to avoid errors in administering drugs based on weight; kilograms is the standard metric for pediatric prescriptions, medical records, and staff communication. Mistakes can occur as a result of poor documentation. For example, one nurse administers a medication yet fails to record it immediately afterward. A second nurse, checking the patient's chart, thinks the drug has not been given, so administers a dose. The patient receives a double dose. The Institute for Safe Medication Practices published a Dangerous Abbreviations list. Among numerous abbreviations, acronyms, and symbols, neither HS nor hs should be used on a medication order or prescription. HS can be mistaken for "taken at bedtime," and hs is often confused with "half-strength." In this example, the nurse would not know whether the prescriber intended the medication to be given at "hour of sleep" or in half-strength.

What emotional response is typical during Rando's confrontation phase of the grieving process? 1) Anger and bargaining 2) Shock with disbelief 3) Denial 4) Emotional upset

4) Emotional upset Rationale: During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities.

A patient has been admitted to the hospital with medical diagnoses of hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient's vital signs are: T = 98.4°F (36.9°C); P = 110; R = 32; BP = 162/102. On physical examination, the nurse notes distended neck veins and 3+ pitting edema in both lower extremities. The patient reports he has been drinking and eating as usual but has been unable to urinate. Which is the most appropriate nursing diagnosis for this patient? 1) Excess Fluid Volume related to excessive food and fluid intake 2) Deficient Fluid Volume related to increased metabolic demands 3) Imbalanced Electrolytes secondary to fluid shifts 4) Excess Fluid Volume secondary to acute renal failure

4) Excess Fluid Volume secondary to acute renal failure Rationale: This patient is experiencing Excess Fluid Volume secondary to acute renal failure. There is no indication that he has engaged in excessive food or fluid intake. There is no laboratory result to indicate an electrolyte imbalance, although his test results will most likely demonstrate abnormalities because of the acute renal failure.

The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription? 1) Chemical 2) Brand 3) Trade 4) Generic

4) Generic Rationale: Furosemide, the generic name, was used by the physician in the drug prescription. The brand or trade name of the drug is Lasix; the chemical name is 4-chloro-N-furfuryl-5-sulfamoylanthranilic acid.

The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

4) Hypoactive bowel sounds Rationale: Hypoactive bowel sounds are low pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched, with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds.

Compared with institutional care, which of the following is a unique feature of home care? 1) Only skilled services are reimbursed by private insurance. 2) The nurse has increased access to the healthcare team. 3) Home care provides a more structured environment. 4) Interactions occur with the patient in his personal environment.

4) Interactions occur with the patient in his personal environment. Rationale: In home care, the nurse is able to provide services the client in his home environment. Skilled needs are required for the client to be eligible for home care services; however, other services are available and reimbursable as long as the primary need for services is skilled care. In the home setting, the nurse has less access to other members of the health team, and the environment is less controlled.

A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4) Iron

4) Iron Rationale: Iron deficiency causes anemia; therefore, the nurse should encourage the patient with anemia to increase his intake of iron. Increasing calcium intake helps prevent osteoporosis. Magnesium supplementation may decrease the risk of hypertension and coronary artery disease in women. Potassium is essential for muscle contraction, acid-base balance, and blood pressure control.

A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley

4) Yogurt and parsley Rationale: Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.

A family member asks the nurse to explain the purpose of hospice care. Which of the following is the best response? Hospice care: 1) Is appropriate when the patient desires to intentionally end his life 2) Focuses on minimizing the disease process as rapidly as possible 3) Focuses on symptom management for patients not responding to treatment 4) Is holistic care for patients dying or debilitated and not expected to improve

4) Is holistic care for patients dying or debilitated and not expected to improve Rationale: Hospice care focuses on holistic care of patients actively dying or not expected to improve. It helps patients face death with dignity and comfort. Euthanasia refers to the deliberate ending of a life. Palliative care is aggressively planned care that manages symptoms of patients whose disease process no longer responds to treatment. Aggressive medical treatment is aimed at stopping the disease process.

Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with? 1) Islam 2) Mormonism 3) Hinduism 4) Jehovah's Witnesses

4) Jehovah's Witnesses Rationale: A core belief of Jehovah's Witnesses is that taking blood into one's body is morally wrong. Thus, they will refuse blood or blood products. There is not a religious rule or objection to receiving blood transfusion or products among the other religions.

The nurse is teaching an older female patient how to manage stress incontinence at home. She instructs her to contract her pelvic floor muscles for at least 10 seconds followed by a brief period of relaxation. What is this intervention called? 1) Prompted voiding 2) Crede technique 3) Valsalva maneuver 4) Kegel exercises

4) Kegel exercises Rationale: Kegel exercises strengthen the pelvic floor muscles that support the uterus, bladder, and bowel. Doing Kegel exercises regularly can reduce urinary incontinence. These exercises involve tightening and relaxing the muscles around the vaginal area. Prompted voiding is a part of a bladder-training program in which the person learns to void based on a schedule, rather than to empty the bladder. The Crede technique is applying manual pressure with your hands to the top portion of the bladder to initiate a urine flow. The Valsalva is the maneuver in which a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose, for example, in strenuous coughing, straining during a bowel movement, or lifting a heavy weight.

Which type of bowel diversion allows the patient to be free from an appliance? 1) Colostomy in the transverse colon 2) Double-barreled colostomy 3) Ileostomy 4) Kock pouch

4) Kock pouch Rationale: A Kock pouch, also known as a continent ileostomy, creates an internal pouch to collect ileal drainage. To drain the pouch, the patient inserts a tube through the external stoma into a pouch several times a day. This allows the patient to be free from an appliance. A colostomy, double-barreled colostomy, and ileostomy all require an appliance.

While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of: 1) fungal infection. 2) poor circulation. 3) iron deficiency. 4) long-term hypoxia.

4) Long-term hypoxia Rationale: Clubbing (when the nail plate angle is 180° or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition, hyperthyroidism, and malnutrition.

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.

4) Make a late entry as an addition to the narrative notes. Rationale: If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed.

Why is patient education important in today's healthcare environment? 1) Primarily it is offered to increase patient confidence for self-care. 2) Nurses do patient teaching to transfer responsibility for care to patients. 3) Patient education contributes to rising healthcare costs. 4) More healthcare is delivered in the home and outpatient settings.

4) More healthcare is delivered in the home and outpatient settings. Rationale: With shorter hospital stays and complex care increasingly being given in homes and the community, effective teaching is essential to protect patient well-being and safety in the home and outpatient environment. The primary goal of patient education is to increase the knowledge and skills needed for quality self-care or for providers delivering care in the outpatient setting. Although patients often feel more confident in the home care they will perform after receiving patient education, the primary objective is to facilitate healing and prevent complications. Patients participate in healthcare decisions. Patients have a responsibility for their own health and the care needed to prevent illness, maintain health, treat disease, and evaluate the response to medical treatment. Patient education can help to decrease the overall cost of healthcare and prevent complications leading to rehospitalization.

The nurse is discontinuing a central venous access device. When she removes the catheter, she notes that a portion of the tip is missing. What action must she take? 1) Apply a tourniquet above the site. 2) Start a new peripheral IV. 3) Apply warm compresses to the site. 4) Notify the physician and radiologist.

4) Notify the physician and radiologist. Rationale: Loss of the catheter tip places the patient at risk for an embolus. Because the catheter was in a central vein, it is not possible to place a tourniquet above the site. Warm compresses are appropriate follow-up care for IV extravasation or infiltration. A new peripheral IV may be needed, but this is not the priority. The nurse must notify the physician and radiologist.

A patient is to receive two units of packed red blood cells. Her blood group is O+. The nurse knows that the patient may receive blood from which of the following donors? 1) AB+, A-, B+, and O- 2) A+ and O+ 3) AB- and O+ 4) O+ and O-

4) O+ and O- Rationale: Persons with O+ blood may receive O+ or O-. Blood group O persons are considered "universal donors." Rh+ persons may receive Rh+ and Rh- blood. Persons who are Rh- may receive only Rh- blood.

The nurse is preparing an enteral feeding for a patient who will be receiving intermittent feedings via nasogastric tube for the first time. The patient is conscious. Which of the following is the priority intervention before administering this feeding? 1) Observe whether the patient can speak. 2) Inject air into the feeding tube while auscultating the stomach. 3) Aspirate stomach contents and measure residual volume. 4) Obtain an x-ray of the chest and abdomen.

4) Obtain an x-ray of the chest and abdomen. Rationale: It is essential to verify that the NG tube is in the stomach and not the airway. The only reliable method among these four is to obtain an x-ray of the chest and abdomen. For subsequent feedings, however, it is not practical to obtain an x-ray each time, and presence of formula in the stomach complicates the pH readings. Therefore, the nurse should use a combination of bedside techniques, including observing appearance and measuring the amount of gastric residual volume, asking the patient to speak, and injecting air ("whoosh" test) while auscultating the stomach.

Which of the following is a common activity of a community-based nurse rather than that of a public health nurse? 1) Planning blood pressure screening program in active senior community 2) Conducting surveillance services for TB to a predominantly Indian community 3) Lobbying for state funding for an immunization program for working-class poor 4) Providing developmental assessment for infants discharged from neonatal intensive care

4) Providing developmental assessment for infants discharged from neonatal intensive care Rationale: Community health nurses function as client advocates, counselors, case managers, educators, and collaborators for patients and their families in the community setting. The public health nurse serves the aggregate community with services such as community-based screening, public surveillance for disease and pandemic infection, and lobbying for issues that impact the public at large.

For a patient with a newly fractured pelvis, not yet in a cast, which of the following actions is appropriate when placing the patient on a bedpan? 1) Place the patient in semi-Fowler's position to defecate. 2) Ask the patient to push up with his feet to lift his hips while you place the bedpan. 3) Place a fracture pan under the buttocks, small end toward the feet. 4) Raise the siderail on the opposite side from where you are working.

4) Raise the siderail on the opposite side from where you are working. Rationale: The nurse should always raise the siderail on the opposite side from where he is working to protect the patient from falls. Placing the patient in semi-Fowler's position or asking the patient to push up with his feet would cause pain and possible dislocation of the fracture. A fracture pan should be used, but the small large end is pointed toward the feet.

An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate? 1) Shock and numbness 2) Yearning and searching 3) Disorganization and despair 4) Reorganization

4) Reorganization Rationale: According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.

When teaching students about how to provide culturally sensitive care to a diverse group of patients, which teaching strategy should the nurse use? 1) Demonstration 2) Lecture 3) Online sources of information 4) Role modeling

4) Role modeling Rationale: Affective learning involves changes in feelings, beliefs, attitudes, and values. It is considered the "feeling domain." Strategies for promoting affective learning include role modeling, panel discussions, electronic mailing lists, support groups, one-to-one instruction, audiovisual materials, and possibly printed materials. Strategies for cognitive learning include online sources of information, concept mapping, panel discussions, and computer-assisted instruction. Strategies for psychomotor learning include demonstration, simulation, audiovisual materials, and printed materials.

Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or supernatural being 3) Rules prohibiting alcohol consumption 4) Sacred writings that reveal the nature of the Supreme Being

4) Sacred writings that reveal the nature of the Supreme Being Rationale: A common factor held by most religions is the sacred writings that are regarded as authoritative and/or reveal the nature of the divine. Not all religions have strict health codes or prohibit the consumption of alcohol. While many religions believe in God or a supernatural being, not all adhere to this belief or practice.

What is the correct term for a belief about the worth of something that serves as a principle or a standard that influences decision making? 1) Morals 2) Attitudes 3) Beliefs 4) Values

4) Values Rationale: A value is a belief you have about the worth of something that serves as a principle or a standard that influences decision making. Morals are private, personal, or group standards of right and wrong. Attitudes are mental dispositions or feelings toward a person, object, or idea. A belief is something that one accepts as true.

What is the preferred site of intramuscular injection for children who are walking? 1) Dorsogluteal 2) Rectus femoris 3) Vastus lateralis 4) Ventrogluteal

4) Ventrogluteal Rationale: The ventrogluteal site, located on the lateral hip, involves the gluteus medius and gluteus minimus muscles. This is the site of choice for intramuscular injections for adults and young children who are walking. Because it is located away from major blood vessels and nerves, it is the safest and least painful site. The dorsogluteal site consists of the gluteal muscles of the buttocks. Because this site is in proximity to the sciatic nerve and superior gluteal artery, it is contraindicated for use in infants, children, and adults. The rectus femoris site, located in the anterior thigh, is no longer recommended for infants and children. The vastus lateralis muscle, located in the anterolateral thigh, is the preferred site for young infants, particularly before walking age, because it is usually the best developed and contains no large nerves or blood vessels, minimizing the risk for injury.

An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has: 1) an infected wound. 2) wound dehiscence. 3) a hematoma. 4) a fistula.

4) a fistula. Rationale: A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Based on the type of surgery and drainage present, the nurse would suspect fistula formation.

The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device: 1) demonstrates the proper method of cleansing her skin. 2) demonstrates proficiency when providing treatment to excoriated skin. 3) states she will start caring for the colostomy after she gets home. 4) proficiently performs colostomy care prior to discharge.

4) proficiently performs colostomy care prior to discharge. Rationale: By performing colostomy care, the patient's behavior reflects acceptance of her colostomy. There is no information to suggest that her skin is excoriated. Waiting until she gets home to start care is delaying acceptance and will not allow her to get assistance or further instruction. Demonstrating correct skin cleansing does not ensure that the client is actually performing colostomy care or has accepted her condition.

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: 1) obese. 2) overweight. 3) average. 4) underweight.

4) underweight Rationale: For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.

Place the steps the nurse will take to irrigate a wound in the proper order of performance. Mark the options in rank order (priority rating) with 1 being the first thing you would do, and 8 last. 1) Don clean nonsterile gloves. 2) Set up a sterile field with supplies. 3) Pour irrigation solution into sterile bowl. 4) Remove soiled dressing. 5) Don sterile gloves. 6) Gently irrigate wound. 7) Fill the irrigation syringe. 8) Administer pain medication.

8) Administer pain medication. 1) Don clean nonsterile gloves. 4) Remove soiled dressing. 2) Set up a sterile field with supplies. 3) Pour irrigation solution into sterile bowl. 5) Don sterile gloves. 7) Fill the irrigation syringe. 6) Gently irrigate wound. Rationale: The nurse administers pain medication before the procedure; then the nurse helps the patient to a comfortable position. The nurse then dons nonsterile gloves to remove the soiled dressing. After removing the dressing, the nurse disposes of the dressing and gloves in a biohazard receptacle. The sterile field and supplies are assembled, and irrigation fluid is poured in the bowl. The nurse dons sterile gloves. Then, the nurse fills the sterile syringe with sterile irrigating fluid, and finally the wound is gently irrigated.

A client who lives alone and relies on Social Security as his only income has had back pain for several years. He says, "I've tried everything, but the doctors can't help me. I saved a little money each month and finally got enough to buy a magnet-therapy mattress. I've had it a week now, and I'm hoping it will help." What should the nurse say? A) "That may be the answer for you. Tell me how you're doing when I come next week." B) "That's great! I understand that magnet therapy is very effective for relieving pain." C) "I hope it works, but there is no scientific evidence that magnet therapy is effective." D) "You should see if they will let you return it. It is a waste of money for you."

A) "That may be the answer for you. Tell me how you're doing when I come next week." Rationale: There is no evidence that magnet therapy is effective for pain; however, it is safe to use. The nurse should remain neutral, document the client's decision, and monitor the effects of the therapy. This is achieved by saying, "That may be the answer for you." Telling the patient that "magnet therapy is very effective" might have a placebo effect; however, it is an untrue statement. Saying, "There is no scientific evidence that magnet therapy is effective" is truthful, but it might have a nocebo effect. Because the client already has made the decision and is using the therapy, the nurse might as well make use of the placebo effect, saying, "That may be the answer for you." The statement "It is a waste of money for you" may be true. However, it does not respect the client's autonomy and questions his judgment.

Identify five components of nursing documentation that demonstrate legally defensible quality care.

Any five of the following components constitute an acceptable answer: Legibility Patient's name, information, and date are on each sheet No blank spaces between entries Accurate and objective Clear and concise Errors lined out and initialed No correction fluid or "inking over" the error Signature of the care provider and his or her title Late entries clearly noted

A client tells the nurse that she is attending a t'ai chi class to help her improve her balance and increase her physical stamina. Which nursing intervention(s) is/are safe and probably effective for the client's purposes? Select all that apply. A) Encourage the client to attend t'ai chi. B) Document that the client is attending t'ai chi. C) Follow up later to monitor the effects and any side effects. D) Find out whether agency policy supports the use of t'ai chi.

A) Encourage the client to attend t'ai chi. C) Follow up later to monitor the effects and any side effects. Rationale: Nurses should promote and use practices that are safe and helpful, not discourage practices that are neutral (safe) and that may help, and discourage and protect the patient against practices that may be harmful. T'ai chi is relatively safe for people of all ages, and it is thought to be beneficial for improving balance and increasing physical stamina. The nurse should not discourage the client's practice. The nurse should document the client's CAM therapies, and monitor improvements and side effects that occur. The nurse does not need to know agency policy because the nurse is not providing the therapy, nor advising the client to use the therapy. For a practitioner-based therapy, such as Reiki, the nurse would need to know agency policy before administering the therapy.

Assessing a client's nails and hair is often not a critical assessment. But these items are important to include in a complete physical exam for which of the following reason(s)? Select all that apply. A. Abnormal assessment findings may indicate a self-care deficit. B. Changes in the distribution of hair and/or color of nailbeds may indicate the presence of a more serious disease. C. Alterations in assessment findings related to hair and nails may represent underlying malnutrition. D. The presence of a callus formation around the nail may indicate a malignancy.

A, B, C Rationale: Nails should be clean and free of debris. A change in nail shape may indicate underlying disease or malnutrition. Nail-picking may result in callus formation, but a callus around the nail does not indicate malignancy.

Which of the following factors should the nurse consider when planning client education? Select all that apply. A. Health beliefs B. Culture C. Age D. Developmental stage

A, B, C, D Rationale: All of the factors should be considered when planning patient education. In addition, you should assess the following personal factors that affect learners' ability to process and retain information: learning needs, client's knowledge level, health beliefs and practices, emotional readiness to learn, ability to learn, literacy level, preferred learning styles, and neurosensory factors, such as vision, hearing, and manual dexterity.

Documentation of nursing care for home health patients requires which of the following? Select all that apply. A. Certification of homebound status B. Use of the OASIS data set C. A weekly summary describing the patient's status and ongoing needs D. Ongoing assessment of need for skilled nursing care

A, B, D. You must document evidence of homebound status, use the OASIS data set, and document ongoing need for skilled nursing care. Rationale: The requirement is for a monthly, not weekly, summary describing the patient's status and ongoing needs.

Which of the following nursing actions facilitates the goal of home healthcare? A. Ensuring that a patient is able to take over the care of his ostomy B. Straight catheterizing a patient every 8 hours C. Administering subcutaneous insulin twice a day D. Changing a wound dressing once a day

A. Ensuring that a patient is able to take over the care of his ostomy Rationale: The goal of home care nursing is to promote self-care. The nurse may complete the other activities listed on a short-term basis but should be teaching the client or family member these skills as the visits progress.

Which of the following is the least reliable source of drug information? A. Internet B. Nursing Drug Handbook C. United States Pharmacopoeia D. Medication package inserts

A. Internet Rationale: Although some Web sites on the Internet offer acceptable drug information, not all Web sites are put up by reliable sources. Some serve as advertisements for the drug, with the aim of product endorsement rather than providing noncommercial drug information.

According to the text calculations, which of the following patients is taking in the correct number of kcal to meet their total energy needs? Choose all that apply. A. Mr. Jones, who weighs 180 lb, is active, has a normal weight, and is taking in 3,240 kcal per day. B. Mrs. Sanchez, who weighs 220 lb, is sedentary, overweight, and taking in 1,000 kcal per day. C. Susan, who weighs 100 lb, is slightly underweight, plays soccer three times a week, and is taking in 1,500 kcal per day. D. Mr. Clark, who works a desk job, weighs 190 lb (a normal weight for his height), and is currently taking in 2,800 kcal per day.

A. Mr. Jones, who weighs 180 lb, is active, has a normal weight, and is taking in 3,240 kcal per day. Rationale: Although Mrs. Sanchez is overweight, her caloric intake may not enable her to meet her daily metabolic needs in terms of maintaining health. Susan's caloric intake is not enough to meet her active lifestyle, and Mr. Clark's caloric intake is too large given his sedentary job.

For which of the following sleep disorders would the nurse most likely need to include safety measures in the plan of care? A. Narcolepsy B. Restless legs syndrome C. Sleep deprivation D. Bruxism

A. Narcolepsy Rationale: Persons with narcolepsy experience sudden, uncontrollable episodes of sleep that may lead to various forms of injury even in the hospital environment.

Suzie is instructed by the charge nurse of the unit to restrain her confused, older patient. Suzie believes she can control the patient's behavior by using alternative means, such as music therapy and calling in the patient's family. Suzie is honoring which ethical principles? A. Nonmaleficence B. Autonomy C. Fidelity D. Veracity

A. Nonmaleficence Rationale: The other responses are incorrect because a confused patient may not be competent enough to make his own decisions (autonomy), there was no promise made in this scenario (fidelity), and this is not an example of having to tell the truth (veracity).

Which of the following factors puts the patient at greatest risk for impaired skin integrity? A. Peripheral vascular disease B. Tanning once a week C. An 1,800-calorie diet D. A temperature of 101.5°F

A. Peripheral vascular disease Rationale: Although tanning and a high fever are risk factors for impaired skin integrity, arterial peripheral vascular disease directly affects the delivery of oxygen and nutrients to the skin and the removal of waste products. An 1,800-calorie diet is not, in and of itself, a risk factor.

The nurse is ambulating Mr. Sanchez, who had a bowel resection yesterday. Suddenly, Mr. Sanchez states, "It feels like I've popped open." The nurse observes that the abdominal incision has opened 3 inches and a small section of the bowel is protruding. In addition to calling the physician immediately, the nurse would do which of the following? A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline. B. Position the patient prone to put pressure on the area, and instruct him not to cough. C. Place the patient supine in bed, legs flat, and cover the wound with dry, sterile dressings. D. Position the patient in Trendelenburg's position, knees flexed, and cover the wound with an occlusive dressing.

A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline. Rationale: This wound likely has eviscerated, which is a total separation of the layers of a wound in which internal viscera protrude through the incision. This is a rare complication and is a surgical emergency. Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bacteria. Have the patient stay in bed supine with knees bent to minimize strain on the incision. Notify the surgeon and ready the patient for a surgical procedure (see Chapter 39 for perioperative care).

In terms of medical practices, administering IV albumin to a person with cirrhosis is an example of: A. allopathy. B. holistic healing. C. placebo therapy. D. integrative care.

A. allopathy. Rationale: Conventional medicine is referred to as allopathy, a term used to indicate medical practice that treats disease with remedies that counteract the effects of the disease. Albumin administered IV to a patient with cirrhosis is a medical practice.

Failure to thrive

Affects institutionalized elders

What approach might the community health nurse use to collect information about the community in her district? Select all that apply. 1) Windshield survey 2) Interviews with residents 3) Internet topographical search 4) Public records 5) Walking tour

All the above. Assessment of the community characteristics is an ongoing process and best when it includes a variety of sources. The community health nurse does a windshield survey by driving or walking through the community and visually noting the condition of residences and other buildings, lighting, streets, litter, transportation, public buildings, and other aspects of the environment. Interviews with residents can provide perceptions and experiences representative of the health conditions in the community. An Internet topographical search is available from global positioning systems (GPS). Satellite mapping devices show the macrocommunity or can be zoomed to a microview of individual homes and property. Public records, such as birth, death, marriage, and divorce statistics and epidemiological records, provide information about the character and health of the community.

Aggregate

An example of a/an _________________________ would be women in the state who have survived breast cancer.

Narrative Charting

Assessment data, interventions, and patient responses written in a detailed chronological manner

Which trait or skill distinguishes a holistic nursing approach? A) Extensive knowledge of therapeutic touch B) Attitude toward patient care C) Knowledge in all areas of CAM D) Excellent assessment skills

B) Attitude toward patient care Rationale: It is your attitude, approach, and interventions that make you a holistic nurse, not the words you use to describe your patient's problem. Nurses need knowledge of CAM therapies, including TT, in order to interact with clients. However, knowledge of these approaches does not imply a willingness to use or discuss these therapies with patients. All nurses need excellent assessment skills.

Identify the holistic nursing theorist who describes disease as disequilibrium, which stimulates the person toward growth and regaining wholeness. A) Jean Watson B) Margaret Newman C) Martha Rogers D) Charles Darwin

B) Margaret Newman Rationale: Margaret Newman identifies disease as disequilibrium, which stimulates the person toward growth and regaining wholeness. Jean Watson identifies caring as the primary focus of nursing. Martha Rogers states that the environmental energy field is in constant and meaningful interaction with the human energy field. Charles Darwin created the theory of natural selection. He is not a nursing theorist.

Which of the following data would you likely obtain during a general survey of the client during the physical examination? Select all that apply. A. Bowel sounds present × 4 quadrants B. Blood pressure 130/70 mm Hg C. Speech appropriate to developmental stage D. Gait steady

B, blood pressure; C, speech appropriate, D, gait steady Rationale: A general survey includes physical appearance, mental status, mobility, client behavior, and vital signs. The general survey provides cues to guide physical assessment. The presence or absence of bowel sounds is determined by auscultating the abdomen, an assessment skill used during a head-to-toe or focused assessment.

The nurse is obtaining a medication history. The patient tells the nurse that he takes 2,000 mg of vitamin C per day and 1,000 units of vitamin E per day to prevent atherosclerosis. Which of the following would be the nurse's best response? A. "That is a very good idea, given your history of hypertension." B. "Research indicates there is no benefit to megadoses of vitamins." C. "Oh that's very, very bad for you, and you should stop right away." D. "You'd better let your doctor know that you are doing that."

B. "Research indicates that there is no benefit to megadoses of vitamins." Rationale: The role of the nurse in this situation should be one of providing information rather than chastising the patient or ignoring a teachable moment by directing him to the physician. Megadoses of vitamins have not shown therapeutic effect. In addition, recent research has demonstrated a potentially harmful effect of high-dose vitamin E supplementation. Because of the potential for harm, the nurse should not support this practice.

Identify the patient with the greatest risk for developing protein-calorie malnutrition. A patient: A. who is HIV positive B. with a fractured leg and pelvis from trauma who is running a fever of 101.5°F (38.6°C) C. weighing 300 lb who has entered the hospital for cardiac bypass surgery D. who is of Hispanic heritage

B. A patient with a fractured leg and pelvis from trauma who is running a fever of 101.5°F (38.6°C). Rationale: The trauma patient with a fever could be developing a wound infection, which demands additional energy for healing. There is no information to indicate that the person with HIV is not eating well. An obese patient may malnourished after surgery, with the diet that is high in calories but low in nutrients, especially protein. Race alone (Hispanic) is not a risk factor for protein-calorie malnutrition.

Which of the following is the best example of an issue reflecting nursing ethics? A. The physician and the patient's family decide to stop tube feedings for the patient. B. A patient with a history of drug abuse has not been receiving adequate pain relief because the lowest dose of the prn narcotic is being given. C. The physical therapist is refusing to work with a patient who is overweight because she (the physical therapist) believes she will be injured. D. A patient with a history of alcohol and drug abuse will receive a liver transplant.

B. A patient with a history of drug abuse has not been receiving adequate pain relief because the lowest dose of the prn narcotic is being given. Rationale: The nurse would be choosing from a "range dose" of pain medication, and the ethical decision would be to medicate the patient for pain without passing judgment on the patient's past behavior. The nurse is not a participant in the final decision to withhold feedings or to transplant the liver or in the physical therapist's decision.

The physician has prescribed enemas for Mr. Gray until the return is clear. The nurse is to use a hypertonic solution. The nurse would question the order if Mr. Gray had which of the following conditions? A. Constipation B. Chronically elevated BUN and creatinine C. Peptic ulcer disease D. Multiple sclerosis

B. Chronically elevated BUN and creatinine Rationale: An elevated BUN and creatinine could indicate the presence of chronic renal disease. Hypertonic solutions are sodium based and could exacerbate water retention in this client if used repeatedly.

A patient's urine specific gravity has been reported at 1.035. Which of the following nursing actions would be appropriate? A. Start an IV of normal saline at 150 mL per hour. B. Encourage the patient to increase fluid intake. C. Insert a straight catheter to assess for urinary retention. D. Obtain an order for fluid restriction from the physician.

B. Encourage the patient to increase fluid intake. Rationale: A specific gravity of 1.035 would indicate concentrated urine, indicating the possibility of dehydration. Starting an IV of normal saline is not an independent nursing action.

Which type of assessment is best suited for use in an emergency or urgent patient situation? A. Ongoing B. Focused C. Psychosocial D. Comprehensive

B. Focused assessment Rationale: Emergency and urgent situations require the use of a focused assessment, which will allow the nurse to quickly gather system-specific data related to a presenting problem. Both a comprehensive and an ongoing assessment would follow a focused assessment once the critical data are obtained. A psychosocial assessment is not directly relevant to a physical examination, especially in an urgent situation.

Which of the following is a complication of wound healing? A. Three centimeters of sanguineous fluid on a surgical dressing B. Hypotension and increased pain at the surgical site C. Presence of beefy red tissue in the center of a closing wound D. Low-grade temperature

B. Hypotension and increased pain at the surgical site Rationale: Falling blood pressure and increasing pain may indicate internal hemorrhage. Responses A and C, sanguineous fluid and red tissue, are normal findings. Response D, low-grade temperature, has other potential causes.

The use of abbreviations in healthcare contributes to which of the following? A. Decreased efficiency in documentation B. Increased risk for medical errors C. Uniform use in all facilities D. Ease in understanding physician orders

B. Increased risk for medical errors Rationale: The Joint Commission identifies the use of abbreviations as a significant risk factor in medical errors and is requiring that the following abbreviations not be used—u, iu, qd, and qod—because these abbreviations have been frequently cited in transcription errors.

When adapting the teaching strategies to geriatric clients, the nurse understands that there are changes that occur with aging that may hinder learning. Which of the following would be considered an abnormal finding? A. Hearing impairment B. Long-term memory loss C. Visual impairment D. Short-term memory loss

B. Long-term memory loss Rationale: Declines in visual perception and hearing acuity, as well as short-term memory loss, occur commonly with aging.

Which of the following is an example of a vulnerable population? A. Persons with an annual salary of $50,000 B. Persons living in an apartment complex for single seniors C. Persons who are members of a health club D. Persons having Blue Cross health insurance

B. Persons living in an apartment complex for single seniors Rationale: Older persons with little family support are at risk for health problems.

Which of the following laboratory results would indicate that a nurse may need to monitor a patient more closely for the development of drug toxicity? A. WBC of 9,000 B. Serum creatinine of 2 mg/dL C. Hematocrit 40 (female patient) D. Serum albumin 4 g/dL

B. Serum creatinine of 2 mg/dL Rationale: An elevated serum creatinine may indicate a potential decrease in kidney function. This could affect excretion of a drug and lead to buildup of active drug and therefore drug toxicity. All of the other lab values are within normal limits. The WBC and hematocrit levels would reflect the results of drug toxicity, not the cause.

Which of the following subjective data gathered from the client would indicate a risk for constipation? A. Use of vitamin C and caffeine B. Taking Maalox often for heartburn C. Drinking 1,500 mL of water during the day D. Eating yogurt for breakfast and taking a magnesium supplement

B. Taking Maalox often for heartburn Rationale: Maalox is an antacid, which would slow peristalsis. Between 1,500 and 2,000 mL of water should be adequate for normal bowel function. Vitamin C and caffeine do not slow peristalsis, nor do yogurt and magnesium; they stimulate peristalsis.

Mike, who is a charge nurse, thinks that honesty is very important. His coworker on the pediatric unit has come in late for the second day in a row, yet she is signing in as "on time." The coworker begs Mike not to report her to the supervisor. Which of the following is Mike is being asked to compromise? A. Integrity B. Values C. Beliefs D. Attitude

B. Values Rationale: A value is a belief that you have about the worth of something (being honest; telling the truth). A belief is something that one accepts as true. Integrity is your decision to do the right thing. Attitudes are mental dispositions or feelings toward a person, object, or idea.

Mrs. Katz has been admitted to the intermediate care unit with a diagnosis of acute gastrointestinal bleeding. Her blood pressure is 88/50 mm Hg, and her pulse is 120 beats/min. The nurse would expect Mrs. Katz's IV therapy to be: A. a blood transfusion. B. an isotonic fluid, such as normal saline. C. a peripheral IV lock. D. a hypotonic fluid, such as 5% dextrose.

B. an isotonic fluid, such as normal saline. Rationale: Although Mrs. Katz may need a blood transfusion, there are no data related to her hematocrit and hemoglobin levels. With a blood pressure of 88/50 mm Hg, she would need IV therapy to replace volume and correct her hypotension, and neither an IV lock nor hypotonic fluid would accomplish this goal.

Mastery Exercises Answers Exercise 1 Which of the following is an example of a vulnerable population? A. Persons with an annual salary of $50,000 B. Persons living in an apartment complex for single seniors C. Persons who are members of a health club D. Persons having Blue Cross health insurance Answer: B. Persons living in an apartment complex for single seniors Rationale: Older persons with little family support are at risk for health problems. Exercise 2 There has been a sudden increase in the number of childhood measles cases in a particular area of a city. To protect the health of the community, which of the following actions should be taken? A. An acute care nurse should investigate the disease prevalence. B. Community-based care should be instituted. C. A public health nurse should be sent into the community. D. A pediatric nurse should be sent to that area of the community. Answer: C. A public health nurse should be sent into the community. Rationale: The other responses are incorrect. An acute care nurse may not have the knowledge base necessary to deal with community health issues. The same may be said for a pediatric nurse. Community-based care is a global term not specific to the issue presented. Exercise 3 Educating 6-year-olds about prevention of tooth decay is what type of intervention? A. Primary intervention of a school nurse B. Secondary intervention of a public health nurse C. Primary intervention of an occupational health nurse D. Tertiary intervention of a parish nurse Answer: A. Primary intervention of a school nurse Rationale: Primary interventions promote health and prevent disease. For this population, a school nurse would facilitate this educational intervention. Exercise 4 Roger is a public health nurse, and he wants to complete an assessment of the community assigned to him. Which of the following would be the least accurate way to complete this task? A. Use various public databases B. Arrange to meet with community focus groups C. Initiate a telephone survey D. Complete a windshield survey Answer: D. Complete a windshield survey Rationale: All other methods would elicit more actual and complete data than merely observing the community from an automobile. Exercise 5 Hospitals were originally established so that surgeons could perform surgeries in a more sterile environment. Answer: False Rationale: Hospitals were established to quarantine individuals with contagious diseases. Exercise 6 Student nurses who "meet" in an online chat room to discuss student issues could be considered a community. Answer: True Rationale: Student nurses share a common "language" and special customs, and they have a common purpose. Exercise 7 In a windshield survey, the nurse places questionnaires on car windshields throughout the community. Answer: False Rationale: A windshield survey entails observing the community through a car window or even on foot. Exercise 8 _________________________ may direct nursing care in a flood zone. Answer: The American Red Cross Exercise 9 _________________________ involves coordination, advocacy, and referral between the client and the community resources. Answer: Case management Exercise 10 An example of a/an _________________________ would be women in the state who have survived breast cancer. Answer: aggregate Exercise 11 Juanita is an RN with Fidelity Home Care. She is doing an initial visit with a new client and notes that the home environment is very dirty. There are unwashed dishes, opened food boxes, spilled and dried food, and overflowing trash containers. Which of the following would be an appropriate action? A. Call in a cleaning service for the client. B. Notify the home care manager that nurses cannot work in this type of environment. C. Go to the local market and buy cleaning supplies, and begin cleaning the area. D. Complete a further assessment of the patient/family situation to determine the cause of the problem. Answer: D. Complete a further assessment of the patient/family situation to determine the cause of the problem. Rationale: Although a dirty environment is of concern because of its potential effect on the client's health, the home care nurse must remember that she is a guest in the client's home. The nurse's best approach would be to collaborate with the client in determining a solution. Exercise 12 Which of the following nursing actions facilitates the goal of home healthcare? A. Ensuring that a patient is able to take over the care of his ostomy B. Straight catheterizing a patient every 8 hours C. Administering subcutaneous insulin twice a day D. Changing a wound dressing once a day Answer: A. Ensuring that a patient is able to take over the care of his ostomy Rationale: The goal of home care nursing is to promote self-care. The nurse may complete the other activities listed on a short-term basis but should be teaching the client or family member these skills as the visits progress. Exercise 13 Medicare would most likely deny reimbursement for home care services for which of the following reasons? The client: A. is unable to leave her home. B. needs grief counseling after the loss of a spouse. C. needs a wound dressing changed three times a day. D. needs twice-a-day antibiotic therapy for severe osteomyelitis.

B. needs grief counseling after the loss of a spouse. Rationale: Grief counseling may be done in a variety of settings. There needs to be evidence that the client is homebound for this to be considered as a home care service.

When reviewing your documentation of a patient, it should reflect: A. everything that could have been done during your shift. B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response. C. details about scheduled procedures, medications administered, and tasks completed during the shift. D. a detailed narrative account of what occurred every 30 minutes to 1-hour during the shift.

B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response. Rationale: Your documentation should be objective, accurate, and comprehensive, focusing on patient assessment data, interventions provided, and evaluation of the patient's response to care or teaching. Response A is incorrect, as you should document care that was provided. Response C only includes interventions and tasks and no assessment or evaluation data. Response D may include unnecessary data. Just document your nursing actions (assessment, diagnosing, planning, interventions, and evaluation).

The most important advantage of using electronid health records is: A. more convenient access to patient health information. B. reduced errors in healthcare delivery. C. increased data available for research. D. easier patient documentation for nurses.

B. reduced errors in healthcare delivery Rationale: Although choices A, C, and D might also be true, a reduced error in healthcare is the most important benefit of using electronic health records.

Mr. Shoen has congestive heart failure. In obtaining a dietary history from Mr. Shoen, the nurse notes that his meals consist of many high-sodium foods. The nurse should teach the patient that a diet high in sodium will cause him to: A. lose too much fluid volume and his blood pressure to fluctuate. B. retain fluid, increasing the workload of his heart. C. lose potassium, putting him at risk for cardiac arrhythmias. D. lose calcium, putting him at risk for osteoporosis.

B. retain fluid, increasing the workload of his heart. Rationale: A high-sodium diet would not cause fluid loss, potassium loss, or calcium loss. Sodium contributes to fluid retention.

Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 inches (7.5 cm) in diameter and ½ inch (1.2 cm) deep around and under the lesion and left the wound open to heal. The wound will heal by: A. primary intention. B. secondary intention. C. third intention. D. tertiary intention.

B. secondary intention.

The tip of all central venous access devices infuses IV fluids into the: A. jugular vein. B. superior vena cava. C. subclavian vein. D. brachial vein.

B. superior vena cava. Rationale: Although central venous access device catheters may be inserted into the jugular, subclavian, or brachial vein, the end of the catheter is threaded into the superior vena cava.

Katie is a new graduate nurse who has just begun working the night shift. She complains that she feels very irritable and is experiencing general malaise. An experienced coworker explains that A. this problem is a result of hypersomnia. B. this problem will resolve as Katie's body adjusts to the new day/night schedule. C. Katie should try medication to help alleviate her symptoms. D. Katie should try cutting down the number of hours she is sleeping during the day.

B. this problem will resolve as Katie's body adjusts to the new day/night schedule. Rationale: Katie is experiencing some mild symptoms of sleep deprivation, which are affecting her circadian rhythm. Hypersomnia may result from sleep deprivation. Medication will not adjust circadian rhythms; cutting down on sleep will exacerbate the problem.

If a child has a cold and the mother calls to ask the nurse whether it is safe to use honey for the child's cough, how should the nurse respond? A) "Yes, it's safe." B) "No, honey is not safe." C) "How old is your child?" D) "Have you asked your doctor?"

C) "How old is your child?" Rationale: Honey is safe as a cough suppressant, but giving it to a child depends on the child's age, so the nurse cannot answer yes or no without knowing the child's age. At least one study has found buckwheat honey to be slightly superior to dextromethorphan in relieving cough frequency and severity in children (Ashkin & Mounsey, 2013; Cohen, Rozen, Kristal, et al., 2012; Shadkam, Mozaffari-Khosravi, & Mozayan, 2010). Advise parents not to give honey to children under 1 year of age because it has definitively been linked to infant botulism in laboratory and epidemiological studies. There is no need to consult the physician because the nurse is not prescribing. Because of the risk of infant botulism, a rare but serious form of food poisoning, never give honey to a child younger than age 1.

A client with back pain is receiving reflexology treatments and aromatherapy with massage. In addition, the client prays daily for pain relief. The client is hoping these treatments will help him avoid seeking a surgical solution. What type of care do these illustrate? A) Integrative B) Complementary C) Alternative D) Allopathic

C) Alternative Rationale: Integrative healthcare refers to coordinated care that encompasses all treatments and health practices used by a patient. A complementary modality is one that is used together with traditional medical care. An alternative modality is one that is used instead of traditional medical care. Allopathic care is traditional medical care focused on counteracting symptoms.

Which of the following patients should the nurse advise not to have deep muscle massage? One who A) is an older adult. B) is an adolescent. C) has a history of phlebitis. D) has much muscle tension.

C) has a history of phlebitis. Rationale: Massage therapy is safe for most people. One of its uses is to relieve muscle tension. Although massage is relaxing, it is not advisable for everyone. People with a history of phlebitis or vascular disorders should not receive deep muscle massage because of the risk of dislodging an embolus.

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion

C, A, D, B Rationale: Inspection begins immediately when the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

Mary, a young adult female, has experienced a miscarriage after 10 weeks of pregnancy. She is crying and states that this probably happened because her husband does not believe in God. What is your best your best response to Mary? A. "God doesn't punish people for their beliefs." B. "Do you want to talk about your anger at your husband's lack of faith?" C. "You sound very upset. Would you like to talk about these feelings?" D. "You sound really upset. Would you like to see the hospital chaplain?"

C. "You sound very upset. Would you like to talk about these feelings?" Rationale: This response acknowledges her distress and doubts and offers her an opportunity to verbalize her conflicts. Response A does not validate her feelings. Response B does not keep the focus on her and her own spiritual needs. Response D can be helpful, but you have missed an opportunity to allow her to explore her feelings related to the miscarriage.

There has been a sudden increase in the number of childhood measles cases in a particular area of a city. To protect the health of the community, which of the following actions should be taken? A. An acute care nurse should investigate the disease prevalence. B. Community-based care should be instituted. C. A public health nurse should be sent into the community. D. A pediatric nurse should be sent to that area of the community.

C. A public health nurse should be sent into the community. Rationale: The other responses are incorrect. An acute care nurse may not have the knowledge base necessary to deal with community health issues. The same may be said for a pediatric nurse. Community-based care is a global term not specific to the issue presented.

The nurse providing preoperative teaching understands that immediacy of need is a motivator for learning. Based on this concept, which topic would the nurse avoid when teaching the patient before surgery? A. Instruction for turning, deep breathing, and coughing B. An explanation of what to expect during the preoperative phase C. Follow-up resources D. Orientation to the hospital

C. Follow-up resources Rationale: The topic of follow-up resources will not be covered during preoperative teaching because it is too distant from the immediate needs of the patient before surgery. Teaching will focus on what the patient will experience from the point at which he enters the hospital through to his surgery.

The nurse is caring for Peter, a 58-year-old man with COPD. Peter's pulse oxygen saturation has declined from 90% to 84% on 2 liters of oxygen. The patient's breath sounds are decreased, and he is now short of breath. The nurse decides that the patient needs a respiratory treatment. This is an example of which of the following? A. Application of wisdom B. Stating data C. Formation of new knowledge D. Informatics

C. Formation of new knowledge Rationale: The nurse has grouped her data and created a meaningful relationship to make a clinical decision. It is more than simply stating data, and knowledge about patient care does not constitute informatics.

Mr. Martinez has had extensive abdominal surgery. In terms of promoting wound healing and tissue growth, which stage of sleep is most important for him? A. NREM I B. NREM II C. NREM III D. REM

C. NREM III

A person who spends a great deal of time reviewing his belief system and comparing and contrasting it with alternatives is experiencing which of the following? A. Spiritual growth B. Religiosity C. Religious struggle D. Spiritual distress

C. Religious struggle Rationale: Religious struggle is conflict that arises within the self, with others, and with God that can lead to spiritual growth, crisis, or despair. Growth is learning and becoming more versed in one's faith and belief system. Religiosity is a preoccupation with religion or religious themes. Spiritual distress is intense conflict between one's faith beliefs and a situation that is counter to or challenges these beliefs.

The nurse would suspect an alteration in a patient's nutritional status if she notes which of the following? A. Fasting serum blood glucose of 87 mg/dL B. BUN of 16 mg/dL C. Serum albumin level of 1.8 g/dL D. Total white blood cell count of 6,000/mm3

C. Serum albumin level of 1.8 g/dL Rationale: All of the other results are within normal limits.

Mrs. Sanchez is awaiting surgery for a right hip fracture. The physician suspects that Mrs. Sanchez has a urinary tract infection. The nurse anticipates that the physician will order which of the following? A. Freshly voided urine specimen in the morning B. Clean-catch specimen C. Sterile urine specimen D. 24-hour urine collection

C. Sterile urine specimen Rationale: For most patients, a clean-catch specimen would be ordered. However, because Mrs. Sanchez would need to use a "fracture pan," it is very likely that the specimen would be contaminated during collection. As a result, a straight catheterization will be needed.

Mrs. Lataya was experiencing nausea when taking her daily dose of tetracycline. Today, she tells the clinic nurse that she started taking Mylanta with the medication and the nausea has subsided. The nurse can expect which of the following? A. There will be no problem as a result of this action. B. The physician will stop the tetracycline. C. The infection will take longer to heal. D. The patient's serum calcium level will decrease.

C. The infection will take longer to heal. Rationale: Mylanta will slow the absorption of tetracycline, which will decrease the bioavailability of the drug. This may decrease its effectiveness in treating the infection. The provider may need to prescribe a longer course of the antibiotic. The interaction of the medications would have no effect on the serum calcium.

Cammy Smith is brought to the emergency room following an attempted robbery. She is extremely distraught and hyperventilating. If an arterial blood gas sample were to be obtained, the nurse would expect to find: A. a falling pH and a rising PCO2. B. a rising pH and a rising PCO2. C. a rising pH and a falling PCO2. D. a falling pH and a falling PCO2.

C. a rising pH and a falling PCO2. Rationale: The patient would be developing respiratory alkalosis, which would be identified by a rise in pH and a decrease in the PCO2 due to the hyperventilation.

The physician prescribes a test for occult blood to be done on Mrs. Petrowski's stool. The result has come back negative. To be sure you do not have a false negative reading, which information do you need to ask Mrs. Petrowski? Whether she has been A. using iron preparations B. eating red meat in the past 3 days C. taking vitamin C D. taking the diuretic, furosemide

C. taking vitamin C Rationale: Vitamin C can cause a false negative result. Iron preparations and red meat can cause a false-positive result, but not a false-negative result, so there is no need for the nurse to obtain this irrelevant data. Response D, furosemide, has no connection whatever to a fecal occult blood test result, so it too is irrelevant.

Jan is an RN, and today she is working with Mary, the new nursing assistant. The nursing supervisor knows that Jan understands proper delegation in relationship to wound care when she asks Mary to: A. debride a clean wound healing by primary intention. B. evaluate how treatment is working for a decubitus ulcer. C. turn a comatose patient every 2 hours. D. irrigate an open wound using vigorous flushing.

C. turn a comatose patient every 2 hours. Rationale: Responses A and B, debridement and treatment evaluation, are the responsibility of the licensed nurse. Response D, vigorous flushing of a wound, may cause damage to healing tissue.

_____ involves coordination, advocacy, and referral between the client and the community resources.

Case management

It is permissible for student nurses to scan, photograph, or print patient information to use at home in preparing for a clinical assignment because students are exempt from HIPAA regulations.

False Rationale: Students are held to the same HIPAA standards as are other members of the healthcare team.

What is the best rationale for gathering data about patients' use of herbal products? A) The nurse practice act requires RNs to monitor all drug dosages. B) Herbal products need to be evaluated for research purposes. C) Patients' medication records must be kept accurate. D) Many herbs are known to interact with medications.

D) Many herbs are known to interact with medications. Rationale: Many herbs are known to interact with medications and to affect some disease processes adversely. Nurse practice acts do require RNs to assess patients but do not specifically require monitoring of drug dosages. Herbal products do need to be evaluated in research, and medication records must be accurate, but they do not provide the rationale for patient data collection.

Mr. Jones, a former patient who survived a serious illness, comes to your patient care unit on Saturday afternoon. He has packets of literature about his religion; its philosophy, values, meeting places; and some prayers. He asks if he can place the information in the family waiting area. What is your best response? A. "Yes, this would be helpful for many of the families. B. "No, hospital policy doesn't allow for it." C. "I would be happy to do it for you. Let's place the literature in the staff lounge." D. "I will need to check the hospital's policy and discuss your request with my manager."

D. "I will need to check the hospital's policy and discuss your request with my manager. Rationale: The best response is to find out whether the hospital has a policy on literature and solicitation before you either encourage or discourage the patient's action. Response A does not represent respecting those patients or families who may be uncomfortable with this literature. Response B can be correct but does not demonstrate respect or appreciation of the patient's spirituality. Response C avoids the problem and does not address the spiritual issues.

Which of the following is/are not an anthropometric measurement of body composition? A. Using calipers to measure the skinfold on the triceps B. Obtaining the waist-to-hip ratio C. Hydrodensitometry D. 24-hour food recall

D. 24-hour food recall Rationale: Asking the client to recall his food intake for the past 24 hours is an example of obtaining subjective data. Exercise 4

In completing a nursing assessment of the skin, the nurse knows to instruct the client to seek medical attention for which of the following? A. Acne on the face and neck B. Crusts that have formed over pustules C. Striae found on a female patient's abdomen D. A mole that has become asymmetrical

D. A mole that has become asymmetrical Rationale: A change in the size, shape, color, or elevation above the skin surface of a mole could indicate the presence of a malignant lesion.

Mr. Martinez is being treated for pain related to prostate cancer that has metastasized to the spine. He tells the nurse that the Fentanyl patch that was applied during the last shift is not working. Which of the following is the nurse's best response? A. Remove the patch, and apply a new one. B. Teach Mr. Martinez that the patch has not yet reached its full effect. C. Call the provider to inform him that the patch is not meeting the patient's pain relief needs. D. Administer the prn IV morphine that is prescribed for breakthrough pain.

D. Administer the prn IV morphine that is prescribed for breakthrough pain. Rationale: The Fentanyl transdermal patch releases a steady amount of medication per hour. Normally the patient will begin to feel the effects of the medication within 1 hour. Applying a new patch would not facilitate immediate pain relief. Merely teaching the patient about the patch is not tending to his pain needs. The provider has already prescribed medication for breakthrough pain and expects the nurse to know how to monitor the patient's response to the medication.

The nurse notes that there has only been 100 mL of urine output from his patient's Foley catheter in 6 hours. The nurse should first do which of the following? A. Instruct the patient to drink two glasses of water. B. Call the doctor immediately. C. Irrigate the Foley catheter with 30 mL of sterile saline. D. Assess the catheter tubing and the patient's abdomen.

D. Assess the catheter tubing and the patient's abdomen. Rationale: The nurse should first determine whether urine is being retained in the bladder. This can be accomplished through palpation of the bladder and/or checking the catheter tubing for kinks.

Mrs. Smith is a patient on a medical unit. It is 0300, and she is requesting that the nurse give her some Kaopectate for her third diarrhea stool. The nurse notes that there is no provider's prescription for this medication. Which of the following would be the nurse's best action? A. Check the PDR for the correct dose, administer the Kaopectate, and obtain a provider's prescription for it in the morning. B. Inform the patient that there is no prescription for this medication and that because it is too late to call the provider she will have to wait until the morning. C. Call the pharmacist to obtain the correct dose, write a verbal prescription from the pharmacist, and administer the medication. D. Assess the patient, gather pertinent data, and call the provider to obtain a prescription for the medication.

D. Assess the patient, gather pertinent data, and call the provider to obtain a prescription for the medication. Rationale: You must obtain a provider's prescription for all medications administered because this is required by your state's nurse practice act. Even though it is good practice to check the PDR for the correct dose, nurses still may not administer a medication without a provider's prescription. A patient with diarrhea could be at risk for fluid and electrolyte imbalances; therefore, diarrhea should not be left untreated. The pharmacist is not permitted to independently write medication prescriptions.

Charting by exception: A. is a reliable form of documentation that minimizes errors. B. should be used only in ambulatory clinics and long-term care facilities. C. increases the risk of malpractice liability because of the belief "not documented, not done." D. can be used to document care accurately on stable patients.

D. Can be used to document care accurately on stable patients. Rationale: Charting by exception simplifies nursing documentation by eliminating the need to document routine, stable patient information. It should be used in conjunction with flowsheets and brief narrative charting to ensure comprehensive documentation. This form of documentation does not minimize risks because nurses need to be sure they have included both routine and variant findings. It can be used successfully in any type of healthcare setting. Liability does not increase if the nurse follows reasonable and prudent guidelines for documenting patient care information.

Facilitating relaxation by placing a lavender-scented sachet near a patient's head, in addition to medicating the patient with a small prescribed dose of alprazolam, an anti-anxiety medication, is an example of which of the following? A. Biofeedback B. Alternative medicine C. Aromatherapy D. Complementary therapy

D. Complementary therapy Rationale: Using a lavender-scented sachet is a form of aromatherapy. When this approach is combined with administration of a tranquilizer, an allopathic treatment, the nurse is practicing complementary therapy.

Juanita is an RN with Fidelity Home Care. She is doing an initial visit with a new client and notes that the home environment is very dirty. There are unwashed dishes, opened food boxes, spilled and dried food, and overflowing trash containers. Which of the following would be an appropriate action? A. Call in a cleaning service for the client. B. Notify the home care manager that nurses cannot work in this type of environment. C. Go to the local market and buy cleaning supplies, and begin cleaning the area. D. Complete a further assessment of the patient/family situation to determine the cause of the problem.

D. Complete a further assessment of the patient/family situation to determine the cause of the problem. Rationale: Although a dirty environment is of concern because of its potential effect on the client's health, the home care nurse must remember that she is a guest in the client's home. The nurse's best approach would be to collaborate with the client in determining a solution.

The nurse notes that a patient on her unit has had a very high temperature for the past 2 days. Today, the patient's skin turgor is poor, and she tells the nurse her mouth feels very dry. Which of the following is the nurse's best response? A. Call the physician to request an IV fluid bolus. B. Place the patient on intake and output measurements. C. Restrict the patient's fluid intake to 600 mL for the rest of the shift. D. Encourage the patient to drink at least 1 liter of fluid during the rest of the shift.

D. Encourage the patient to drink at least 1 liter of fluid during the rest of the shift. Rationale: The patient is slightly dehydrated, and an IV fluid bolus would only be necessary if the patient exhibited serious signs of hypovolemia or could not tolerate oral liquids. You would not restrict the fluid intake. Merely measuring the patient's intake and output will not address the dehydration.

Mrs. Sebink has been in the acute care facility for 4 days. It is 0100 and she tells the nurse that this is the third night that she has not been able to get to sleep. The nurse's most appropriate action is to do which of the following? A. Have the patient begin a sleep diary. B. Provide the patient with a warm cup of tea. C. Obtain the patient's sleep history. D. Obtain a prescription from the physician for a sleeping pill.

D. Obtain a prescription from the physician for sleep-enhancing medication. Rationale: Other responses are incorrect. Although the information gathered from a sleep diary and/or sleep history would be helpful, the patient's problem is most likely a temporary problem related to the strange hospital environment. A brief sleep history should be available on Mrs. Sebink's admission assessment. Most teas contain caffeine, which might exacerbate the problem of difficulty falling asleep.

Susan is a nurse who works on a busy rehabilitation unit. She finds a research article containing evidence that putting food coloring in tube feeding solutions increases the incidence of diarrhea in that patient population. She brings the research article to the policy committee to investigate having the policy changed. Susan is doing which of the following? A. Overstepping her bounds as a nurse B. Using nursing informatics C. Creating an electronic health record D. Participating in evidence-based practice

D. Participating in evidence-based practice Rationale: Susan is attempting to change a practice routine based on current and scientifically sound research. The other choices are incorrect because the nurse is doing more than just using nursing informatics. In addition, there is nothing in the scenario to indicate that she used informatics at all. She is definitely not overstepping her bounds as nurses have a professional obligation to provide patient care that is supported by sound, scientific evidence. An electronic health record is documentation of patient information.

The law requiring children to be vaccinated against diphtheria can best be justified by using which ethical frameworks? A. Feminine ethics B. Autonomy C. Deontology D. Utilitarianism

D. Utilitarianism Rationale: Utilitarianism takes the position that the value of an action is determined by its usefulness: that an act must result in the greatest good for the greatest number of people. Vaccinations will protect entire populations. This would be the opposite of the deontological perspective in which parents may not want a child vaccinated because they fear neurological side effects. Some may argue for the principle of beneficence or nonmaleficence; however, those principles apply only to the particular child being vaccinated. So if, out of beneficence, you wanted to protect one child from harm, you would vaccinate only that child, not all children.

Medication Administration Record (MAR)

Documents routine, one-time, and prn medications

Insomnia

Difficulty in falling asleep or staying asleep

BMR

Energy required by resting tissue

Persons who are depressed have a heightened ability to fall asleep rapidly.

False

A person's reading level is a primary indicator of his health literacy.

False Rationale: A person's reading level is not necessarily a good indicator of the person's health literacy. A person might be able to read and write proficiently but not understand what the nurse is trying to communicate in the healthcare setting for knowledgeably making healthcare decisions. For instance, if the healthcare provider uses medical jargon or technical terminology that the patient does not understand, then there would be a gap in understanding, which is health illiteracy. General verbal skills and capacity for language in addition to knowledge about health-related terminology and concepts contribute to health literacy.

Tylenol is a generic name for a brand of analgesic medication.

False Rationale: Acetaminophen is the generic name; Tylenol is the trade name.

Herbs are all-natural products; therefore, there is no danger in using them as a complementary therapy.

False Rationale: Although many herbs are "natural," they often contain chemically active ingredients that can interact with prescription medications. Patients should be urged to let their care providers know about their use of herbs.

All medications that produce sleep are habit forming and therefore should be avoided as long as possible.

False Rationale: Although they have not undergone extensive testing, there are several herbal products available that may be used as sleep aids.

Patients who are placed on a fluid restriction may still have as much crushed ice as they desire.

False Rationale: Crushed ice must be counted as fluid intake, as is everything that becomes liquid at room temperature.

Drug dependence always leads to drug addiction.

False Rationale: Drug dependence is a physical need for the drug. Drug addiction occurs in those patients who seek the drug also to meet a deep psychological need for the euphoric effect of the drug.

Hospitals were originally established so that surgeons could perform surgeries in a more sterile environment.

False Rationale: Hospitals were established to quarantine individuals with contagious diseases.

The best overall measurement of total body fluid loss or gain is the measurement of intake and output.

False Rationale: Intake and output only measures the fluid that enters and exits the vascular system. It will not measure the fluid contained interstitially or fluid that is in a third space.

It is good for nurses to all use different terms to describe the same data because this will increase diversity in nursing language.

False Rationale: It should be a professional goal to make our professional language uniform, which should improve communication and understanding.

The most important assessment for the nurse to complete when evaluating a patient's nutritional status is lab results.

False Rationale: Lab results reflective of nutritional status may be skewed by many factors, including hydration status, medications, organ function, and so on.

It is permissible to crush the drug MS Contin SR (an enteric-coated, timed-released opioid) to administer it through a gastrostomy feeding tube.

False Rationale: MS Contin is an enteric-coated, timed-released opioid narcotic. Crushing this medication could lead to a fatal medication error, because of the immediate release of a large drug dose.

If the nurse is unsuccessful in his attempt to perform venipuncture for IV therapy, he should keep trying until the catheter is placed successfully in the vein.

False Rationale: Many institutions have policies regarding the number of attempts that may be made at venipuncture by the nurse. These policies often direct the nurse to enlist the assistance of a CRNA or IV nurse if unable to establish venous access after a number of attempts. We recommend, as do several guidelines, making only two attempts before seeking help.

The Braden scale is a way to measure the depth of a decubitus (pressure) ulcer.

False Rationale: The Braden scale is used to calculate a patient's risk for skin breakdown.

List the important factors to document when taking a provider's verbal order.

For verbal orders, the following factors are important to document: Write the prescription only if you heard it yourself; no third-party involvement is acceptable. Repeat the prescription even if you believe you have understood it entirely. Spell unfamiliar names using a system such as "B as in bravo." Pronounce digits of numbers separately; for example, instead of "seventeen" say "one, seven." Make sure the verbal orders make sense with the patient's status. If possible, have a second nurse listen to the order to verify accuracy. Directly transcribe the prescription to minimize the possibility of error. When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document "V.O.," followed by the ordering provider's name before yours. Be sure you have the contact information for the provider to allow access if future questions arise. The physician must countersign all verbal and phone orders within 24 hours.

Low-density lipoproteins

Increase the risk for cardiovascular disease

Change-of-shift report

Information received on the status of a group of individual patients

Discharge Summary

Initiated at time of admission and completed at discharge

Sodium

Intake should not exceed 5.8 grams/day

Magnesium

Involved in multiple biochemical reactions

List six teaching strategies.

Lecture Group discussion Demonstration and return demonstration One-to-one instruction and mentoring Audiovisual materials Printed materials Internet sources of information Role modeling

Faith, hope, love

List three core issues of spirituality.

Potassium

Low serum levels can lead to cardiac arrhythmias

Costovertebral angle

Percussion of the _________________________ that results in pain or discomfort could indicate the presence of an inflammatory process in the kidney.

Name one abnormal assessment finding related to the external eye.

Possible answers include crusting, swelling, pterygium, ectropion, entropion, and ptosis.

Z-track

Prevents medication leakage

SOAP/PIE

Progress note that reflects only one health focus

Carbohydrates

Provides nearly all the energy for the brain

Bicarbonate

Serves as part of the buffering system

Esherichia coli is an intestinal bacterium that is frequently responsible for urinary tract infections.

True

Once a week, Mrs. Jones sends data from her implanted cardiac defibrillator via a special computer to the healthcare center 50 miles away. On the basis of the data, the doctor there adjusts her cardiac medications. This is an example of which of the following? A. Wisdom B. Telehealth C. Faxing D. Electronic mail

Telehealth

The nurse strongly believes in honoring a patient's desire to use herbs as complementary therapy while she is hospitalized. The physician refuses to prescribe the herbs even though there are no obvious drug-drug interactions. The nurse may experience which of the following? A. Moral dilemma B. Moral outrage C. Moral distress D. Moral defeat

The answer depends on how the nurse sees the situation. If the nurse focuses on her own action so that she is unable to do what she believes is right, the answer would be moral distress. If the nurse focuses on the physician's actions and judges that the physician is not doing the right thing and that she can do nothing to change it, the answer would be moral outrage.

If a 3-year-old child becomes fearful and cries during a physical assessment, it would be helpful to continue the assessment while the child sits in the lap of a parent. True False

True

People of differing ages have different learning needs and require different approaches when being taught new material.

True

vastus lateralis

The site used for an intramuscular injection into the muscle of the outer thigh area.

Sending the patient for an x-ray of the chest and abdomen is the most reliable way to ensure that a nasogastric feeding tube has been placed correctly.

True

A person who has the blood type B+ could receive a transfusion from an O+ donor.

True

A pulse rate of 54 beats/min is an example of data.

True

Calcium

Vital for cardiac function

The following key dimensions are assessed with the JAREL scale: Faith/belief Life/self-responsibility Life satisfaction/self-actualization

What three key dimensions are assessed with the JAREL spiritual well-being scale?

Nursing Code of Ethics

a set of principles that reflect the primary goals, values, and obligations of the profession. Used by the state board of nursing to evaluate a nurse's ethical behavior.

Alcohol-sleep

a substance that disrupts REM sleep, causes spontaneous awakenings, and can induce nocturia.

Refractomete

an instrument that is used to measure the specific gravity of urine.

A patient has the right to choose to stop dialysis. This illustrates the ethical principle of _________________________.

autonomy Rationale: Autonomy is the right of a competent patient to accept or refuse treatment.

Carpuject

delivers medication in prefilled syringes.

Micronutrient

fat-soluble vitamins

Webconferencing

form of electronic communication that would allow participants to pick up on a person's nonverbal language.

Electronic Health Record

format used to store the healthcare data for a particular patient in a digital database.

Crede's maneuver

is the application of gentle, manual pressure over the bladder to promote bladder emptying.

Conventional urostomy or ill conduit

type of urinary diversion that involves implanting the ureters into a small segment of the small intestine, which is then brought to the abdominal wall where a stoma is created.

Putting aside the value of monogamous relationships to care for a person who has multiple sex partners is an example of value _________________________.

neutrality Rationale: Value neutrality means that we attempt to understand our own values regarding an issue and to know when to put them aside, if necessary, to become nonjudgmental.

Electroencephalogram (EEG)

record of the electrical activity of the brain

Ethics

systematic study of right and wrong conduct in situations in which there are issues of values and morals.