Nursing 1010 Exam 2

The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations.

a. Allow the patient to reminisce.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients' problems. d. Formulate standardized care plans for groups of patients.

b. Take immediate action when a patient's condition worsens.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

D Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions.

A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1. "A person with the educational background to solve problems." 2. "A person who finds the problem and does what is best to fix it." 3. "It's someone who uses the scientific method to solve problems." 4. "Someone who uses a system to work through and solve a problem."

2. "A person who finds the problem and does what is best to fix it." A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions.

The concept of nursing responsibility is best reflected in which of the following nursing actions? 1. Providing accurate and timely documentation regarding an incident resulting in a client fall 2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4. Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

4. Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury.

Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression

C, D, E Self-confidence Humility Independent attitude A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards.

The nurse is caring for a patient with chronic low back pain. In providing care for this patient, the nurse wonders whether the guidelines utilized for this type of pain are adequate. The nurse wants to determine the best evidence-based practice regarding these guidelines. What is the best database for the nurse to access? a. MEDLINE b. EMBASE c. PsycINFO d. AHRQ

D. AHRQ The Agency for Healthcare Research and Quality (AHRQ) includes clinical guidelines and evidence summaries. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biomedical and pharmaceutical studies. PsycINFO deals with psychology and related health care disciplines.

Fecal impactions occur in which portion of the colon? a. Ascending b. Descending c. Transverse d. Rectum

D. Rectum A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

b. A urinary catheter.

A patient states that everything has been going great; however, the nurse observe the patient biting his nails and fidgeting. What assessment can the nurse make? The patient's communication type is a. linguistic. b. paralinguistic. c. explicit. d. inadequate.

b. paralinguistic. Mixed messages involve the transmission of conflicting or incongruent messages by the speaker.

Critical Thinking: The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. "What are the common elements here?" b. "Tell me again about your experiences." c. "Am I correct in understanding that..." d. "Tell me everything from the beginning."

c. "Am I correct in understanding that..." Clarification ensures that both the nurse and patient share mutual understanding of the communication. The distracters encourage comparison rather than clarification and present implied questions that suggest the nurse was not listening.

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? a. Administer pain medication before any activity. b. Provide intravascular bolus as needed for breakthrough pain. c. Give medications around-the-clock. d. Administer pain medication only when nonpharmacological measures have failed.

c. Give medications around-the-clock.

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.

"I don't feel good" is the feedback because the feedback is the message the receiver returns.

Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1. "Think about several interventions that you could use with this client." 2. "Don't draw subjective inferences about your client—be more objective." 3. "Please think harder—there is a single solution for which I am looking." 4. "Trust your feelings—don't be concerned about trying to find a rationale to support your decision."

1. "Think about several interventions that you could use with this client." The nurse educator is asking the student to synthesize critical thinking skills by encouraging the student to examine alternatives to meet the client's unique needs within the context of the nursing process. Drawing inferences is a specific critical thinking competency used in diagnostic reasoning.

The primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff is: 1. Critical thinking 2. Years of education 3. Professional licensure 4. Complexity of the task

1. Critical thinking

The second component of critical thinking in the "critical thinking model" is: 1. Experience 2. Competencies 3. Specific knowledge 4. Diagnostic reasoning

1. Experience Experience is the second component of critical thinking in the "critical thinking model."

The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1. Has a documented blood pressure of 90/50 2. Was medicated for back pain 10 minutes ago 3. Has an order to be out of bed and ambulated 4. Requires instructions for wound care before discharge

1. Has a documented blood pressure of 90/50 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practice-based criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslow's hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care.

The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is "not right" with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology

1. Intuition

Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1. Reporting client difficulties 2. Offering an alternative approach 3. Looking for a different treatment option 4. Sharing ideas about nursing interventions

1. Reporting client difficulties

Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1. "I feel it's good practice to always have alternative interventions in mind." 2. "I trust my feelings about a client's needs since I work hard at knowing my client." 3. "I always try to keep an open mind about what interventions my client will require." 4. "I will wait until my assessment is completed before determining the client's needs."

2. "I trust my feelings about a client's needs since I work hard at knowing my client."

A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs? 1. "That surgery is painful. I'll get her pain medication ready." 2. "She was sleeping when I checked 15 minutes ago. I'll go back in right now." 3. "I'll be responsible for her PM care so I can spend some uninterrupted time with her." 4. "A mastectomy is a blow to a woman's self image. I'll notify her provider that she is depressed."

2. "She was sleeping when I checked 15 minutes ago. I'll go back in right now." Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this client's tears, there are other possible reasons, so making an assumption is not appropriate.

With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1. The veteran nurse has a varied history of client care experiences 2. Critical thinking improves with experience, longevity, and interest 3. Today's short hospital stays minimize the opportunity to develop critical thinking skills 4. New graduates often lack the self-confidence to take the risks often required of critical decision making

2. Critical thinking improves with experience, longevity, and interest

A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1. Curiosity 2. Experience 3. Perseverance 4. Scientific knowledge

2. Experience

Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new admission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client's allergy to an ordered medication

2. Placing a client experiencing shortness of breath on oxygen Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a client's immediate distress.

The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1. Humility 2. Risk-taking 3. Accountability 4. Independent thinking

2. Risk-taking

Which of the following nursing situations best reflects accountability? 1. The nurse takes the oncology nursing certification examination. 2. The nurse files an incident report regarding a medication error. 3. The nurse assesses the client for the possible cause of his pain. 4. The nurse tells the client, "I don't know but I will find out for you."

2. The nurse files an incident report regarding a medication error.

1. The scope of a client's health problem is a result of which of the following factors? (Select all that apply.) 1. Religious beliefs 2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships 6. Educational background

2.Life experiences 3.Lifestyle choices 4.Work environment 5.Family relationships

Which of the following statements made by a new graduate nurse regarding a client's care needs requires follow-up by the mentor? 1. "No one really enjoys being hospitalized." 2. "Every client is offered a back rub at bedtime." 3. "All post surgery clients are reluctant to ambulate." 4. "I always spend extra time with new clients to help them relax."

3. "All post surgery clients are reluctant to ambulate."

A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1. "I'm sure that friction and pressure have caused this problem." 2. "Please be sure that her ankles are well padded when you place her in bed." 3. "Do you have any suggestions on how we can minimize the pressure to her ankles?" 4. "It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour."

3. "Do you have any suggestions on how we can minimize the pressure to her ankles?"

Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1. A new admission admitted for swelling in the right ankle and knee 2. A second day postoperative client who received pain medication 30 minutes ago 3. A client who the nursing assistant found crying in the bathroom 4. A client ready for discharge who requires a final assessment and documentation

3. A client who the nursing assistant found crying in the bathroom This client has an acute need that requires the nurse's attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority.

The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management 3. Problem-solving 4. Diagnostic reasoning

3. Problem-solving

The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences

3. Testing possible options

Which of the following nursing actions is the best example of problem solving? 1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3. Trying several difficult wound dressings to determine which one the client can apply the most effectively 4. Calling for another pain medication order when the current drug results in the client experiencing nausea

3. Trying several difficult wound dressings to determine which one the client can apply the most effectively

Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit's nurse manager? 1. "Mary and I were comparing foot wound dressing techniques." 2. "I've been caring for orthopedic clients for 10 years and I think I've seen it all." 3. "I can't believe that my client isn't improving after 2 weeks of physical therapy." 4. "I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

4. "I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4." Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs.

Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process? 1. "I believe that this client is getting depressed." 2. "The client doesn't look right to me; I think something is wrong." 3. "The client's husband told me that she is feeling very uncomfortable." 4. "The client reports more pain than yesterday and her blood pressure is elevated."

4. "The client reports more pain than yesterday and her blood pressure is elevated."

Which of the following is the best example of a nurse's use of reflection? 1. The nurse places a client experiencing respiratory difficulties in a high-Fowler's position. 2. The nurse calls the provider when a client reports feeling "chilled and achy" while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client's pulse oximetry reading when he "doesn't sound right." 4. A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."

4. A nurse tells a client; "When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time."

Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician's order 2. Recognizes conflicts of interest 3. Listens to both sides of the story 4. Approaches assessment logically

4. Approaches assessment logically

Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1. Determining that the client's ankle edema is worse after he ambulates 2. Asking the client to rate his ankle pain after receiving oral pain medication 3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4. Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

4. Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1. Giving medication at the time ordered 2. Following a procedure for catheterization step-by-step 3. Reviewing all clients' medical records thoroughly 4. Discussing various alternative pain management techniques

4. Discussing various alternative pain management techniques

The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation

4. Implementation

The nurse is best demonstrating perseverance by: 1. Having a perfect attendance record 2. Completing a lengthy course on current chemotherapies 3. Repeatedly irrigating the nasogastric tube until it is patent 4. Sitting with a client until she is ready to discuss why she is crying

4. Sitting with a client until she is ready to discuss why she is crying

Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1. Being physically present when a client is given the results of a tissue biopsy 2. Witnessing the client sign consent for surgery forms before cardiac surgery 3. The client is informed of the various treatments available for his condition. 4. The nurse explains to the client the risks of leaving the hospital against medical advice.

4. The nurse explains to the client the risks of leaving the hospital against medical advice. The nurse is presenting the possible outcomes, and therefore is presenting consequences.

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.

A, B Asking the patient to void and to discard the first sample. Keeping the urine collection container on ice. When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.

During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel movement? (Select all that apply.) a. Increase fiber intake. b. Increase water consumption. c. Decrease physical exercise. d. Refrain from alcohol. e. Refrain from smoking.

A, B Increase fiber intake. Increase water consumption. Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcohol and smoking have no direct effect on bowel movements

Before conducting any study with human subjects, the researcher must obtain approval from the agency's human subjects committee or institutional review board (IRB). The IRB ensures that the researcher (Select all that apply.) a. Obtains informed consent. b. Minimizes risk to subjects. c. Ensures confidentiality. d. Identifies risks and benefits of participation. e. Ensures that subjects complete the study.

A, B, C, D a. Obtains informed consent. b. Minimizes risk to subjects. c. Ensures confidentiality. d. Identifies risks and benefits of participation.

Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi

A, B, D Sediment occluding within the tubing Blood clots in the bladder following surgery Bladder infection Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder.

When conducting a health history assessment, the nurse would want to know what important information about the patient's elimination status? (Select all that apply.) a. Recent changes in elimination patterns b. Changes in color, consistency, or odor of stool or urine c. Time of day patient defecates d. Discomfort or pain with elimination e. List of medications taken by patient f. Patient's preferences for toileting

A, B, D, E Recent changes in elimination patterns Changes in color, consistency, or odor of stool or urine Discomfort or pain with elimination List of medications taken by patient Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medications the patient is on as this may affect elimination. Time of day is not important, nor is the patient's preferences for toileting. They are personal preferences and do not affect elimination.

The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.) a. Past medical history of gastric ulcer b. Patient states last bowel movement was 4 days ago c. Stated allergy to aspirin d. Patient states has 2/10 intermittent joint pain e. Patient experienced respiratory depression after administration of an opioid medication

A, C a. Past medical history of gastric ulcer c. Stated allergy to aspirin

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

A, C, D, E Identifying patient needs Determining priorities of care Setting goals Performing nursing interventions

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

A. Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses.

The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration

B, C Osmosis Diffusion Osmosis and diffusion are the two processes used to clean the patient's blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen. Gravity has no effect on cleansing of the blood. Filtration is the process that occurs in the glomerulus as blood flows through the kidney.

Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria

B, C, D Nausea and vomiting Headache Altered mental status Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.

Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed

B, C, E, F b. A female patient who is outgoing and flirty c. An older adult patient who is demanding e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed

The nurse is writing a research article on a patient care topic. The nurse realizes that the section that will get the reader to read the article because of the value of the topic for the reader is the a. Abstract. b. Introduction. c. Literature review or background. d. Results.

B. introduction

Professional standards influence a nurse's clinical decisions by a. Bypassing the patient's feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses' needs.

C. Requiring the nurse to use critical thinking for the highest level of quality nursing care. Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care

A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination b. Removing all of the patient's metallic jewelry c. Administering a colon cleansing product 12 hours before the examination d. Obtaining an order for a pain medication before the test is performed

Removing all of the patient's metallic jewelry No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.

The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by a. Applying liberal amounts of stool to the guaiac paper. b. Testing the quality control section before collecting the specimen section. c. Reporting any abnormal findings to the provider. d. Applying sterile disposable gloves.

Reporting any abnormal findings to the provider. Abnormal findings such as a positive test should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.

The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. The best response from the nurse would be which of the following? a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." b. "Some people have a slower bowel than others, and this is nothing to be concerned about." c. "The foods you eat contribute to peristalsis, so you should eat more fiber in your diet." d. "Bowel peristalsis is slow because you are not walking. Get more exercise during the day."

a. "Anesthesia during surgery and pain medication after surgery may slow peristalsis in the bowel." Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."

a. "Drink your nightly glass of milk earlier in the evening." Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake

A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a. "How shall we start today?" b. "Shall we talk about losing your privileges yesterday?" c. "Let's get started discussing your marital relationship." d. "What happened when your family visited yesterday?"

a. "How shall we start today?" The interview is patient centered; thus, the patient chooses issues.

A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? a. "I can use a fleet enema to save money because it contains the same irrigation solution." b. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." c. "I should never attempt to reach into my stoma to remove fecal material." d. "Using warm tap water will reduce cramping and discomfort during the procedure."

a. "I can use a fleet enema to save money because it contains the same irrigation solution." Enema applicators should never be used in the stoma because they can cause damage. A special coned irrigation device is used for ostomies. Irrigating a stoma into the toilet is an effective management technique. Fingers and other objects should not be placed into the stoma because they may cause trauma to the intestinal wall. Warm tap water will reduce cramping during irrigation.

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a positive result, I have gastrointestinal bleeding." b. "I should not eat red meat before my examination." c. "I should schedule to perform the examination when I am not menstruating." d. "I will need to perform this test three times if I have a positive result."

a. "If I get a positive result, I have gastrointestinal bleeding." A positive result does not mean GI bleeding; it could be a false positive from consuming red meat, some raw vegetables, or NSAIDs. Proper patient education is important for viable results. The patient needs to avoid certain foods to rule out a false positive. If the test is positive, the patient will need to repeat the test at least three times. Menses and hemorrhoids can also lead to false positives.

Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation will help me sleep through the pain because it opens the gate." c. "Meditation stops the occurrence of pain stimuli." d. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."

a. "Meditation controls pain by blocking pain impulses from coming through the gate."

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

a. "When was the last time you voided?"

The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease

a. A 12-year-old female with severe abdominal trauma Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.

1. To provide patient care of the highest quality, nurses utilize an evidence-based practice approach because evidence-based practice is a. A guide for nurses in making clinical decisions. b. Based on the latest textbook information. c. Easily attained at the bedside. d. Always right for all situations.

a. A guide for nurses in making clinical decisions.

Which of the following is not a function of the large intestine? a. Absorbing nutrients b. Absorbing water c. Secreting bicarbonate d. Eliminating waste

a. Absorbing nutrients Nutrient absorption is done in the small intestine. The other options are all functions of the large intestine

A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.

a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void.

The nurse would expect the least formed stool to be present in which portion of the digestive tract? a. Ascending b. Descending c. Transverse d. Sigmoid

a. Ascending The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool would be in the ascending.

When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein

a. Bacteria Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.

The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? a. Bowel sounds b. Presence of flatulence c. Bowel movements d. Nausea

a. Bowel sounds The nurse does want to hear the presence of bowel sounds; absent bowel sounds may indicate a complication from the surgery. Bowel movements and flatulence are not expected in the hours after surgery. The nurse does want to hear the presence of bowel movements. Nausea is not a problem following colonoscopy.

The hospital's quality improvement committee has identified a problem on one of the units. In using the PDSA method to help determine ways to deal with the issue, the committee decides to do a literature review. This is an example of quality improvement a. Combined with evidence-based practice. b. With inability to make the right decision. c. With delay in the action needed. d. With no designated method for dealing with issues.

a. Combined with evidence-based practice. Quality improvement combined with evidence-based practice is the foundation for excellent patient care and outcomes. Once a committee defines a problem, it applies a formal model for exploring and resolving quality concerns. One part of the PDSA cycle is the "Do" section, which requires the selection of an intervention on the basis of data reviewed. Therefore the committee is taking the right action and is not unduly delaying action; data must be obtained that are needed to make the right decision as part of the PDSA method, which is in place.

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

a. Data on the chart can sometimes be documented in a biased manner.

Nurses who make the best communicators a. Develop critical thinking skills. b. Like different kinds of people. c. Learn effective psychomotor skills. d. Maintain perceptual biases.

a. Develop critical thinking skills.

After a patient returns from a barium swallow, the nurse's priority is to a. Encourage the patient to increase fluids to flush out the barium. b. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure. c. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times. d. Thicken all patient drinks to prevent aspiration.

a. Encourage the patient to increase fluids to flush out the barium. Encourage the patient to increase fluid intake to flush and remove excess barium from the body. Barium swallow is a noninvasive procedure for which no trauma would produce blood or mucus or increase aspiration risk. Barium is not a radioactive substance, so multiple flushes are not needed.

The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which of the following methods will provide the nurse with the right kind of data?(Select all that apply.) a. Experimental research b. Surveys c. Evaluation research d. Phenomenology e. Grounded theory

a. Experimental research b. Surveys c. Evaluation research

What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar

a. Fever and chills The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL

a. Glomerular filtration rate of 20 mL/min Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Grape and walnut chicken salad sandwich on whole wheat bread b. Broccoli and cheese soup with potato bread c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing d. Turkey and mashed potatoes with brown gravy

a. Grape and walnut chicken salad sandwich on whole wheat bread A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

A nurse has committed a serious medication error and has reported their error to the hospital's adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.

a. Have the nurse present an in-service related to the cause of the error.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? a. Hypoactive bowel sounds b. Jaundice in sclera c. Decreased skin turgor d. Soft tender abdomen

a. Hypoactive bowel sounds Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation.

Alan is a 30-year-old male admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen. b. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours. c. Phenergan 25 mg IM q 6 hours. d. Tylenol 325 mg q 6 hours.

a. IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen. A variety of routes of administration are used to deliver analgesics. A principle of pain management is to use the oral route of administration whenever feasible. All of the first-line analgesics used to manage pain are available in short-acting and long-acting formulations. For patients who have continuous pain, a long-acting analgesic, such as modified-release oral morphine, oxycodone, or hydromorphone, or transdermal fentanyl, is used to treat the persistent baseline pain. A fast-onset, short-acting analgesic (usually the same drug as the long-acting) is used to treat breakthrough pain if it occurs. When the oral route is not possible, such as in patients who cannot swallow or are NPO or nauseated, other routes of administration are used, including intravenous (IV), subcutaneous, transdermal, and rectal. Norco, Benadryl, Phenergan, and Tylenol are not appropriate solo choices for acute pancreatitis with pain reported as 10/10.

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. Increasingly higher doses of opioid are needed to control pain. b. The patient needed a substantial dose of naloxone (Narcan). c. The patient asks for pain medication close to the time it is due around the clock. d. The patient no longer experiences sedation from the usual dose of opioid.

a. Increasingly higher doses of opioid are needed to control pain. Opioid tolerance occurs when a patient needs higher doses of an opioid to control pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects of opioid overdose. Taking pain medications regularly around the clock is an effective way to control pain. The pain medication for this patient is most likely effectively managing the patient's pain because the patient is not asking for the medication before it is due. A patient no longer experiencing a side effect of an opioid does not indicate opioid tolerance.

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether he has any complaints or a history of heart problems. The nurse is utilizing which critical thinking skill? a. Interpretation b. Evaluation c. Self-regulation d. Explanation

a. Interpretation Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data.

A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria

a. Involuntary urine leakage Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.

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

a. Journaling allows reflection, an important critical thinking skill.

The nurse should place the patient in which position when preparing to administer an enema? a. Left Sims' position b. Fowler's c. Supine d. Semi-Fowler's

a. Left Sims' position Side-lying Sims' position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon. This helps to improve retention of the enema. Administering an enema in a sitting position may allow the curved rectal tube to scrape the rectal wall.

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced.

a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. Long-term laxative use can lead to constipation. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Natural laxatives like mineral oil come with their own set of risks, such as inability to absorb fat-soluble vitamins. Even if malnourished, the body will produce waste if substance is consumed.

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? a. Lubricating the nares with water-soluble lubricant b. Applying a small ice bag to the nose for 5 minutes every 4 hours c. Instilling Xylocaine into the nares once a shift d. Changing the tape holding the tube in place once a shift

a. Lubricating the nares with water-soluble lubricant The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation. Ice is not applied to the nose. Ice may be applied externally to the throat if the patient reports a sore throat. Xylocaine requires a physician order and is used to treat sore throat, not nasal mucosal excoriation. Changing the tape should be done daily, not every shift.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR

a. Narrative In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation.

A patient does not make eye contact with the nurse and is folding his arms at his chest. Which aspect of communication has the nurse assessed? a. Nonverbal communication b. A message filter c. A cultural barrier d. Social skills

a. Nonverbal communication

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally smokes marijuana. d. Patient takes antianxiety medications.

a. Patient drinks 1 to 2 glasses of wine every night. The major adverse effect of acetaminophen is hepatotoxicity. Because both alcohol and acetaminophen are metabolized by the liver, when taken together, they can cause liver damage.

A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.

a. Perform pelvic floor exercises. Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem.

The hospital quality improvement committee has noted that the incidence of needlestick injuries on a particular unit has increased. When faced with issues, the committee applies the PDSA model, a formal model for exploring and resolving quality concerns. Because the committee is multidisciplinary in nature, and few members are nurses, it is imperative that the committee first a. Plan. b. Do. c. Study. d. Act.

a. Plan.

While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? a. Positioning the patient in the dorsal recumbent position with a bed pan b. Assisting the patient to the bedside commode c. Stopping the enema cleansing and rolling the patient into right-lying Sims' position d. Inserting a rectal plug to contain the enema solution

a. Positioning the patient in the dorsal recumbent position with a bed pan Patients with poor sphincter control may not be able to hold in all of an enema solution. Positioning the patient on a bed pan in dorsal recumbent position will allow the nurse to continue to administer the enema. Having the patient get up to toilet is unsafe because the rectal tube can damage the mucosal lining. The purpose of the enema is to promote defecation; stopping it early may inhibit its effectiveness. Use of a rectal plug to contain the solution is inappropriate.

Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

a. Pre-interaction

. Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing

a. Recording an output that is larger than the amount instilled Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure

a. Relax

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Relaxation and guided imagery b. Transcutaneous electrical nerve stimulation (TENS) c. Herbal supplements with analgesic effects d. Pudendal block

a. Relaxation and guided imagery

A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? a. Salem sump b. Dobhoff c. Sengstaken-Blakemore d. Small bore

a. Salem sump A bowel obstruction causes a backup into the gastric area; a nasogastric tube may be inserted to decompress secretions and gases from the gastrointestinal tract. The Salem sump has the width and functionality needed to both feed and suction, and it is ideal for a bowel obstruction. A Dobhoff tube is used for instillation of feedings. A Sengstaken-Blakemore tube is used to compress stomach contents to prevent hemorrhage. A small bore is intended for nutritional feedings only and does not have suction capacity.

In reviewing literature for an evidence-based practice study, the nurse realizes that the most reliable level of evidence is the a. Systematic review and meta-analysis. b. Randomized control trial (RCT). c. Case control study. d. Control trial without randomization.

a. Systematic review and meta-analysis. In a systematic review or meta-analysis, an independent researcher reviews all of the RCTs conducted on the same clinical question and reports whether the evidence is conclusive, or if further study is needed. A single RCT is not as conclusive as a review of several RCTs on the same question. Control trials without randomization may involve bias in how the study is conducted. Case control studies also have room for bias.

Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior? a. The nurse aide is calling the older adult patient "honey." b. The nurse aide is facing the older adult patient when talking. c. The nurse aide cleans the older adult patient's glasses. d. The nurse aide allows time for the older adult patient to respond.

a. The nurse aide is calling the older adult patient "honey."

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient's lower left quadrant is tender to the touch. d. The nurse hears bowel sounds present in all four quadrants.

a. The patient reports eliminating a soft, formed stool. The nurse's goal is for the patient to be on opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not further address bowel elimination. Present bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? a. The patient's need for analgesic medication decreases during the dressing changes. b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. c. The patient's facial expressions are stoic during the procedure. d. The patient can tolerate more pain, so dressing changes can be performed more frequently.

a. The patient's need for analgesic medication decreases during the dressing changes.

In collecting the best evidence, the gold standard for research is a. The randomized controlled trial (RCT). b. The peer-reviewed article. c. Qualitative research. d. The opinion of expert committees.

a. The randomized controlled trial (RCT).

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.

a. Use a picture board.

To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.

a. Use room temperature irrigation solution. Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.

A student nurse is studying clinical judgment theories and is working with Tanner's Model of Clinical Judgment. The student nurse can generalize the process as a. a reflective process where the nurse notices, interprets, responds, and reflects in action. b. one conceptual mechanism for critiquing ideas and establishing goal-oriented care. c. researching best practice literature to create care pathways for certain populations. d. assessing, diagnosing, implementing, and evaluating the nursing care plans.

a. a reflective process where the nurse notices, interprets, responds, and reflects in action.

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

a. call the physician, explain rationale, and suggest a different medication.

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

a. explain to coworkers that this is a characteristic of critical thinking and is important for the GN to improve reasoning skills. Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this.

Critical Thinking: The nurse and the patient are conversing face to face. What communication technique is this? a. linguistic b. paralinguistic c. explicit d. metacommunication

a. linguistic Conversing face to face, reading newspapers and books, and even texting are all common forms of linguistic communication. Paralinguistics include less recognizable but important means of transmitting messages such as the use of gestures, eye contact, and facial expressions. Explict communication is not a therapeutic communication technique. Metacommunication factors that affect how messages are received and interpreted would include internal personal states (such as disturbances in mood), environmental stimuli related to the setting of the communication, and contextual variables (such as the relationship between the people in the communication episode).

A 19-year-old male has sustained a transaction of C-7 in an MVA rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristic of a. neuropathic pain. b. ghost pain. c. mixed pain syndrome. d. nociceptive pain.

a. neuropathic pain. Neuropathic pain results from the abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Simply put, neuropathic pain is pathologic. Examples of neuropathic pain include postherpetic neuralgia, diabetic neuropathy, phantom pain, and post stroke pain syndrome. Patients with neuropathic pain use very distinctive words to describe their pain, such as "burning," "sharp," and "shooting." Ghost pain is pain associated with loss of a limb or digit. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting.

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system-wide. b. large tidal volumes and decreased lung capacity. c. decreased tumor growth and longevity. d. decreased carbohydrate, protein, and fat destruction.

a. prolonged stress response and a cascade of harmful effects system-wide. Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, which can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevity are not associated with unrelieved pain. Decreased carbohydrate, protein, and fat are not associated with pain or stress response.

The nurse knows that the ideal time to change an ostomy pouch is a. Before eating a meal, when the patient is comfortable. b. When the patient feels that he needs to have a bowel movement. c. When ordered in the patient's chart. d. After the patient has ambulated the length of the hallway.

a. Before eating a meal, when the patient is comfortable. The nurse wants to change the ostomy appliance when as little output as necessary ensures a smooth procedure. Patients with ostomies do not feel the urge to defecate because the sensory portion of the anus is not stimulated. Changing the ostomy pouch is a nursing judgment decision. After a patient ambulates, stool output is increased.

Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

a. Considering what is important in a given situation.

Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine

b, d, f, g b. Labeling all specimens with date, time, and initials d. Allowing the patient adequate time and privacy to void f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. "This is probably a false negative; we should rerun the test." b. "Do you take iron supplements?" c. "You should schedule a colonoscopy as soon as possible." d. "Sometimes severe stress can alter stool color."

b. "Do you take iron supplements?" Certain medications and supplements, such as iron, can alter the color of stool. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."

b. "I feel uncomfortable hearing that statement." Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic.

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? a. "Older patients often have difficulty determining what is causing their pain." b. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." c. "As adults age, their ability to perceive pain decreases." d. "Patients who have dementia probably experience pain, and their pain is not always well controlled."

b. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. The best response by the nurse is: a. "The patient is angry about the dementia diagnosis." b. "The patient is losing sphincter control due to the dementia." c. "The patient forgets where the bathroom is located due to the dementia." d. "The patient wants to leave the hospital."

b. "The patient is losing sphincter control due to the dementia." Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of the dementia.

Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? a. "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." b. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." c. "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." d. "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."

b. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief."

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. "Have you considered working with a physical therapist?" b. "What activities, if any, has your pain prevented you from doing?" c. "Would you please rate your pain on a scale from 1 to 10 for me?" d. "What effect does your pain medication typically have on your pain?"

b. "What activities, if any, has your pain prevented you from doing?"

Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old patient with three final examinations on the same day c. A 40-year-old woman with major depressive disorder d. An 80-year-old man in an assisted-living environment

b. A 21-year-old patient with three final examinations on the same day Stress can stimulate digestion and increase peristalsis. Ignoring the urge to defecate, depression, and age-related changes of the elderly are causes of constipation.

The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure

b. A 30-year-old patient requiring drug screening for employment

The nurse is developing a PICO question related to whether her patient's blood pressure is more accurate while measuring with the patient's legs crossed versus with the patient's feet flat on the floor. With P being the population of interest, I the intervention of interest, C the comparison of interest, and O the outcome, the nurse determines that this is a. A true PICO question, because the outcome always comes before the intervention. b. A true PICO question regardless of placement of elements. c. Not a true PICO question, because the comparison comes after the intervention. d. Not a true PICO question, because the outcome comes after the population.

b. A true PICO question regardless of placement of elements.

The nursing student can best develop critical thinking skills by doing which of the following? a. Studying 3 hours more each night b. Actively participating in all clinical experiences c. Interviewing staff nurses about their nursing experiences d. Attending all open skills lab opportunities

b. Actively participating in all clinical experiences Nursing is an applied science, and to apply knowledge learned and develop critical thinking skills to make clinical decisions, the student should actively participate in all clinical experiences. Studying for longer hours, interviewing nurses, and attending skills labs do not provide opportunities for clinical decision making, as do actual clinical experiences.

A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.

b. Allow time for the patient to respond.

The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? a. Age and gender b. Anxiety and fear c. Culture d. Previous pain experience

b. Anxiety and fear

An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap. b. Apply a skin protective lotion after perineal care. c. Tape an occlusive moisture barrier pad to the patient's skin. d. Massage the skin with deep kneading pressure.

b. Apply a skin protective lotion after perineal care. Proper skin care and perineal cleaning require that the nurse gently clean the skin and apply a moistening barrier cream. Tape and occlusive dressings can damage skin. Excessive pressure and force are inappropriate and may cause skin breakdown.

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider to verify the dosage and frequency of the medication. c. Ask the health care provider for an order for a nonsteroidal antiinflammatory drug (NSAID). d. Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.

b. Ask the health care provider to verify the dosage and frequency of the medication. The maximum 24-hour dosage for acetaminophen is 4 grams. If the patient took 2 tablets of Vicodin ES every 6 hours, the patient would take in 6 grams of acetaminophen in 24 hours. This exceeds the safe dosage of acetaminophen, so the best action is to question this order. Giving the medication as ordered would possibly result in the patient taking more acetaminophen than what is considered a safe dose. Acetaminophen overdose can result in liver failure. NSAIDs are used to treat mild to moderate pain. At this moment, the patient is experiencing severe pain. Implementing music therapy is a nursing intervention and is an independent nursing action. Thus, an order to start music therapy is not needed.

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Ask the patient to rate and describe the pain. c. Raise the head of the bed. d. Administer pain relief medications.

b. Ask the patient to rate and describe the pain.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

b. Asking for an orientation to the unit. Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit.

The hospital policy states that when starting an intravenous (IV) catheter, the nurse must first prepare the potential IV site with alcohol and dress it using a gauze dressing. The nurse has done a literature review and believes that evidence-based practice dictates the use of a transparent dressing to prevent catheter dislodgment. What should the nurse do? a. Begin to use transparent dressing instead of gauze dressings. b. Bring findings to the policy and procedure committee. c. Use transparent dressings on half of her IV starts and gauze on the other. d. Continue following hospital policy without saying anything.

b. Bring findings to the policy and procedure committee. As a result of her finding, the nurse should meet with the policy and procedure committee to recommend routine use of transparent dressings. However, until the policy is changed, or the nurse receives approval to conduct a pilot study, the nurse is obligated to follow hospital procedure. If the nurse has information that can lead to better patient care, he or she has an obligation (moral and professional) to bring it to the attention of policy makers.

In conducting a research study, the researcher must guarantee that any information the subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team. This concept is known as a. Anonymity. b. Confidentiality. c. Informed consent. d. The research process.

b. Confidentiality.

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

b. Determine whether the patient agrees with the care plan.

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Donning gloves for digital removal of the stool c. Positioning the patient on the left side d. Inserting a rectal tube

b. Donning gloves for digital removal of the stool When enemas are not successful, digital removal of the stool may be necessary occasionally to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence but would not be applicable or effective for this patient.

The nurse knows that most nutrients are absorbed in which portion of the digestive tract? a. Stomach b. Duodenum c. Ileum d. Cecum

b. Duodenum Most nutrients are absorbed in the duodenum with the exception of certain vitamins, iron, and salt (which are absorbed in the ileum). Food is broken down in the stomach. The cecum is the beginning of the large intestine.

The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. c. Perineal care is often neglected by nursing staff. d. Bedpans and urinals are not stored properly and transmit infection.

b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explain to the patient that nothing else has been ordered. b. Explore other options for pain relief. c. Offer to notify the health care provider after morning rounds are completed. d. Discuss the surgical procedure and reason for the pain.

b. Explore other options for pain relief. The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit. The nurse realizes that nursing research is important in that it is designed to (Select all that apply.) a. Enhance the nurse's chance at promotion. b. Identify new knowledge. c. Improve professional practice. d. Enhance effective use of resources. e. Lead to decreases in budget expenditures.

b. Identify new knowledge. c. Improve professional practice. d. Enhance effective use of resources.

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit

b. Impaired verbal communication

11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins

b. Maintaining fluid and electrolyte balance The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.

The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because a. The digested food needs to make room for recently ingested food. b. Mastication triggers the digestive system to begin peristalsis. c. The smell of bowel elimination in the room would deter the patient from eating. d. More ancillary staff members are available after meal times.

b. Mastication triggers the digestive system to begin peristalsis. Peristalsis occurs only a few times a day; the strongest peristaltic waves are triggered by mastication of the meal. The intestine can hold a great deal of food. A patient's voiding schedule should not be based on the staff's convenience.

Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services

b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Mind-body therapies are designed to enhance the mind's capacity to affect bodily function and symptoms and include music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy, among many others. Stationary exercise bicycle, free weights, and spinning are not mind-body therapies. They are classified as exercise therapies. Chamomile tea and IcyHot gel are not mid-body therapies per se. They are classified as herbal and topical thermal treatments. Acupuncture is an ancient Chinese complementary therapy, while attending church services is a religious prayer mind-body therapy capable of enhancing the mind's capacity to affect bodily function and symptoms.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary

b. Nonverbal

Which of these findings, if identified in a plan of care, should the registered nurse revise because it is not characteristic of critical thinking and the nursing process? a. Patient's reactions to diagnostic testing b. Nurse's assumptions about hospital discharge c. Identification of five different nursing diagnoses d. Documentation of patient's ability to cope with loss

b. Nurse's assumptions about hospital discharge

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

b. On admission, along with the initial assessment

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

b. Orientation

When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift

b. Performing hand hygiene before and after providing perineal care Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Noxious odor from the stool d. Continuous output from the stoma

b. Presence of blood in the stool Blood in the stool may indicate a problem with the surgical procedure, and the physician should be notified. All other options are expected findings for an ileostomy.

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group

b. Public

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? a. Administering laxatives to the patient b. Raising the head of the bed c. Preparing to administer a barium enema d. Withholding narcotic pain medication

b. Raising the head of the bed Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

b. Reddened irritated skin on the buttocks. Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurse's assumptions.

b. Reviewing the effectiveness of nursing actions.

Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence

b. Risk of infection Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.

A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying Selecting a pouch that holds a large volume of output will decrease the frequency of emptying the pouch and may ease patient anxiety about pouch overflow. The barrier device should be changed every few days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Approximately 1/16 of an inch is present between the barrier device and the stoma. Excess space allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown.

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has? a. Visceral pain b. Somatic pain c. Peripherally generated pain d. Centrally generated pain

b. Somatic pain Somatic pain comes from bone, joint, or muscle. Visceral pain arises from the visceral organs such as the GI tract and pancreas. Peripherally generated pain can be caused by polyneuropathies or mononeuropathies. Centrally generated pain results from injury to the central or peripheral nervous system.

Which physiological change can cause a paralytic ileus? a. Chronic cathartic abuse b. Surgery for Crohn's disease and anesthesia c. Suppression of hydrochloric acid from medication d. Fecal impaction

b. Surgery for Crohn's disease and anesthesia Surgical manipulation of the bowel can cause a paralytic ileus. The other options are incorrect.

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. c. Sufficient medication is left in the PCA syringe. d. The patient presses the control button to deliver pain medication.

b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. d. The nurse is allowing personal beliefs about pain to influence pain management at this time.

b. The patient's culture is possibly influencing the patient's experience of pain.

An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print.

b. Turn off the television. Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.

If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra

b. Ureters Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? a. Elevate the head of the bed 45 degrees 60 minutes after breakfast. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Administer a soap suds enema every 2 hours.

b. Use a mobility device to place the patient on a bedside commode. The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible while defecating. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed would be appropriate if the patient were to void with a bed pan. However, the patient's condition does not require use of a bed pan. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soaps suds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? a. Ask the parents if they think their child is in pain. b. Use the FACES scale. c. Ask the child to rate the level of pain on a 0 to 10 pain scale. d. Check to see what previous nurses have charted.

b. Use the FACES scale. Assessing pain intensity in children requires special techniques. Young children often have difficulty expressing their pain. The FACES scale assesses pain in children who are verbal. Because a 4-year-old is verbal, this is an appropriate scale to use with this child.

A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication

b. Utilizing the power of suggestion by turning on the faucet and letting the water run To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

When evaluating quality improvement (QI) programs in relation to evidence-based practice (EBP), it is easy to note that a. Both are designed to improve performance. b. When implementing EBP projects, it is important to review QI data. c. EBP is not at all related to QI. d. Evaluation of processes is the realm of performance improvement (PI), not QI.

b. When implementing EBP projects, it is important to review QI data. Evidence-based practice and quality improvement go hand in hand. When implementing an EBP project, it is important to review available QI data. Reliable QI data improve the relevance and scope of an EBP project. Performance improvement (PI) analyzes performance. QI analyzes processes.

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.

b. Would feel more comfortable assuming a normal voiding position.

You are caring for a patient who has suffered a spinal cord injury. You are concerned about the patient's elimination status. As the nurse, your primary concern is to a. speak with the patient's family about food choices. b. establish a bowel and bladder program for the patient. c. speak with the patient about past elimination habits. d. establish a bedtime ritual for the patient.

b. establish a bowel and bladder program for the patient. Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is okay, but it is not the primary concern. Speaking with the patient to know past elimination habits does not apply, because the spinal cord injury changes elimination habits. Establishing a bedtime ritual does not apply to elimination.

Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of a. neuropathic pain. b. nociceptive pain. c. chronic pain. d. mixed pain syndrome.

b. nociceptive pain. Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain.

An 80-year-old male patient is in the ICU status fractured femur and MVA. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round the clock opioids doses q 4 hours. The best immediate course of nursing action is to a. call a Code Blue. b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. c. call the primary hospitalist in charge of patient. d. call the anesthesia provider on call.

b. stop opioid; consider administering naloxone, call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status. Stop opioid; consider administering naloxone; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider; and monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. Calling a Code Blue solely for a somnolent patient is not indicated as a solitary response. Calling the hospitalist assigned to the patient is an option only after the immediate treatment plan is enacted to reverse the opioid. Calling anesthesia is appropriate after stopping the opioid first.

Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

c. "Do you experience urine leakage when you cough or sneeze?" Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? a. "This is the only pain medication I will need to be on." b. "I can administer the pain medication as frequently as I need to" c. "I feel less anxiety about the possibility of overdosing." d. "I will need the nurse to notify me when it is time for another dose."

c. "I feel less anxiety about the possibility of overdosing." A PCA is a device that allows the patient to determine the level of pain relief delivered, reducing the risk of oversedation. Its use often eases anxiety because the patient is not reliant on the nurse for pain relief. Other medications, such as oral analgesics, can be given in addition to the PCA machine. The PCA does have a time limit to prevent overdose, but the patient can lengthen the amount of time between doses. One benefit of PCA is that the patient does not need to rely on the nurse to administer pain medication; the patient determines when to take the medication.

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? a. "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." b. "The patient is sleeping, so I pushed her PCA button for her." c. "I need to reassess the patient's pain 1 hour after administering oral pain medication." d. "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."

c. "I need to reassess the patient's pain 1 hour after administering oral pain medication." Because oral medications usually peak in about an hour, you need to reassess the patient's pain within an hour of administration. Nurses must believe any patient report of pain, even if nonverbal communication is not consistent with pain ratings. The patient is the only person who should push the PCA button. Pushing the PCA when a patient is sleeping is dangerous and may lead to narcotic overdose or respiratory depression. Giving the patient a placebo and telling her it is her medication is unethical.

Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."

c. "I will be anesthetized so that I lie perfectly still during the procedure." Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? a. "Ibuprofen helps to remove factors that cause or stimulate pain." b. "Ibuprofen reduces anxiety, which will help you better cope with your pain." c. "Ibuprofen helps to decrease the production of prostaglandins." d. "Ibuprofen binds with opiate receptors to reduce your pain."

c. "Ibuprofen helps to decrease the production of prostaglandins." NSAIDs like ibuprofen most likely work by decreasing the synthesis of prostaglandins to inhibit cellular responses to inflammation. Ibuprofen does not remove factors that cause pain, nor does it enhance coping with pain. Opioids bind with opiate receptors to modify perceptions of pain.

A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."

c. "My medication may discolor my urine; this should resolve once the medication is stopped." Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "Pain assessment scales determine the quality of a patient's pain." d. "A patient's behavior is more reliable than the patient's report of pain."

c. "Pain assessment scales determine the quality of a patient's pain." To gain a better understanding of a patient's current pain status and to determine what interventions are needed, the nurse should assess both current and previous pain scores.

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? a. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." d. "You need to take oral pain medications when you experience severe pain."

c. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain."

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. "This medication will still be providing you relief at the time of your dressing change." b. "OK, swallow this pain pill, and I will return in a minute to fill your wound." c. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" d. "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."

c. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" STAT doses of medication can be given to patients in certain circumstances, as with an extensive dressing change. By asking to hold off on the dose, the patient is indicating that the dressing changes are extremely painful. The regularly scheduled dose might not be as effective for the patient. Oral medications take 30 to 60 minutes to take effect. If the nurse began the dressing change right then, the medication would not have been absorbed yet. The patient has the right to refuse to take a medication. It is the nurse's responsibility to communicate with the provider and with the patient about a pain control plan that works for both.

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? a. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "You need to drink plenty of fluids and eat a diet high in fiber." d. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

c. "You need to drink plenty of fluids and eat a diet high in fiber."

The nurse anticipates administering an opioid fentanyl patch to which patient? a. A 15-year-old adolescent with a broken femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip

c. A 50-year-old patient with prostate cancer A fentanyl patch is an extended-relief opioid that provides pain relief for 24 hours a day. This is ideal for patients who have chronic severe pain, such as those who have cancer. The other patients are expected to experience acute pain. Therefore, they will most likely benefit from oral or IV opioids for short-term pain relief.

The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.

c. A 56-year-old male admitted for bladder irrigation A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.

The nurse should question which order? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema with a patient with fluid volume excess c. A Kayexalate enema for a patient with hypokalemia d. An oil retention enema for a patient using mineral oil laxatives

c. A Kayexalate enema for a patient with hypokalemia Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Because mineral oil laxatives and an oil retention enema have the same intended effect of lubricating the colon and rectum, an oil retention enema is not needed.

While caring for a hospitalized older adult female post hip surgery, the new graduate nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. The nurse exhibits critical thinking to perform this task by a. Following textbook procedure. b. Notifying the physician of the need for a urologist consult. c. Adapting the positioning technique to the situation. d. Postponing catheter insertion until the next shift.

c. Adapting the positioning technique to the situation.

Which person is the best referral for a patient who speaks a foreign language? a. A family member b. A speech therapist c. An interpreter d. A mental health nurse specialist

c. An interpreter

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? a. Assess the patient's body language. b. Observe cardiac monitor for increased heart rate. c. Ask the patient to rate the level of pain. d. Ask the patient to describe the effect of pain on the ability to cope.

c. Ask the patient to rate the level of pain.

The nurse enters a room to find the patient sitting up in bed crying. How would the nurse display a critical thinking attitude in this situation? a. Tell the patient she'll be back in 30 minutes. b. Set a box of tissues at the patient's bedside before leaving the room. c. Ask the patient why she is crying. d. Limit visitors while the patient is upset.

c. Ask the patient why she is crying. The nurse should try to find out why the patient is crying to intervene appropriately. Telling the patient that she will return, providing tissues, and limiting visitors may be appropriate actions but do not address the reason why the patient is crying.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

c. Assess for bladder distention. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? a. Increased energy levels b. Distended abdomen c. Decreased serum bicarbonate d. Increased blood pressure

c. Decreased serum bicarbonate Chronic diarrhea can result in metabolic acidosis, which is diagnostic of low serum bicarbonate. Patients with chronic diarrhea are dehydrated with decreased blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen would indicate constipation.

2. In caring for patients, it is important for the nurse to realize that evidence-based practice is a. The only valid source of knowledge that should be used. b. Secondary to traditional or standard care knowledge. c. Dependent on patient values and expectations. d. Not shown to provide better patient outcomes.

c. Dependent on patient values and expectations. Even when the best evidence available is used, application and outcomes will differ based on patient values, preferences, concerns, and/or expectations.

A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? a. Rectal skin breakdown b. Contamination of existing wounds c. Falls from attempts to reach the bathroom d. Cross-contamination into the upper GI tract

c. Falls from attempts to reach the bathroom The nurse is most concerned about the worst injury the patient could receive, which involves falling while attempting to get to the bathroom. To reduce injury, the nurse should clear the path and reinforce use of the call light. The question is asking for the greatest risk of injury, not the most frequent occurrence or the event most likely to occur.

The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills

c. Frequency Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.

The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient a. Has a decreased level of anxiety. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.

c. Has a bowel movement. A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic.

A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter.

c. Has not collected any urine in the drainage bag for 2 hours. If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed.

c. History of angina The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R).

To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.

c. Hold the labia apart while voiding into the specimen cup. The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

c. Improves a plan of care while thinking back on interventions performed

What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? a. Keeping the reversal agent in a syringe in the patient's bedside table b. Applying a gauze dressing to the epidural catheter insertion site c. Labeling the tubing that leads to the epidural catheter d. Asking the nursing assistive personnel to check on the patient at least once every 2 hours

c. Labeling the tubing that leads to the epidural catheter To reduce the accidental administration of IV medications into the epidural catheter, the tubing that leads to the epidural catheter needs to be labeled clearly. Medications used to reverse the action of the anesthetic medication need to be kept in a secured location, not in the patient's room in an unsecured location. The epidural insertion site needs to be covered by a clear occlusive dressing to prevent infection and allow the nurse to assess the site. Patients receiving epidural anesthesia need to be monitored every 15 minutes until stabilized and then at least hourly.

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.

c. Limit fluid and caffeine intake before bed.

The first step in evidence-based practice is to ask a clinical question. In doing so, the nurse needs to realize that in researching interventions, the question a. Is more important than its format. b. Will lead you to hundreds of articles that must be read. c. May be easier if in PICO format. d. May be more useful the more general it is.

c. May be easier if in PICO format.

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Neurological factors b. Competency of the surgeon c. Meaning of pain d. Postoperative support personnel

c. Meaning of pain

A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend

c. Mutuality Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants.

The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh

c. Placing the drainage bag on the side rail of the patient's bed Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation for patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. What type of research is the nurse conducting? a. Evaluation research b. Experimental research c. Qualitative research d. Nonexperimental research

c. Qualitative research Qualitative research involves using inductive reasoning to develop generalizations or theories from specific observations or interviews. Evaluation and experimental research are forms of quantitative research. Nonexperimental descriptive studies describe, explain, or predict phenomena such as factors that lead to an adolescent's decision to smoke cigarettes.

. The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately.

c. Self-examines personal communication skills.

The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body? a. Large intestine b. Stomach c. Small intestine d. Pancreas

c. Small intestine Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Frequently reassesses the patient's pain scores b. Reassures the patient that the provider will come to the emergency department soon c. Softly plays music that the patient finds relaxing d. Teaches the patient how to do yoga

c. Softly plays music that the patient finds relaxing

The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.

c. Spinal anesthetics can temporarily disable urethral sphincters. Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.

The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.

c. Sweet smelling. Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.

A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with stir fried vegetables and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with macaroni and cheese and soda

c. Turkey meatloaf with white rice and apple juice During the first week or so after ostomy placement, the patient should consume easy-to-digest low-fiber foods such as poultry, rice and noodles, and strained fruit juices. Fried foods can irritate digestion and can cause blockage. Foods high in fiber will be useful later in the recovery process but can cause blockage if the GI tract is not accustomed to digesting with an ileostomy.

The nurse would anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Upper endoscopy d. Flexible sigmoidoscopy

c. Upper endoscopy Black tarry stools are an indication of ulceration or bleeding in the upper portion of the GI tract; upper endoscopy would allow visualization of the bleeding. No other option would allow upper GI visualization.

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

c. Working

An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. guided imagery, relaxation breathing, and meditation. c. herbs, vitamins, and tai chi. d. alternating ice and heat to relieve pain and inflammation.

c. herbs, vitamins, and tai chi. Nonpharmacologic strategies encompass a wide variety of nondrug treatments that may contribute to comfort and pain relief. These include the body-based (physical) modalities, such as massage, acupuncture, and application of heat and cold, and the mind-body methods, such as guided imagery, relaxation breathing, and meditation. There are also biologically based therapies which involve the use of herbs and vitamins, and energy therapies such as reiki and tai chi. Pilates, breathing exercises, aloe vera, guided imagery, relaxation breathing, meditation, and alternating ice and heat are multimodal therapies for pain management. They are not exclusively biologically based, which involves the use of herbs and vitamins.

Critical Thinking: A patient states, "I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which response by the nurse would be an example of interpersonal therapeutic communication? a. "It sounds as though you were uncomfortable with the content of your dream." b. "I understand what you're saying. Bad dreams leave me feeling tired, too." c. "So, all in all, you feel as though you had a rather poor night's sleep?" d. "Can you give me an example of what you mean by a 'bad nightmare'?"

d. "Can you give me an example of what you mean by a 'bad nightmare'?" The technique of clarification is therapeutic and helps the nurse examine meaning. The distracters focus on patient feelings but fail to clarify the meaning of the patient's comment.

The nurse is admitting a patient to the medical/surgical unit. Which communication technique would be considered appropriate for this interaction? a. "I've also had traumatic life experiences. Maybe it would help if I told you about them." b. "Why do you think you had so much difficulty adjusting to this change in your life?" c. "You will feel better after getting accustomed to how this unit operates." d. "I'd like to sit with you for a while to help you get comfortable talking to me."

d. "I'd like to sit with you for a while to help you get comfortable talking to me." Because the patient is newly admitted to the unit, allowing the patient to become comfortable with the setting a technique that can assist in establishing the nurse-patient relationship. It helps build trust and convey that the nurse cares about the patient.

The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? a. "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." b. "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." c. "If the pain becomes severe, we may need to transfer you to an intensive care unit." d. "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."

d. "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps." The patient is responding well to the oral pain medication and it can take up to 2 hours for oral medications to relieve pain. Trying nonpharmacological interventions as an addition to opioid medications is appropriate at this time. If nonpharmacological interventions combined with the oral opioid are ineffective, the nurse needs to notify the health care provider and ask for a change in the medication or for additional pain medication. Saying that the patient has to wait 4 hours for additional pain medication is inaccurate because the nurse needs to provide further nursing interventions if pain is not relieved at an acceptable level for the patient. Admission to an intensive care unit is not typically necessary to manage pain following surgery for a hernia.

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

d. "It must be difficult not to know what the surgeon will find. What can I do to help?" "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them.

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "You do not look like you are in pain." c. "OK, I will go get you some narcotic pain relievers immediately." d. "What would you like to try to alleviate your pain?"

d. "What would you like to try to alleviate your pain?"

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

d. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? a. A 40-year-old patient with an ileostomy b. A 25-year-old patient with Crohn's disease c. A 30-year-old patient with C. difficile d. A 70-year-old patient with stool incontinence

d. A 70-year-old patient with stool incontinence A bowel elimination program is helpful for a patient with incontinence. It helps the person who still has neuromuscular control defecate normally. An ileostomy, Crohn's disease, and C. difficileall relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

d. A scientific knowledge base

The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.

d. Administering an antihistamine medication to the patient. Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete.

The researcher is preparing to publish his study findings. In doing so, the researcher is aware of many ways that the study could have been done better, but that he did not have the ability to do. The researcher discloses these limitations in the manuscript, but they are most likely detected during which phase of the research process? a. Problem identification b. Study design c. Formulation of recommendations d. Analysis of data

d. Analysis of data

A guaiac test has been ordered. The nurse knows that this is a test for a. Bright red blood. b. Dark black blood. c. Blood that contains mucus. d. Blood that cannot be seen. `

d. Blood that cannot be seen. Fecal occult blood tests are used to test for blood that may be present in stool that cannot be seen by the naked eye. This is usually indicative of a GI bleed. All other options are incorrect.

The quality improvement committee has been alerted to an increased number of falls in the hospital. Most of these falls have occurred at night and have involved patients who were trying to crawl over bedrails. A literature review brought out that most falls occur because patients are trying to go to the bathroom. The committee created a practice change that bedrails should be left in the down position, and hourly nursing rounds should be conducted. What is the committee's next step? a. Evaluate the changes in 1 month. b. Wait a month before implementing the changes. c. Implement the changes as a pilot study. d. Communicate to staff the results of this inquiry.

d. Communicate to staff the results of this inquiry.

The nurse has used her PICO question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more support staff than is available at this time. What is the nurse's best option? a. Drop the idea of making the change at this time. b. Insist that management hire the needed staff to facilitate the change. c. Seek employment in another institution that may have the staff needed. d. Conduct a pilot study to develop evidence to support the change.

d. Conduct a pilot study to develop evidence to support the change.

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing himself with two hands on the water fountain. Which critical thinking attitude is utilized in this situation? a. Humility b. Confidence c. Risk taking d. Creativity

d. Creativity

When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.

d. Discuss causes and solutions to problems related to micturition. The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.

The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious.

d. Dyspneic, has a tracheostomy, and is anxious. Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words.

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection. Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.

The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? a. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. b. Infants have an increased sensitivity to pain when compared with older children. c. Pain cannot be accurately assessed in infants. d. Infants respond behaviorally and physiologically to painful stimuli.

d. Infants respond behaviorally and physiologically to painful stimuli.

A nurse who is caring for a patient with a pressure ulcer fails to apply the recommended dressing according to hospital policy. If the patient is harmed, the nurse could be subject to legal action for not adhering to a. Fairness. b. Intellectual standards. c. Independent reasoning. d. Institutional practice guidelines.

d. Institutional practice guidelines. Institutional practice guidelines are established standards and policies that can be used in court to make judgments about nursing actions.

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram

d. Intravenous pyelogram Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

d. Making a clinical decision based on previous shift assessments

A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.

d. Monitor the patient for fever, rash, and difficulty breathing. Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.

The quality improvement committee is examining an increase in medication errors on a particular unit. In conducting its analysis, what should be the committee's primary focus? a. Nurses who administer the medications b. Pharmacy that prepares the medications c. Secretaries who enter the orders d. None of the above

d. None of the above

The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? a. Monthly in-services about contact precautions b. Placing all contaminated items in biohazard bags c. Mandatory cultures on all patients d. Proper hand hygiene techniques

d. Proper hand hygiene techniques Proper hand hygiene is the best way to prevent the spread of bacteria. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficilecomes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.

A nurse uses SBAR during hand-offs. The purpose of SBAR is to a. Use common courtesy. b. Establish trustworthiness. c. Promote autonomy. d. Standardize communication.

d. Standardize communication. When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, a risk of miscommunication arises. Accurate communication is essential to prevent errors. SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is moist. c. Stool is discharging from the stoma. d. Stoma is purple.

d. Stoma is purple. A purple stoma may indicate strangulation or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. Stool is an expected outcome of stoma placement.

Qualitative nursing research is valuable in that it a. Excludes all bias. b. Uses randomization in structure. c. Determines associations between variables and conditions. d. Studies phenomena that are difficult to quantify.

d. Studies phenomena that are difficult to quantify.

A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? a. Oil retention b. Carminative c. Saline d. Tap water

d. Tap water Tap water enema would draw fluid into the system and would help flush out excess sodium. Oil retention would not address sodium problems. Carminative enemas are used to provide relief from distention caused by gas. A saline enema would worsen hypernatremia.

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

d. The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week. Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient's wishes, knowing that the patient will most likely cheat. The patient will be allowed to "cheat." The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to take a scheduled dose of maintenance pain medication b. The patient who needs to be premedicated before walking c. The patient with a PCA running who needs to have the syringe replaced d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication

d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication STAT medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order.

Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation.

d. Transpersonal communication to enhance meditation. Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power."Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions.

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence

d. Urinary incontinence

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

d. Visceral pain Visceral pain comes from visceral organs, such as those from the gastrointestinal tract. Visceral pain is diffuse and radiates in several directions. Superficial pain has a short duration and is usually a sharp pain. Pain of an unknown cause is called idiopathic pain. Chronic pain lasts longer than 6 months.

A primary prevention tool used for colon cancer screening is a. abdominal x-rays. b. blood, urea, and nitrogen (BUN) testing. c. serum electrolytes. d. occult blood testing.

d. occult blood testing. Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer screening.