nursing fundamentals

extravasation.

The whole organ comes out

A patient who was admitted after receiving a blow to the head begins to show signs of shock. How should the patient be positioned?

With the head lower than the body. (aka) Trendelenburg

When shaving a patient, the nurse must remember to use an electric razor when:

a bleeding tendency is present

When the nurse is collecting a specimen for a wound culture, the specimen should never be collected from:

a dressing

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs? (Select all that apply).

a. Immobility. b. Restlessness. c. Risk for impaired circulation. d. Risk for skin impairment . e. Incontinence All apply

The nurse who diligently works for the protection of patients' interests is functioning in the role of:

advocate

The nurse is attempting to control bleeding in a patient with a profusely bleeding scalp wound. The most effective initial treatment of bleeding is to:

apply direct pressure.

A nursing program certified by a state agency is said to be

approved

To keep the patient comfortable during a dressing change, the nurse may administer an analgesic:

at least 30 minutes before the dressing change.. wet-to-dry dressing

Maslow' hierarchy or needs is based on the premise that:

basic needs must be met before the next level of needs can be met

When lifting or moving a patient, the nurse should protect his or her back by:

bending knees and hips

A nurse assesses an accident victim who has bright red blood spurting from a laceration on his right forearm. After applying direct pressure and elevating the limb, the nurse should apply pressure to the right:

brachial artery

To meet the needs of an unconscious patient with a risk for skin impairment, the nurse will plan to have the patient's position changed every:

120 minutes = 2 hrs

When collecting a stool specimen for a guaiac (occult blood in stool), the nurse should take a specimen from different parts of the stool.

2

For the first 24 hours following surgery, the nurse assesses for bleeding by observing the dressing and the area under the patient every:

2-4 hrs

The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area and should last at least:

20-30 min

Place the nursing activities in priority order for the preparation of a patient to ambulate:

4. Inform the patient of activity. 5. Roll up the head of the bed 1. Dangle the patient at the side of the bed. 2. Apply a gait belt. 3. Assist the patient to stand. Order: 4,5,1,2,3

When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?

Discuss it with the charge nurse, asking for direction

cellulitis.

Inflammation of the wound

Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?

Leaving a copy of the patient's history and physical in the photocopier

The document in which the role and responsibilities of the LPN/LVN are identified is the:

Nurse Practice Act

evisceration.

Protrusion of organ

When preparing to remove a dressing, the nurse should don gloves.

clean

By protecting the information in a patient's record, the nurse fulfills the ethical responsibility of:

confidentiality

A patient who had taken a poisonous substance was brought to the emergency department. The nurse should first:

contact the poison control center

The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. The nurse recognizes this as an indication of:

dehiscence.. (separation of the wound/ did not support their wound(I.e. heavy lifting) )

When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse then _________ the specimen.

discards

The nurse caring for a patient with a surgical wound promotes healing by:

encouraging the consumption of small frequent meals..

The nurse follows the basic concept of wound irrigation when directing the flow of the irrigate:

from the area of least contamination to the area of most contamination.

To protect a patient from aspiration following a bronchoscopy, the nurse should keep the patient NPO for 2 hours until the:

gag reflex has returned..

When bathing a patient with a deep vein thrombosis in the left leg, the nurse will modify the attention to the left leg by:

gently washing the leg and patting dry with a towel.

Before applying a safety reminder device (SRD), the nurse must:

get a physician's order

The nurse must follow the principles of medical asepsis while making a patient's bed, including procedures for handling linens. Soiled linens should be:

held away from the uniform

A system of comprehensive patient care that considers the physical, emotional, and social environment and spiritual needs of a person is

holistic health care

The patient's lower chest has been punctured with a knife that is still in place. The nurse should initially:

immobilize the knife with dressings and tape..

Because a sputum specimen must come from deep in the bronchial tree, the nurse will attempt to collect the specimen:

in the early morning

When teaching personal hygiene, the nurse teaches the patient that no matter how minimal, an important component is:

independence

The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?

informed consent

The nurse manager clarifies that "safe hospital environment" implies that in the hospital setting, people will be free from:

injury

During assessment of a postoperative patient, the nurse discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. The nurse recognizes these findings as indicative of:

internal hemorrhage.. (if dressing is soaked with blood it would be external hemorrhage)

Before administration of contrast media, the nurse should assess if the patient:

is allergic to iodine.

The nurse is assisting a victim of an accident who requires bandaging of the right lower extremity. When applying the bandage, the nurse should:

leave the toes exposed. ( Check circulation and sensation (Capillary refill)

If there is bright red blood in the stool, the nurse recognizes that the probable source of the blood is the

lower gastrointestinal tract..

A nurse who failed to irrigate a feeding tube as ordered, resulted in harm to the patient could be found guilty of:

malpractice

The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound, which when removed results in:

mechanical debridement.. (pre-medicate pt. before performing wet-to-dry)

The cleanest part of the voided urine specimen is collected after voiding is initiated and before it is finished. This is called a:

midstream specimen..

Primary intention has a marked advantage over other phases of wound healing because:

minimal scarring results

Although the nurse may disagree with a do-not- resuscitate (DNR) order, legally he or she:

must follow order

The responsibility for notifying the physician when laboratory and diagnostic studies deviate from the norm belongs to the:

nurse

Assuming responsibility for a patient's care forms a legally binding situation described as:

nurse-patient relationship

When obtaining a throat culture, the nurse must use a cotton-tipped applicator to swab the:

pharynx.. (back of the mouth by the throat)

The nurse teaches a patient with epistaxis (nosebleed) that the best way to control bleeding is to:

place ice on the nose and pinch the nostrils.. (Ice vasoconstricts and slows down the bleeding)

When providing hand and foot care, the person best prepared to provide nail care for patients with extremely hard nails is the:

podiatrist

The nurse assessing a patient's skin for signs of impaired skin integrity knowing that a major manifestation is a(n):

pressure ulcer

The nurse assessing a patient's wound notes thick, yellow drainage. The nurse documents this finding as:

purulent drainage..

An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. The best nursing action is to:

report the bruises to the charge nurse

The nurse assessing a patient's wound notes bright red drainage. The nurse documents this finding as:

sanguineous drainage..

The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as:

seroanguineous..(bloody= blood with fluid)

The nurse assessing a patient's wound notes pale, red, watery drainage. The nurse documents this finding as:

serosanguineous drainage.

The nurse assessing a patient's wound notes a clear, watery drainage. The nurse documents this finding as:

serous drainage..

The nurse counsels the immobilized patient that to prevent muscle atrophy and contractures, the patient must have:

some type of exercise

A visitor in the hospital slips and falls. The arm appears dislocated and the visitor is unable to move it. The nurse's first action is to:

splint the arm

Universal guidelines that define appropriate measures for all nursing interventions that should be observed during the performance of those interventions are known as:

standard of care

The nurse focuses on oral hygiene to maintain a healthy state of the oral cavity, as well as to:

stimulate appetite

The nurse instructs a patient who has a drain in a surgical wound that the wound will heal by:

tertiary intention.. (occurs when there is a need to delay closing a wound, such as when there is poor circulation in the wound area or infection)

When discussing the healthcare delivery system, the nurse must recognize that:

the major goal is to achieve optimal levels of healthcare.

The nurse explains that the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility is:

the minimum answer would be 5 min

The nurse performing passive range of motion (ROM) for the patient will move the joint through the ROM to:

the point of pain

Because some patients are unable to obtain a sputum specimen by coughing and expectorating, the nurse may collect the specimen by:

tracheal suctioning

The nurse should cleanse the meatal-catheter junction of a patient with an indwelling catheter at least:

twice a day

The nurse assessing a red blister over the right superior iliac area documents this decubitis ulcer as stage:

two

A newly licensed LPN/LVN may practice:

under the supervision of a physician or RN

Since a nurse's first duty is to the patient's health, safety, and well-being, it is necessary to report:

unethical behavior of other staff members

An implementation the nurse may use to improve safety during a transfer is:

using a transfer belt

The process to obtain a nursing license in another state when the person has passed the NCLEX® Examination in their own state is to:

utilize the reciprocity agreement between states

A nurse instructs a nursing assistant about the proper use of a gait belt. The nurse should intervene after observing the nursing assistant:

walking on the patient's strong side

The nurse should explain to the patient that following a barium enema the color of the stools will be:

white

To reduce the effort of moving a heavy object, the nurse should:

widen the base of support in the direction of movement.