Peer Tutor Practice exam questions
Your patient has just returned from the postanesthetic care unit (PACU) following left tibia open reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to administer the patients first scheduled dose of hydromorphone (Dilaudid). Prior to administering the drug, you would prioritize which of the following assessments? Hydration status Electrolyte levels Allergy status Blood pressure
Allergy Status
The nurse knows that this patient is at greatest risk for developing multiple adverse effects of immobility: A 1 year-old with a hernia repair An 80 year-old woman who has suffered a hemorrhagic cardiovascular accident (CVA) A 51 year-old woman in the Post Anesthesia Care Unit following a thyroidectomy A 38 year-old woman undergoing a hysterectomy
An 80 year-old woman who has suffered a hemorrhagic cardiovascular accident (CVA)
The nurse is caring for a client with congestive heart failure. On assessment, the nurse notices as dyspnea and crackles in lungs audible on auscultation. What additional manifestations of excess fluid volume would the nurse expect to note? Flat jugular veins and decreased urinary output Weight loss, flat hand veins and dry skin An increase in blood pressure with cough and increased respirations Weakness and decreased central venous pressure (blood pressure in vena cava)
An increase in blood pressure with cough and increased respirations
The nurse is caring for a client with diabetes. Which of the following is a characteristic of chronic illness? Managing chronic conditions must be an individual process. Chronic conditions only involve one aspect of a person's life. One chronic disease never develops into another chronic condition. Chronic illness affects the entire family.
Chronic illness affects the entire family
Which client is at risk for the development of a sodium level of 130 mEq/L? Client taking corticosteroids Client with Cushing's syndrome Client with hyperaldosteronism Client taking diuretics
Client taking diuretics
Which client is at risk for development of a potassium level of 5.5 mEq/L? Client that has been overusing locations Client with Cushing's syndrome Client who has sustained a traumatic burn Client with colitis
Client who has sustained a traumatic burn
A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal consult with the health care provider about using a different treatment protocol to control the patient's pain.
Consult with the health care provider about using a different treatment protocol to control the patient's pain.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. What interventions should the nurse take? SELECT ALL THAT APPLY Contact the surgeon Instruct the client to remain quiet Prepare the client for wound closure Document the findings and actions taken Place a sterile saline dressing and ice packs over the wound Place the client in the supine position without a pillow under the head
Contact the surgeon Instruct the client to remain quiet Prepare the client for wound closure Document the findings and actions taken
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinson's disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? Aggressively continuing to fight the disease process Supporting the patient's and family's values and choices Moving the patient to a long-term care facility when it becomes necessary Including the children in planning their father's care
Supporting the patient's and family's values and choices
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? The patient and family should be viewed as a single unit of care. Persistent symptoms of terminal illness should not be treated. Each member of the interdisciplinary team should develop an individual plan of care. Terminally ill patients should die in the hospital whenever possible.
The patient and family should be viewed as a single unit of care
A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? The patient will choose a diet that distributes calories throughout the day. The patient will follow a diet and exercise plan that results in weight loss. The patient will state the reasons for eliminating simple sugars in the diet. The patient will reach a glycosylated hemoglobin level of less than 7%.
The patient will reach a glycosylated hemoglobin level of less than 7%.
A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurses most plausible conclusion based on this assessment finding? The patient should withhold his next scheduled dose of insulin. The patient should promptly eat some protein and carbohydrates. The patient's insulin levels are inadequate. The patient would benefit from a dose of metformin (Glucophage).
The patient would benefit from a dose of metformin (Glucophage).
The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the health care provider? The patient complains of nausea after eating. The patient's respiratory rate is 10 breaths/minute. The patient has not had a bowel movement for 3 days. The patient has a distended bladder and has not voided.
The patient's respiratory rate is 10 breaths/minute
You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain should inform your care planning? They are typically more comfortable with underlying pain than patients without chronic pain. They often have a lower pain threshold than patients without chronic pain. They often have an increased tolerance of pain. They can experience acute pain in addition to chronic pain.
They can experience acute pain in addition to chronic pain.
The effects of immobility on the cardiac system include which of the following (select all that apply) Thrombus formation Increased cardiac workload Weak peripheral pulses Irregular heartbeat Orthostatic hypotension
Thrombus formation Increased cardiac workload Orthostatic hypotension
A nurse at an assisted living facility knows that the best way to prevent pressure ulcers is to increase patients calcium intake Turn and position q5hr Turn and position q2hr Sitting the patient up in semi- fowlers position
Turn and position q2hr
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? Twitching Hypoactive bowel sounds negative Trousseau's sign hypoactive deep tendon reflexes
Twitching
The nurse reviews a client's electrolytes and notes the potassium is 2.5 mEq/L. Which patterns should the nurse watch for on the electrocardiogram? SATA. U waves Absent P waves Inverted T waves Depressed ST segments Widened QRS complexes
U waves Inverted T waves Depressed ST segments
A Certified Nursing Assistant reports to the nurse that a postsurgical patient is complaining of pain that she rates as 8 on a 0-to-10 point scale. He also tells the nurse that he thinks the patient is exaggerating and does not need pain medication. What is the nurse's best response? Pain often comes and goes with postsurgical patients. Please ask her about pain again in about 30 minutes. Unless there is strong evidence to the contrary, we always take the patients report at face value. You are right, the patient is probably making it up to get attention. You might be right, but we still have to give some pain medication. Let's just give her a little and see if she's faking or not.
Unless there is strong evidence to the contrary, we always take the patients report at face value.
During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? Stress Urinary Incontinence Reflex Urinary Incontinence Functional Urinary Incontinence Urge Urinary Incontinence
Urge Urinary Incontinence
A patient who receives opioids by any route must be assessed frequently for changes in respiratory status. Sedation is an expected effect of a narcotic analgesic, though severely decreased LOC is problematic. Fluid overload and paradoxical increase in pain are unlikely, though opioid-induced hyperalgesia (OIH) occurs in rare instances. Use the visual analog scale Use a chart with English on one side of the page and the patients native language on the other so he can rate his pain Use the services of a translator each time you assess the patient so you can document the patients pain rating. Ask the patient to write down a number according to the 0-to-10 point pain scale.
Use a chart with English on one side of the page and the patients native language on the other so he can rate his pain
Which nutrient is needed for antibody formation and important for capillary formation, tissue synthesis and wound healing through collagen formation? Vitamin C Copper Water Sinc
Vitamin C
The nurse is caring for a client who has been receiving IV diuretics and suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? Weight loss and poor skin turgor Increased respirations and increased blood pressure Lung congestion and increased HR Decreased hematocrit and increased urine output
Weight loss and poor skin turgor
A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer? Half a sandwich with a protein-based filling Half of a cup of juice, followed by cheese and crackers A combination of protein and carbohydrates, such as a small cup of yogurt Two teaspoons of sugar dissolved in a cup of apple juice
Half of a cup of juice, followed by cheese and crackers
A nurse has been working with an older school-age athlete with diabetes who has hopes of traveling with his team to Little League championships in another state. What finding is the best indicator that the child's diabetes is under good control? He reports that he has been eating well and limiting refined carbohydrates. He has not developed celiac disease, which often co-occurs with type 1 diabetes. His hemoglobin A1C (HbA1C) level is 5.7%. He has not developed acanthosis nigricans.
He has not developed acanthosis nigricans.
The nurse is planning discharge teaching for an 80-year-old patient with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. When planning the necessary health education for this patient, what should the nurse plan to do? Set long-term goals with the patient. Provide a list of useful Web sites to supplement learning. Keep visual cues to a minimum to enhance the patients focus. Keep teaching periods short.
Keep teaching periods short
Which of the following is not a preventative measure for pressure-ulcer formation? Repositioning a patient at least every two hours. Padding bony areas on the body Keeping the patient in a sitting position while in bed. Changing soiled linens and clothing promptly
Keeping the patient in a sitting position while in bed
A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual's risk for developing diabetes? Have blood glucose levels checked annually. Stop using tobacco in any form. Undergo eye examinations regularly. Lose weight, if obese
Lose weight, if obese
The nurse who is a member of the palliative care team is assessing a patient. The patient indicates that he has been saving his PRN analgesics until the pain is intense because his pain control has been inadequate. What teaching should the nurse do with this patient? The patient will likely benefit more from distraction than pharmacologic interventions. Pain medication can be increased when the pain becomes intense. It is difficult to control chronic pain, so this is an inevitable part of the disease process. Medication should be taken when pain levels are low so the pain is easier to reduce.
Medication should be taken when pain levels are low so the pain is easier to reduce.
The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patient's death is imminent? Bowel incontinence. Mottling of the lower limbs. Increased swallowing. Slow, steady pulse.
Mottling of the lower limbs
A high school football player hurts his foot while playing a game. He complains of intense pain with muscle spasms and swelling of the toe. Which of the following pain assessment tools will the nurse most likely use to assess the patient's pain level? FACES pain scale Numeric rating pain scale FLACC scale CRIES scale
Numeric rating pain scale
A client is getting up for the first time after a period of bedrest. The nurse should first Obtain a baseline blood pressure Assist the client to sit at the edge of the bed Document that the patient is getting out of bed Ask the client if he/she feels lightheaded
Obtain a baseline blood pressure
A client is receiving morphine through a patient-controlled analgesia (PCA) system following surgery. The nurse states to the patient.. Your family may adjust your PCA for you Whenever you feel pain, push this button Only you can push this button for medication The nurse and doctor are the only ones allowed to press your PCA button
Only you can push this button for medication
Which is not a symptom of an elderly client with pneumonia? Pain in the back of the leg which is alleviated by rest. Green sputum with dyspnea Fine crackles or rales on ausculation of the lungs Change in mentation.
Pain in the back of the leg which is alleviated by rest
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that a client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on an assessment of the client's sacral area? Intact skin Full-thickness skin loss Exposed bone, tendon, or muscle Partial-thickness skin loss of the dermis
Partial-thickness skin loss of the dermis
The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the sacral area of the client? Partial-thickness skin loss of the dermis Intact skin with no discoloration. Slightly erythematous, intact skin. Full-thickness skin loss.
Partial-thickness skin loss of the dermis
A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests "something for pain that will work quickly." The nurse will document this as somatic pain referred pain neuropathic pain breakthrough pain
breakthrough pain
Opioid analgesics are effective pain management tools for many clients. A significant demographic within your practice are older adults who suffer from chronic pain. What impact does their age have on their initial dosing? reduced dosing increased dosing dosage is the same for all the dosage does not matter
reduced dosing
A client with Diabetes whose mother recently died reports elevated blood glucose levels. She admits she is too stressed to eat and is barely eating. How will the nurse best respond to this client? "Blood glucose levels can increase in times of stress because of sympathetic nervous system response increasing the need for energy." "The body reacts strangely and completely unpredictably to grief." "Have you checked the batteries in your glucose monitor recently?" "You probably do not realize all that you are eating during this stressful time."
"Blood glucose levels can increase in times of stress because of sympathetic nervous system response increasing the need for energy."
A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe? "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase." "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it." "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."
"Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down."
A staff nurse is precepting a new graduate nurse and the new graduate nurse is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? "I will be sure to cue in to any indicates that the client may be exaggerating their pain." "I will be sure to ask the client to rate the pain level on a scale of 0-10." "I know that I should follow up after giving medication to make sure it is effective." "I know that pain in the older client might manifest as sleep disturbances or depression."
"I will be sure to cue in to any indicates that the client may be exaggerating their pain."
Which statement by a patient diagnosed with heart failure indicates a correct understanding of prevention and clinical manifestation of hypervolemia? "I must drink a quart of liquids each day." "I will weigh myself every morning before I eat or drink." "I will use a seasoning mix such as season salt when preparing and eating my meals." "I will drink a soda every night before bedtime."
"I will weigh myself every morning before I eat or drink."
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? A client on long-term corticosteroid therapy A client receiving frequent wound irrigations. A client with an ileostomy A client with heart failure
A client with an ileostomy
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a patient who is experiencing chronic pain. Which statement made by the new graduate nurse indicates a need for further teaching regarding pain management. "I will be sure to ask my client what his pain level is on a scale of 0 to 10" "I know that I should follow up after giving medication to make sure it is effective" "I know that pain in the older client might manifest as sleep disturbances or depression" "If the patient asks about complementary alternative therapies, I will recommend applying ice or heat to the affected area for at least 45 minutes"
"If the patient asks about complementary alternative therapies, I will recommend applying ice or heat to the affected area for at least 45 minutes"
A patient has just been told that her illness is terminal. The patient tearfully states, "I can't believe I am going to die. Why me?" What is your best response? "I know how you are feeling." "You have lived a long life." "This must be very difficult for you." "Life can be so unfair."
"This must be very difficult for you."
A medical nurse is caring for a patient with type 1 diabetes. The patient's medication administration record includes the administration of regular insulin three times daily. Knowing that the patient's lunch tray will arrive at 11:45, when should the nurse administer the patient's insulin? 11:50 10:45 11:15 11:45
11:15
A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADAs recommendations include? 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
The client who has the chronic condition of diabetes, reports blurry vision, and admits to non-adherence to the diet and medications. The home health nurse checks the client's fasting blood glucose level, which is 412 mg/dL. What phase of the Trajectory Model of Chronic Illness does the nurse assess this client is in? Comeback Acute Pre-trajectory Stable
Acute
Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA) pump and the patients orders specify an initial bolus dose. What is your priority assessment? Assess for decreased level of consciousness Assess for respiratory depression Assess for fluid overload Assess for paradoxical increase in pain
Assess for respiratory depression
The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a PCA pump for pain control. The nurse enters the room and finds the client very drowsy, with temp of 97.2 orally, pulse 52 BPM, BP 101/58, RR 11 breaths/min and SpO2 of 93% on 3 L of oxygen via nasal cannula. What action should the nurse take next? Contact the PHCP immediately. Document the findings as normal. Attempt to arouse the client. Check the medication administration history of the PCA pump.
Attempt to arouse the client
The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes: Avoid tight fitting pants or clothing Drink 6 glasses of water per day Type of soap when bathing has no significance in this area. Voiding pattern in the course of the day has no significance with this problem
Avoid tight fitting pants or clothing
A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? Apples Asparagus Carrots Bananas
Bananas
The nurse provides corrective instruction to the nursing assistant when the assistant refers to the client as the Man with a stroke Woman who has multiple sclerosis Person who is disabled Blind diabetic patient
Blind diabetic patient
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: Decreased peristalsis decreased heart rate increased urinary output increased blood pressure
Decreased peristalsis
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? Diarrhea Dilute urine Increased muscle tone Joint pain
Dilute urine
On your nursing care plan for a patient with a urinary tract infection, which of the following would be appropriate nursing interventions? SELECT-ALL-THAT-APPLY: Encourage voiding every 2-3 hours while awake. Restrict fluid intake to 1-2 liters per day. Monitor intake and output daily. The patient verbalizes the importance of using vaginal sprays to decrease reoccurrence of urinary tract infections prior to discharge home.
Encourage voiding every 2-3 hours while awake. Monitor intake and output daily.
Two patients on your unit have recently returned to the postsurgical unit after knee arthroplasty. One patient is reporting pain of 8 to 9 on a 0-to-10 pain scale, whereas the other patient is reporting a pain level of 3 to 4 on the same pain scale. What is the nurses most plausible rationale for understanding the patients different perceptions of pain? One of the patients may be experiencing opioid tolerance. One of the patients is exaggerating her/his sense of pain. Endorphin levels may vary between patients, affecting the perception of pain The patients are likely experiencing a variance in vasoconstriction.
Endorphin levels may vary between patients, affecting the perception of pain
The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? SATA Ensure adequate oxygenation Provide assistance to prevent falls Monitor medication administration of diuretics Monitor for numbness and tingling around the mouth Prevent complications during potassium administration
Ensure adequate oxygenation Monitor medication administration of diuretics Monitor for numbness and tingling around the mouth Prevent complications during potassium administration
The nurse is caring for a client who is a doctor in a general hospital. He complains about the stressful condition of his job. Lately, he has become increasingly susceptible to colds, headaches, muscular tension, excessive tiredness, and many other symptoms. At what stage of stress is the client? Secondary stage Exhaustion stage Alarm stage Resistance stage
Exhaustion stage
A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? Fasting plasma glucose greater than or equal to 126 mg/dL Random plasma glucose greater than 150 mg/dL Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions Random plasma glucose greater than 126 mg/dL
Fasting plasma glucose greater than or equal to 126 mg/dL
You are the nurse caring for an 85-year-old patient who has been hospitalized for a fractured radius. The patient's daughter has accompanied the patient to the hospital and asks you what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What would be your best response? Try to help your father increase his intake of dairy products. Make sure that he applies sunscreen each morning. Dry skin is an age-related change that is largely inevitable. He should likely take showers rather than baths, if possible.
He should likely take showers rather than baths, if possible
Which of the following are common sites for development of pressure ulcers? (select all that apply) Sternum Heels Sacrum Lateral Malleolus Trochanters Tip of great toe
Heels Sacrum Lateral Malleolus Trochanters
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? Muscle twitches Decreased urinary output Hyperactive bowel sounds Increased specific gravity of the urine
Hyperactive bowel sounds
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate? Hypermagnesemia Hyponatremia Hypocalcemia Hyperkalemia
Hypocalcemia
A patient has been brought to the emergency department by paramedics after being found unconscious. The patients Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? IV bolus of 5% dextrose in 0.45% NaCl IV administration of 50% dextrose in water Subcutaneous administration of 10 units of Humalog Subcutaneous administration of 12 to 15 units of regular insulin
IV administration of 50% dextrose in water
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? Impaired physical mobility Ineffective health mintenance Ineffective role performance Disturbed sensoru perception: kinesthetic
Impaired physical mobility
When reviewing their knowledge of stages of infections, the nurse knows that which period precedes the first symptoms of infection? Prodromal Period Incubation Period Colonization of organism Convalescent period
Incubation Period
The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid? Scheduled toileting Indwelling urinary catheter. Condom catheter. Incontinence pads.
Indwelling urinary catheter
You are admitting a patient who presents with inflammation of his right ankle. When planning this patients care, which of the following statements regarding acute inflammation should you recognize? Inflammation is essentially synonymous with infection. Inflammation may impair the healing process. Inflammation is a defensive reaction intended to remove an offending agent. Inflammation inhibits the release of histamines in the tissues.
Inflammation is a defensive reaction intended to remove an offending agent.
The nurse is reading a PHCP's progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approx 800 mL daily." The nurse should make a notation that insensible fluid loss occurs through which type of excretion? Urinary output Wound drainage Integumentary output GI tract
Integumentary output
A nurse is providing AM care to a comatose patient. The patient has been immobile for several weeks and is at risk for muscle atrophy and contractures. What action should the nurse take in caring for the patient> Passive range of motion exercises should be done with the patient. Before oral care, the head of bed should be made flat, and the patient's head should be turned to the side to prevent aspiration. Wake the patient up to do active range of motion exercises in bed. Perineal care should be provided, but a full bed bath should be avoided due to risk for pressure sores.
Passive range of motion exercises should be done with the patient
You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? Patient performs range-of-motion exercises. Patient elevates her body parts that are susceptible to edema. Patient avoids placing her body weight on the healing site. Patient demonstrates the technique for massaging the wound site.
Patient performs range-of-motion exercises.
You walk into your patients' room and find her sobbing uncontrollably. When you ask what the problem is your patient responds "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this patient's care plan you note a nursing diagnosis of "Ineffective coping related to stress". What is the best outcome you can expect for this patient? Patient will avoid stressful situations. Patient will start anti-anxiety agent. Patient will adapt relaxation techniques to reduce stress. Patient will be stress free.
Patient will adapt relaxation techniques to reduce stress
During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. Perineal skin irritation Fluid intake of less than 1,500 mL/day History of antihistamine intake History of frequent urinary tract infections Heart rate
Perineal skin irritation Fluid intake of less than 1,500 mL/day History of frequent urinary tract infections
Which of the following is a true statement regarding placebos? A positive response to placebo means that the patients pain isn't real Placebos do not measure pain Placebos are the only effective tool when measuring a patient's pain Placebos should never be used to test truthfulness about pain
Placebos should never be used to test truthfulness about pain
A middle-aged woman's father has passed away, and her mother requires physical and emotional help due to disabilities. The woman is married and raising two children, along with working full time. All of the factors described are Stressors Demands Illnesses Stimuli
Stressors
You are caring for a 20-year-old patient with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this patient, what variables should the nurse consider? Select all that apply. Gender Comorbid conditions Type of procedure to be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving pain.
Prior effectiveness in relieving pain. Comorbid conditions Type of procedure to be performed Changes in neurologic function due to the procedure
The client had a cerebrovascular accident with drooping of the face. Speech is slurred. The nurse is obtaining the admission assessment data. It would be best for the nurse to Ask a family member the questions. Wait until past medical records can be obtained. Chart that the nurse is unable to obtain information. Repeat back what the client states.
Repeat back what the client states
While assessing a patient with impaired mobility, the nurse observes that the patient is unable to perform range of motion exercises. Complications to which system are most likely to occur in the patient? Metabolic Respiratory Integumentary Musculoskeletal
Respiratory
A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. Limit fluids to avoid the burning sensation on urination. Review symptoms of UTI with the client. Wipe the perineal area from back to front. Wear cotton underclothes. Take baths rather than showers.
Review symptoms of UTI with the client. Wear cotton underclothes.
The nurse assesses the client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? Red, hard skin Serous drainage Purulent drainage Warm, tender skin
Serous drainage
The nurse knows to monitor for all of the following nonverbal indicators of pain except. Restlessness Sleeping High blood pressure Moaning
Sleeping
You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient? Whole wheat macaroni with cheese Skim milk, oatmeal, and whole wheat toast Steak, baked potato, spinach and strawberry salad Eggs, hash browns, coffee, and an apple
Steak, baked potato, spinach and strawberry salad
