Quiz VII-VIII
A patient smokes in the hospital bathroom and starts a fire. Which is the nurse's first response? a. Remove the patient to a safe area. b. Close the door to contain the fire. c. Call the operator to activate the fire alarm. d. Utilize a fire extinguisher to put out the fire.
A
A patient's spouse smokes cigarettes in the kitchen while the patient uses supplemental oxygen in the bedroom. Which is the priority nursing diagnosis for this family? a. Risk for injury related to smoking near supplemental oxygen b. Risk-prone health behavior related to inability to quit smoking c. Ineffective health maintenance related to continued use of cigarettes d. Ineffective family therapeutic regimen management related to noncompliance
A
The nurse has just completed teaching the patient about how to use crutches safely. Which statement by the nurse will help determine that the teaching was effective? a. "Now I want to see you walk using the crutches correctly." b. "Here are written instructions in case you forget my directions." c. "I will make a note in the chart that you were taught how to use crutches." d. "Please let me know if you have any questions about how to use crutches."
A
The nurse is caring for a patient who has ongoing headaches, nausea, dizziness, and fatigue since the weather turned cold and snowy. Which assessment question is most important to ask the patient? a. "Has your furnace been inspected lately?" b. "Have you checked your roof for any leaks?" c. "When was the last time your house was painted?" d. "When did you change your smoke detector batteries?"
A
The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room? a. American Association of Poison Control Centers b. Centers for Disease Control and Prevention c. Agency for Healthcare Research and Quality d. Institute for Safe Medication Practices
A
The nurse is caring for a patient who will be having emergency surgery in a few minutes for appendicitis. Which preoperative teaching is most important? a. What to expect when waking up in the postanesthesia care unit b. Interventions to minimize risk of postoperative wound infection c. Demonstration of incentive spirometer and deep-breathing exercises d. Importance of early ambulation to prevent pneumonia and atelectasis
A
The nurse is caring for a patient with a traumatic injury to the cerebellum. Which assessment finding will be expected as a result? a. The patient sways from side to side when walking. b. The patient's ligaments are weak and easily ruptured. c. The patient has fine tremors with purposeful movement. d. The patient's joints are reddened, swollen, and warm to touch.
A
The nurse is caring for a patient with arthritis who wants to exercise but finds it difficult due to joint pain and stiffness. Which nursing diagnosis is appropriate for this patient? a. Activity intolerance related to exertional discomfort b. Noncompliance related to lack of motivation to exercise c. Unilateral neglect related to health beliefs about chronic illness d. Powerlessness related to expressions of uncertainty about benefits of exercise
A
The nurse is caring for a patient with right-sided hemiplegia after a stroke. Which is the appropriate goal for the diagnosis impaired transfer ability related to insufficient muscle strength? a. The patient will safely transfer from bed to chair with the assistance of one person. b. The patient will verbalize feelings about physical limitations due to immobility. c. The nurse will reposition the patient every 2 hours and pad bony prominences. d. The nurse will utilize a gait belt around the patient's low back for all transfers.
A
The nurse is caring for a patient with right-sided hemiplegia. Which intervention will help prevent damage to the patient's right shoulder? a. Place the patient's right arm in a sling whenever the patient is sitting upright. b. Set up the patient's meal trays so that all food is within easy reach for the left arm. c. Elevate the head of the patient's bed at least than 30 degrees in the lateral position. d. Assess for increased joint resistance when repositioning the patient.
A
The nurse is caring for a pregnant mother of two small children who is on bed rest for several months until the baby is born. Which outcome is most appropriate to address the diagnosis of compromised family coping related to mother's prolonged bed rest? a. The family will verbalize need for support and identify available resources. b. The family will discuss alternatives to bed rest with the health care provider. c. The mother will verbalize need for bed rest to minimize risk of premature birth. d. The mother will report increased psychological comfort with each passing week.
A
The nurse is to transfer an obese, hemiplegic patient from the bed to the chair. Which is the safest way for the nurse to do this? a. Use of a mechanical patient lift device b. Use of a gait belt around the patient's waist c. Use of three staff members to assist the patient d. Use of a roller board to slide from the bed to the chair
A
The patient lives in an apartment and has difficulty getting on and off of the toilet. Which is the best intervention to protect the patient's safety? a. Place a bedside commode over the toilet. b. Screw grab bars into the wall by the toilet. c. Attach suction cup grab bars to the wall by the toilet. d. Instruct the patient to lean forward when rising to stand.
A
What is the priority nursing diagnosis for a patient with osteoporosis? a. Risk for injury (fracture) related to fragile bone tissue b. Activity intolerance related to pain and joint stiffness c. Impaired tissue integrity related to red, swollen, painful joints d. Fatigue related to chronic inflammatory destruction of tissues
A
Which action is appropriate for transferring a hemiplegic patient from the bed to the wheelchair? a. The nurse ensures that the wheelchair brakes are locked before helping the patient to stand. b. The patient's arms are placed around the nurse's neck before the patient is helped to stand. c. The nurse secures the gait belt under the patient's arms and uses it to lift the patient to a standing position. d. The nurse's legs are kept straight and close together to avoid tripping the patient during the transfer.
A
Which assessment finding indicates that the patient developed osteoporosis after a long period of immobility? a. The patient fractured three ribs after coughing on spicy food. b. The patient is unable to dorsiflex the foot, leading to an unsteady gait. c. The patient has a steppage gait with exaggerated flexion of the hip and knee. d. The patient's knees curve inward and bump against each other with ambulation.
A
Which assessment finding indicates that the patient is at higher risk for a motor vehicle accident? a. The patient is 18 years of age. b. The patient drives a bright blue sedan. c. The patient is the youngest of six children. d. The patient has a history of juvenile arthritis.
A
Which assessment finding indicates that the patient is at risk for developing hypothermia? a. The patient is disoriented due to senile dementia. b. The patient is 5-foot 6-inch tall with a BMI of 35. c. The patient has a history of congestive heart failure. d. The patient takes three different antihypertensive medications.
A
Which intervention will be most effective for prevention of foot drop in an immobile patient? a. Apply high-top tennis shoes to the patient's feet. b. Obtain a podiatry consult for all toenail and foot care. c. Encourage the patient to wear sturdy shoes when ambulating. d. Apply moisturizing lotion to the heels of the feet and between the toes.
A
Which intervention will help prevent the development of footdrop for a comatose patient? a. Place high-top tennis shoes on the patient's feet. b. Place pillows under the legs to keep the heels off the mattress. c. Apply sequential compression devices to the patient's feet. d. Assist the patient to a lateral position whenever possible.
A
Which intrinsic assessment finding could lead a patient to fall? a. The patient has orthostatic hypotension and faints when standing too quickly. b. The patient's room is located at the end of the hall far from the nursing station. c. The patient's roommate sometimes spills the contents of a urinal on the floor. d. The patient's room is crowed with walkers, wheelchairs, and bedside commodes.
A
Which is an appropriate outcome for an elderly patient with the nursing diagnosis adult failure to thrive related to placement in extended care agency after right hip fracture? a. The patient will participate in social activities and maintain usual weight. b. The patient will exercise both legs to minimize effects of unilateral neglect. c. The patient will verbalize need for extended nursing care during rehabilitation. d. The patient will not demonstrate symptoms of deep vein thrombus development.
A
Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several days of bed rest? a. Risk for falls related to light-headedness upon standing and getting out of bed b. Dressing/grooming self-care deficit related to cognitive impairment and fatigue c. Impaired bed mobility related to inability to move from supine to sitting position d. Excess fluid volume related to insensible fluid loss due to prolonged immobility
A
Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery? a. Ineffective breathing pattern related to incisional pain and anesthesia b. Deficient diversional activity related to boredom from hospitalization c. Readiness for enhanced comfort related to desire for rest after surgery d. Risk for suffocation related to emotional and cognitive stress after surgery
A
Which is the priority outcome for the patient with the nursing diagnosis fluid volume deficit related to ongoing postoperative bleeding? a. The patient's urine output will be at least 30 mL/hour. b. The patient's temperature will remain within normal limits. c. The patient's surgical incision will remain intact with sutures. d. The patient will verbalize measures to reduce fluid volume loss.
A
Which is the safest method for a patient with a left leg injury to navigate up a set of stairs? a. Sit down on the stairs and use the right leg to lift the body up each step. b. Use a gait belt, the left handrail, and a crutch under the right arm. c. Securely place both crutches on the next step and swing the body upward. d. Bend the knee of the right leg when lifting the left leg up to the next step.
A
Which nursing diagnosis is the highest priority for a family with small children? a. Risk for suffocation related to unattended swimming pool in back yard b. Risk for caregiver role strain related to four children under 6 years of age c. Readiness for enhanced immunization status related to request for medical records d. Readiness for enhanced parenting related to attachment between family members
A
Which nursing diagnosis is the highest priority for a sexually active adolescent? a. Risk for infection related to participation in unprotected sexual activity b. Disturbed body image related to depersonalization and fear of rejection c. Spiritual distress related to inability to integrate sexuality with church teaching d. Risk for compromised human dignity related to loss of respect from peer group
A
Which patient would benefit from the use of a hand roll? a. A patient with paralysis of the right hand after a left-sided stroke b. A paraplegic patient who requires assistance moving up in the bed c. A confused patient who is attempting to pull out the urinary catheter d. A patient with lymphedema of the right arm and hand after mastectomy
A
Which surgery is classified as a palliative procedure? a. Release of bowel obstruction in a patient with end-stage colon cancer b. Thoracotomy to determine if a patient's lung nodule is cancerous or benign c. Tummy tuck and repair of umbilical hernia after the patient gave birth to triplets d. Removal of the donor's heart, lungs, and cornea for transplant in recipient patients
A
Which nursing goals are appropriate for a patient with the nursing diagnosis of impaired walking related to neuromuscular weakness and deconditioning? (Select all that apply.) a. The patient will be able to ambulate 25 feet in the hallway. b. The patient will demonstrate correct use of a rollator walker. c. The nurse will keep the patient's heels elevated off the mattress. d. The patient will use the over-bed trapeze to reposition self every 2 hours. e. The nurse will ensure that the floors are kept free of clutter or spills. f. The nurse will assess the patient's pulse before and after ambulation.
A, B
The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday. Which are the appropriate actions of the nurse? (Select all that apply.) a. Assist the patient to sit up in the chair and ambulate in the hallway. b. Watch the patient use the incentive spirometer and ensure hourly usage. c. Teach the patient to splint the incision when coughing to minimize pain. d. Dim the lights, provide warm blankets, and maintain a quiet environment. e. Maintain patient privacy and use therapeutic touch as desired by the patient.
A, B, C
Which assessment findings indicate increased risk of infection following hip replacement surgery? (Select all that apply.) a. The patient has been a type 2 diabetic for the last 5 years. b. The patient had an indwelling urinary catheter during surgery. c. The patient takes adalimumab for rheumatoid arthritis. d. The patient received two units of packed red blood cells after surgery. e. The patient's platelet count has been 300,000 to 350,000/mm3 after surgery
A, B, C
Which assessment findings place the patient at high risk of pulmonary embolism due to immobility? (Select all that apply.) a. The patient has had polycythemia vera for the last 5 years. b. The patient refuses daily injections of enoxaparin. c. The patient has worn compression hose since the day of surgery. d. The patient has an indwelling urinary catheter to bedside drainage. e. The patient cannot tolerate intermittent sequential compression devices.
A, B, E
A patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing, and a wrist restraint is applied after an order is received. Later, the patient reports tingling and numbness in the fingers and hand. Which actions should the nurse take? (Select all that apply.) a. Stay with the patient. b. Medicate the patient for pain. c. Notify the health care provider. d. Remove the restraint immediately. e. Tell the patient to relax and it will feel better shortly.
A, C, D
Which interventions are appropriate for the postoperative patient with the nursing diagnosis risk for ineffective peripheral tissue perfusion related to venous thromboembolism from immobility after surgery? (Select all that apply.) a. Apply graduated compression stockings after measuring the patient's legs. b. Encourage weight loss in order to minimize risk of chronic venous insufficiency. c. Carefully assess for any swelling or redness in the patient's upper and lower legs. d. Apply sequential compression devices to the patient's legs when resting in bed. e. Carefully assess the patient for dyspnea, tachycardia, and low pulse oximetry. f. Teach the patient to inspect the legs daily for dry skin, coolness, and hair loss.
A, C, D, E
The patient's electricity has been shut off after failure to pay the utility bills. Which actions by the patient pose health hazards? (Select all that apply.) a. The gas oven is used to warm the kitchen. b. Extra layers of warm clothing are worn. c. Food is smelled to determine if it is edible. d. Dry ice is used to keep milk and eggs cold. e. Lit taper candles are placed around the house.
A, C, E
Which interventions are appropriate for the patient at risk for peripheral neurovascular dysfunction related to casted right ankle? (Select all that apply.) a. Regularly assess the patient's toes for warmth and capillary refill. b. Apply graduated compression stockings to both legs to prevent DVT. c. Encourage the patient to frequently wiggle the toes to increase circulation. d. Educate the patient that numbness and tingling of the area is to be expected. e. Elevate the ankle above the level of the heart and apply ice to the ankle area.
A, C, E
Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action of the nurse? a. Notify the surgeon immediately and prepare the patient for emergency surgery. b. Keep the patient NPO and document the finding in the patient's medical record. c. Allow the patient to have clear liquids as tolerated to help bowel function return. d. Provide meticulous oral care and allow the patient to have ice chips for dry mouth.
B
How does the nurse maintain a low center of gravity while transferring the patient from the bed to the chair? a. The nurse ties the gait belt loosely around the patient's waist. b. The nurse stands with the knees slightly bent and legs spread apart. c. The nurse bends at the waist when setting the patient's feet on the floor. d. The nurse leans backward slightly when helping the patient to stand.
B
Into which seating position will the nurse teach a family to place their 18-month-old toddler in the family car? a. Front seat facing backward b. Rear seat facing backward c. Front seat facing forward d. Rear seat facing forward
B
The nurse is applying soft wrist restraints to the patient. Where will the restraints be tied to the patient's bed? a. Side rails b. Bedframe c. Footboard d. Headboard
B
The nurse is teaching the patient about postoperative exercises including incentive spirometry. How can the nurse best determine that the teaching was effective? a. The patient states that the preoperative anxiety has decreased significantly. b. The patient correctly demonstrates the exercises and how to use the spirometer. c. The patient senses a caring presence of the nurse in the therapeutic relationship. d. The patient explains to the nurse why the exercises and spirometer are important.
B
The nurse suspects that the postoperative patient has developed a deep vein thrombosis. Which is the priority action of the nurse? a. Obtain an order for STAT bleeding time, D-dimer, and platelet count. b. Elevate the patient's leg and assess for chest pain or shortness of breath. c. Apply a mobile compression device (MCD) to the patient's affected leg. d. Use a Doppler machine to confirm the presence of bilateral pedal pulses.
B
The patient refuses to get out of bed to ambulate after surgery. Which is the appropriate response of the nurse? a. "No problem. You should rest quietly in bed today so that you can heal." b. "It is important to get out of bed and walk to prevent blood clots or pneumonia." c. "I will notify your doctor that you refused and make a notation in your chart." d. "You can have your next dose of pain medication after you get up and walk."
B
The patient will be having knee-replacement surgery at 2:00 p.m. What is the latest time that the patient can have a cup of coffee with cream? a. 6:00 a.m. b. 8:00 a.m. c. 10:00 a.m. d. 12:00 noon
B
The wrong type of medication was administered to the patient. Which type of error is this? a. Exposure-related accident b. Procedure-related accident c. Equipment-related accident d. Organization-related accident
B
Which action of the nurse will help to reduce the effects of orthostatic hypotension? a. Perform isometric and range-of-motion exercises. b. Encourage the patient to move from a sitting position to standing position slowly. c. Place trochanter rolls on either side of the patient's hips. d. Participate in chest physiotherapy and incentive spirometry.
B
Which assessment finding leads the nurse to add ineffective protection to the patient's care plan? a. The patient follows a gluten-free, low-sodium, antiinflammatory diet. b. The patient has not received immunizations against influenza or pneumonia. c. The patient recently divorced after being in an unhappy marriage for 4 years. d. The patient takes levothyroxine daily to treat hypothyroid disease.
B
Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter? a. The patient does not wish to get out of bed and ambulate to the toilet. b. The patient just underwent radical prostatectomy surgery 2 days ago. c. The drainage bag contains 300 mL of clear yellow urine from the last 4 hours. d. The patient is to be discharged home after a final assessment by the surgeon.
B
Which instruction directs the patient to perform an isometric exercise? a. "Use the trapeze to lift your upper body off the bed." b. "Tighten and hold your stomach muscles for 15 seconds." c. "Close your fists and squeeze them tightly, release and repeat." d. "Lift your buttocks off the bed by pushing against the mattress."
B
Which is an appropriate goal for a patient with the nursing diagnosis of sedentary lifestyle related to generalized weakness and fatigue? a. The patient will identify barriers that limit social interactions. b. The patient will increase physical activity to 3500 steps daily. c. The patient will use a pain rating scale to identify levels of discomfort. d. The patient will verbalize the risks of continuing noncompliance with treatment.
B
Which is the appropriate intervention for a patient with risk for constipation related to prolonged immobility? a. Check the patient's rectum for the presence of a fecal impaction. b. Encourage the patient to consume plenty of fluids and dietary fiber. c. Instruct the patient about the body's need for daily bowel movements. d. Recommend the use of daily laxatives to prevent constipation or impaction.
B
Which is the appropriate intervention for the patient with the diagnosis powerlessness related to pain and weakness after right hip fracture? a. Place the patient's personal items within view on the left side of the bed. b. Encourage the patient to participate in self-care and recreational activities. c. Assess the patient's sleep patterns and potential for obstructive sleep apnea. d. Reposition the patient and pad bony prominences to prevent skin breakdown.
B
Which is the appropriate outcome for the patient with the nursing diagnosis risk for ineffective peripheral tissue perfusion related to prolonged immobility? a. The patient's urinary output will remain at least 30 mL/hour. b. The patient's legs will maintain strong peripheral pulses and no edema. c. The patient's abdomen will stay soft with bowel sounds present 4 quadrants. d. The patient will remain alert and appropriate with no changes in mental status.
B
Which is the highest priority nursing diagnosis for a college student who is living away from home for the first time? a. Sleep deprivation related to noisy dormitory environment b. Risk-prone health behavior related to weekend binge drinking c. Relocation stress syndrome related to moving away from home d. Risk for loneliness related to being away from family and old friends
B
Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in the operating room? a. Powerlessness related to unconscious state from general anesthesia b. Hypothermia related to cool ambient temperature in the operating room c. Risk for impaired oral mucus membranes related to prolonged NPO status d. Risk for caregiver role strain related to lengthy waiting period for family members
B
Which is the priority intervention for a patient with the nursing diagnosis of impaired physical mobility related to muscle weakness and neuromuscular impairment? a. Allow the patient to decide when and how far to ambulate each day. b. Utilize a walker, gait belt, and two nursing staff members for ambulation. c. Suggest a variety of physical activities to encourage patient engagement. d. Encourage the patient to use positive self-talk to gradually increase strength.
B
Which outcome is most appropriate for a patient with the diagnosis impaired wheelchair mobility related to neuromuscular impairment and fatigue? a. The patient will feel comfortable navigating the motorized wheelchair. b. The patient will demonstrate ability to safely operate the motorized wheelchair. c. The patient will understand the need to use a motorized wheelchair for mobility. d. The patient will demonstrate correct use of the trapeze bar for repositioning self.
B
Which patient care need may be delegated to the nursing assistant? a. Providing discharge teaching about fall precautions in the home b. Responding to the patient's bed alarm as the patient attempts to get up c. Performing a mental status assessment to check for confusion or delirium d. Obtaining a consult for physical therapy for strengthening/balance exercises
B
The nurse is caring for a patient who is ordered to remain on bed rest. Which is the appropriate action of the nurse to facilitate emptying of the patient's bladder? a. Assist the patient to the bedside commode for voiding. b. Insert an indwelling urinary catheter to bedside drainage. c. Place the patient in high Fowler's position when using the bedpan. d. Place the patient in Trendelenburg's position when using the bedpan.
C
The nurse is caring for a patient who must lay flat in bed for several days after spinal surgery. Which is the priority nursing diagnosis for this patient? a. Impaired social interaction related to prolonged bed rest b. Toileting self-care deficit related to inability to use the restroom c. Ineffective breathing pattern related to prolonged supine position d. Ineffective thermoregulation related to lengthy period of immobility
C
The nurse is caring for a patient who suffered a fractured arm. Which assessment finding is expected after the patient's cast is removed after 6 weeks? a. The skin is thin with no hair growth. b. The radial pulse is weak and thready. c. The arm muscles are atrophied and weak. d. The fingernail beds are thick and clubbed.
C
The patient is aggressively attempting to pull out IV lines and hurt staff members. Which is the first action of the nurse? a. Conduct a thorough mental status assessment. b. Contact the health care provider to obtain an order for restraints. c. Place the patient in soft restraints to prevent injury. d. Document the patient's actions in the medical record.
C
The patient keeps more than 30 cats in the home and is unable to adequately care for them. Which is the priority nursing diagnosis for this patient? a. Disturbed sensory perception related to inability to smell cat feces b. Caregiver role strain related to inability to adequately care for 30 cats c. Impaired home maintenance related to unhygienic, unclean surroundings d. Risk for situational low self-esteem related to neglected home environment
C
The patient's home is filled with papers and trash that has accumulated over the last 20 years. Which is the priority nursing diagnosis for the patient? a. Unilateral neglect related to inadequate support systems b. Ineffective coping related to hoarding behaviors c. Risk for falls related to cluttered walkways and untidy environment d. Readiness for enhanced comfort related to desire for nicer surroundings
C
The postanesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first? a. Foley catheter and surgical fluid intake b. Intravenous lines for patency or redness c. Airway, lung sounds, and pulse oximetry d. Nasogastric tube and presence of bowel sounds
C
When a parent asks how to seat a 6-year-old child in the family car, how will the nurse respond? a. In the rear seat with lap and shoulder seat belts b. In the front seat with lap and shoulder seat belts c. In the rear seat with a belt-positioning booster seat d. In the front seat with a belt-positioning booster seat
C
Which action by the nurse demonstrates correct technique for repositioning the patient in bed? a. The nurse's knees are kept stiff to enhance lifting strength potential. b. The nurse's abdominal muscles are relaxed to prevent back injury. c. The nurse's pelvis is tucked inward to maintain balance during the procedure. d. The nurse's torso twists with the patient to facilitate upper extremity muscle use.
C
Which action by the patient indicates appropriate use of the walker? a. The patient leans over the walker when rising to a standing position. b. The patient's elbows are bent at a 45-degree angle when holding onto the walker. c. The patient ensures that the walker is locked in the open position before using it. d. The patient looks down at the walker when walking to keep from kicking it.
C
Which action demonstrates correct use of a cane by a patient following a left leg injury? a. The patient holds the cane securely in the left hand. b. The patient uses the cane when stepping forward with the right leg. c. The patient's left leg and cane move forward together when walking. d. The patient leans slightly to the left when advancing the cane forward.
C
Which action demonstrates correct use of crutches by a patient following a left leg injury? a. The handgrips are set so that the axillae fully support the patient's body weight. b. The patient looks down at the floor when taking each step with the crutches. c. The patient moves the crutches approximately 12 inches forward with each step. d. The patient's elbows are flexed at a 45-degree angle when holding the handgrips.
C
Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism? a. The patient's platelet count was 45,000/mm3 this morning. b. The patient's last bowel movement was before surgery, 4 days ago. c. The patient has refused enoxaparin injections after surgery. d. The patient required transfusion of two units of packed red blood cells.
C
Which assessment finding leads the nurse to add risk for poisoning to the patient's care plan? a. The patient takes alprazolam 0.25 mg every 8 hours. b. The patient rinses with a fluoride mouthwash after brushing the teeth. c. The patient takes acetaminophen 1000 mg every 4 hours around the clock. d. The patient frequently uses an alcohol-based sanitizer for hand hygiene.
C
Which assessment finding leads the nurse to include risk for ineffective airway clearance to the surgical patient's care plan? a. The patient is extremely anxious about the upcoming surgery. b. The patient will be receiving a local anesthetic for the procedure. c. The patient sleeps poorly and wakes up every morning with a headache. d. The patient speaks no English and requires the services of an interpreter.
C
Which equipment should the nurse utilize when ambulating a patient with a history of severe COPD? a. Penlight b. Stethoscope c. Pulse oximeter d. Doppler ultrasound
C
Which exercise program should be avoided by a patient with osteoporosis? a. Yoga b. Tai chi c. Tennis d. Water aerobics
C
Which is an example of a procedure-inherent accident? a. The patient suffered a burn due to a malfunctioning heating pad. b. The patient suffered a tongue laceration during a grand mal seizure. c. The nurse suffered a back injury when repositioning a heavy patient in bed. d. The physician suffered a broken wrist after it was caught in the elevator door.
C
Which is the appropriate disposal method for used insulin syringes at home? a. Engage the safety cap over the needle and place it in the recycle bin. b. Remove the needle from the syringe and then flush it down the toilet. c. Place the used syringes in a sharps container that is mailed back for destruction. d. Place the used needles in a plastic can that is placed in the center of the trash bin.
C
Which is the best position for a patient who is acutely short of breath? a. Lateral b. Prone c. High-Fowler's d. Sims'
C
Which is the most appropriate outcome for the postoperative patient with the nursing diagnosis ineffective breathing pattern related to side effects of pain medication? a. The patient will correctly demonstrate how to use pursed-lip breathing. b. The patient will report the ability to breathe comfortably without anxiety. c. The patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute. d. The patient will rest comfortably and rate pain no higher than 4 on 0-to-10 scale.
C
Which is the role of the nurse regarding a malfunctioning IV pump? a. Contact the IV pump manufacturer. b. Initiate a work order on the IV pump. c. Tag the IV pump and remove it from the area. d. Clean the fixed IV pump and return it to the floor.
C
Which nursing diagnosis is the highest priority for a patient who had spinal anesthesia for hysterectomy surgery? a. Nausea related to side effect of spinal anesthesia b. Constipation related to manipulation of bowel during surgery c. Risk for falls related to impaired motor function from anesthesia d. Impaired oral mucus membranes related to NPO status before surgery
C
Which outcome is appropriate for the patient with the nursing diagnosis ineffective protection related to use of anticoagulant medications? a. The patient will remain free of signs or symptoms of infection. b. The patient will have a soft formed stool at least every other day. c. The patient will verbalize precautions to take in order to prevent bleeding. d. The patient will have clear lung sounds bilaterally and no sign of cyanosis.
C
Which position should be avoided for a patient who is unconscious? a. Semi-Fowler's b. Sims' c. Supine d. Lateral
C
Which scale is used to assess the patient's risk for development of pressure injury? a. Baker b. Morse c. Braden d. Hendrich
C
Which surgical procedure may be performed using conscious sedation? a. Knee-replacement surgery b. Coronary artery bypass surgery c. Cataract removal with lens implant d. Modified radical mastectomy surgery
C
Which type of anesthesia will the patient receive during surgery on the cervical spine? a. Local b. Spinal c. General d. Epidural
C
Which assessment findings lead the nurse to select the nursing diagnosis impaired bed mobility for the patient? (Select all that apply.) a. The patient uses a seat belt and footrest when seated in the wheelchair. b. The patient utilizes a rollator walker to ambulate to and from the bathroom. c. The patient struggles to use the over-bed trapeze for repositioning in bed. d. The nursing staff must log-roll the patient to get on and off the bedpan. e. The patient transfers to the wheelchair with assistance of the nurse and a gait belt.
C, D
Which are the appropriate interventions for the patient with the diagnosis impaired bed mobility related to hemiplegia after stroke? (Select all that apply.) a. Assist the patient to reposition in the bed at least every 3 hours. b. Maintain the patient's bed in high Fowler's position whenever possible. c. Instruct the patient how to use the over-bed trapeze to reposition self in bed. d. Utilize a sliding sheet to minimize skin trauma during repositioning of the patient. e. Position the patient's affected limbs in neutral alignment between ranges of motion.
C, D, E
Which home care equipment should be ordered for a patient who had a massive stroke with right-sided hemiplegia? (Select all that apply.) a. Crutches b. Quad cane c. Wheelchair d. Knee walker e. Shower bench f. Toilet safety rails
C, E, F
A patient had surgery two days ago. Which intervention will be included in the plan of care for this patient wearing compression stockings? a. The patient's stockings should be removed at night for washing. b. Slippers should not be applied over the stockings for ambulation. c. Regular size stockings are for females and large size are for males. d. Make sure that the patient's toes are not sticking out of the stockings.
D
A small amount of mercury was spilled on the floor after an old sphygmomanometer was broken. What is the priority action of the nurse? a. Disinfect the area with a solution of chlorine bleach. b. Contact the housekeeping staff to mop up the liquid. c. Wipe up the liquid using paper towels and nitrile gloves. d. Consult the agency's materials safety data sheets (MSDS).
D
The nurse is caring for a patient undergoing a surgical procedure that will take 7 to 8 hours to complete. Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization? a. The patient's skin will be assessed prior to surgery to identify areas at risk. b. The patient's privacy and dignity will be maintained throughout the procedure. c. The patient's bony prominences will be padded with pressure-reducing cushions. d. The patient's skin will be free of redness or breakdown when surgery is complete.
D
The nurse is caring for a patient who is recovering from a cerebrovascular accident. Which assessment finding indicates that the patient's cerebellum was damaged by the stroke? a. The patient has continuous double vision. b. The patient has slurred speech and dysphagia. c. The patient is incontinent of bowel and bladder. d. The patient has poor balance and has an unsteady gait.
D
The nurse is caring for a patient with nonblanchable redness of the coccyx after a lengthy surgical procedure in the supine position. Which nursing diagnosis is appropriate for this patient? a. Risk for impaired skin integrity related to lengthy surgical procedure b. Noncompliance related to failure to frequently reposition self c. Ineffective therapeutic regimen management related to improper positioning d. Impaired skin integrity related to tissue pressure from prolonged supine position
D
Which action by the nurse demonstrates correct use of a gait belt? a. The patient holds on to the gait belt during transfer to the chair. b. The gait belt is used to lift the patient whose legs are too weak to stand. c. The gait belt is tied loosely around the patient's waist just above the hips. d. The nurse follows behind the patient holding onto the gait belt during ambulation.
D
Which assessment finding is expected for a patient who suffered a left-sided thrombotic stroke? a. Bilateral footdrop b. Fine tremors of the hands c. Curvature of the lumbar spine d. Weakness of the right arm and leg
D
Which exercises are appropriate for a quadriplegic patient? a. Active range-of-motion exercises b. Weight-bearing exercises c. Aerobic exercises d. Passive range-of-motion exercises
D
Which is the appropriate intervention for a patient with the nursing diagnosis wandering related to disorientation, memory loss, and urge incontinence? a. Raise three of the four side rails on the patient's bed. b. Assign the patient to a room close to the nursing station. c. Remind the patient to always ask for help before getting up. d. Place a bed alarm to notify staff when the patient is getting up.
D
Which is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet? a. Encourage the patient to participate in tai chi exercises to promote balance. b. Instruct the patient to wear a medical alert bracelet that identifies risk for falls. c. Evaluate the patient's blood pressure for orthostatic hypotension. d. Teach the patient to wear low-heeled, comfortable, supportive footwear at all times.
D
Which nursing diagnosis is the highest priority for a patient who just underwent hip replacement surgery? a. Risk for perioperative positioning injury related to anesthesia, immobilization b. Dressing/grooming self-care deficit related to inability to bend over or cross legs c. Impaired walking related to toe-touch weight bearing to operative lower extremity d. Risk for injury related to dislodgement of prosthesis, unsteadiness with ambulation
D
Which task may be delegated to the nursing assistant? a. Determine the patient's need for a low-air-loss mattress overlay. b. Assess the patient's legs for the presence of thromboembolism. c. Teach the patient about the contractures and the benefits of resting hand splints. d. Reposition the patient at least every 2 hours using pillows and foam wedges.
D
Which term best describes the relationship between the hamstring and quadriceps muscles? a. Synergistic b. Ergonomic c. Antigravity d. Antagonistic
D