RNSG 1413 - exam 1 chapter review questions & case studies

The nursing student is listening to a lecture on pay-for-performance (P4P) models. Which statement indicates that teaching has been effective? "Medical care was less regulated then, this contributed to lower health care costs." "Patients demanded newer, expensive care." "Providers are required to address factors not considered under the fee-for -service model." "This era saw huge advancements in medicine."

"Providers are required to address factors not considered under the fee-for -service model." In P4P programs, hospitals are required to address a large number of factors that they previously, in traditional fee-for-service systems, had no incentive to consider. The remaining options are true of the traditional fee-for-service model.

A 3-month-old infant is diagnosed with bronchiolitis, and the ELISA for RSV antigen is positive. The infant is hospitalized because of an 86% SaO2, frequent coughing, and copious nasal secretions. The mother is breastfeeding and has continued to pump while the infant is hospitalized. The nurse anticipates the infant will be discharged based on the following assessment findings. • Vital signs: pulse 130 beats/min, respirations 30 breaths/min, temperature 98.8 °F (37.1°C) • 97% SaO2 on room air • Minimal nasal discharge • Lungs clear to auscultation Which discharge teaching information about bronchiolitis listed below would be appropriate discharge teaching for the parents of this infant? Keep infant in supine position to assist with nasal secretions. Have parents purchase a pulse oximeter. Instill normal saline nose drops before feedings and at bedtime. Have mother continue pumping breasts for another week after discharge. Have parents offer 5-10 mL of fluid to the infant every 15 to 20 minutes to maintain hydration. Review discharge medications, including antipyretics and bronchodilators. Have parents verbalize interventions that promote ventilation. Encourage parents to h

-Instill normal saline nose drops before feedings and at bedtime. -Have parents offer 5-10 mL of fluid to the infant every 15 to 20 minutes to maintain hydration. -Review discharge medications, including antipyretics and bronchodilators. -Have parents verbalize interventions that promote ventilation. Skill: Take action Item type: Matrix Client needs: Management of Care > Perform procedures necessary to safely admit, transfer, and/or discharge a client (NCSBN, 2018, p. 8) Rationale: Breastfeeding mothers are encouraged to continue feeding their infants. The parents should be taught how to instill normal saline drops into the nares and suction the mucus with a bulb syringe before feedings and before bedtime to help the infant eat, rest, and sleep better. Discharge instructions regarding medications and techniques or interventions to assess and promote ventilation are needed. The infant should be placed in a more upright position with the head elevated to facilitate breathing, not the supine position. It is not advisable to have an infant sleep with the parent in their bed because of the risk of suffocation, sudden infant death syndrome (SIDS), and other sleeprelated deaths. Room sharing, or infants sleeping in the same bedroom as the parent(s), is recommended because it reduces the risk of SIDS and other sleep-related deaths.

A 64-year-old client calls the clinic and asks about when he would be eligible for Medicare insurance. The client reported that he was having difficulty driving and getting to medical appointments because of failing eyesight and that he could not afford going to see an eye doctor until he has Medicare. The nurse is aware that advocacy is an important role in providing nursing care. Which are the top four nursing actions that are appropriate actions as a client advocate? - Review client medical record and verify date of birth. -Provide assistance in enrolling client in Medicare. -Schedule the client for an eye exam. -Arrange meetings with secondary insurance companies to determine the best supplemental insurance plan. -Arrange for community transportation to pick up client for medical appointments. -Explain to client that he will receive his Medicare card within 6 months of his 65th birthday -Assist in the interpretation and translation of difficult medical terms. - Protect the client's rights.

-Schedule the client for an eye exam. -Arrange meetings with secondary insurance companies to determine the best supplemental insurance plan. -Provide assistance in enrolling client in Medicare. -Arrange for community transportation to pick up client for medical appointments. Rationale: The client's top priorities relate to vision problems, which need to be addressed. The client will be eligible for Medicare at age 65 years. Older adults may need assistance in enrolling in Medicare, especially using the Medicare.gov website. Clients often need an advocate to assist them to navigate the Medicare system and identify where to go for services, how to enroll in supplemental insurance plans, and so on. The nurse, as a client advocate, ensures clients have the information necessary to make informed decisions in choosing and using services appropriately. In addition, it is important for the nurse advocate to support and sometimes defend the client's decisions with families and agencies. When the person is enrolled in Medicare, the Medicare card is sent in the mail 3 months before the 65th birthday or on the 25th month of getting disability benefits, not at 6 months.

The nurse spends time with a patient and family reviewing a dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? 1. Educator 2. Advocate 3. Caregiver 4. Communicator

1. Educator The nurse is demonstrating the role of educator. An educator explains concepts and facts about health, describes the reason for routine care activities, demonstrates procedures such as homecare activities, reinforces learning or patient behavior, and evaluates the patient's progress in learning through return demonstration

Match the advanced practice nurse specialty with the statement about the role. 1. Clinical nurse specialist 2. Nurse anesthetist 3. Nurse practitioner 4. Nurse-midwife a. Provides independent care, including pregnancy and gynecological services b. Expert clinician in a specialized area of practice such as adult diabetes care c. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions d. Plans and delivers anesthesia and pain management to patients across the life span

1b, 2d, 3c, 4a. The role statements describe the activities performed and the role of the advanced practice nurse specialty. Nurse-midwives care for women who are pregnant or have women's health needs. Clinical nurse specialists typically see hospitalized patients with a specific type of illness or health problem. Nurse practitioners usually practice in a primary care setting and care for patients who are healthy or have minor acute or stable chronic conditions. Certified nurse anesthetists care for patients during the surgical experience and administer anesthesia during surgery

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the operation to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: 1. Educator 2. Advocate 3. Caregiver 4. Communicator

2. Advocate An advocate protects patients' human and legal right to make choices about their care. An advocate may also provide additional information to help a patient decide whether or not to accept a treatment or find an interpreter to help family members communicate their concerns.

The examination for RN licensure is the same in every state in the United States. This examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Provides the minimal standard of knowledge for an RN in practice 4. Guarantees standardized education across all prelicensure programs

3. Provides the minimal standard of knowledge for an RN in practice RN candidates must pass the NCLEX-RN® to attain licensure. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States.

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation, you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code? 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong to provide patient care

4. Defines the principles of right and wrong to provide patient care When giving care, it is essential to provide a specified service according to standards of practice and to follow a code of ethics. The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It serves as a guide for carrying out nursing responsibilities to provide high-quality nursing care and the ethical obligations of the profession

A nurse is caring for four patients. Which would the nurse refer to case management? 24 years old; long leg cast and crutches after femur fracture 52 years old; recovering from coronary artery bypass graft 68 years old; post stroke, needs total care and tube feedings 76 years old; receiving chemotherapy and wound care at home

76 years old; receiving chemotherapy and wound care at home Patients appropriate for case management include those with complex and costly care. A patient getting chemotherapy and wound care at home most likely has a central line and needs an infusion nurse and a wound-ostomy nurse. This care is complex and expensive. The patient with a leg fracture is young, most likely healthy, and should be expected to recover fully. The middle-aged patient after coronary artery bypass grafting should be referred to cardiac rehab but will not need case management because the care of this patient is not complex. If the family took the 24-year-old patient home, they would need some support but not case management because caring for someone who is in this patient's condition is not as complex as caring for the other patients.

The nurse executive reviews quality audits on the hospital's core measures. Which core measures does the nurse manager expect to see? (Select all that apply.) Acute myocardial infarction Congestive heart failure Pneumonia Surgical care improvement process Ventilator weaning trials

Acute myocardial infarction Congestive heart failure Pneumonia The Joint Commission developed 15 core measures sets for quality divided into four major categories, which are acute myocardial infarction, heart failure, pneumonia, and the surgical care improvement process (SCIP). Ventilator weaning trials is not a core measure.

A nurse on the unit is looking for articles associated with nurse/patient ratios. Which government agency would provide the highest level of evidence for this change? Agency for Health Care Research and Quality American Public Health Association Centers for Disease Control and Prevention Institute of Medicine (IOM)

Agency for Health Care Research and Quality In 2007, the AHRQ funded research to review studies from 11 databases to assess how nurse/patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals. These factors influence nurse staffing policies and strategies that improve patient outcomes. While the other options are reputable sources, the AHRQ provides relevant information on this topic.

A nurse from the Quality Improvement Team makes an appointment with a unit manager to discuss a quality indicator. What does the manager believe will be discussed at this meeting? A deficiency noted during the latest Joint Commission inspection and audit process An item of concern noticed due to a nursing practice problem on the unit Areas of nursing practice on the unit that show dedication to patient quality New patient safety and quality goals that need to be addressed on the unit

An item of concern noticed due to a nursing practice problem on the unit A quality indicator is an area of concern that came about because of a problem with nursing practice. It is not an area that demonstrates dedication to quality. It is not a new patient safety and quality goal. It might or might not have been discovered during a Joint Commission inspection.

Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.) 1. A walker is useful for patients who have impaired balance. 2. The patient uses a walker by pushing the device forward. 3. Leaning over the walker improves the patient's balance. 4. Walkers should not be used on stairs. 5. If the patient has difficulty advancing the walker, a walker with wheels is an option.

Answer 1, 4, 5. A walker can be used by a patient who is weak or has problems with balance. Walkers with wheels are useful for patients who have difficulty lifting and advancing the walker as they walk because of limited balance or endurance. A patient uses a walker correctly by holding the handgrips on the upper bars, taking a step, moving the walker forward, and taking another step. A walker requires a patient to lift the device up and forward. The patient should not lean over the walker or walk behind it; otherwise, the patient might lose balance and fall. Walkers should not be used on stairs

A nurse is caring for a patient who was in an auto accident and has entered rehab after a 6-day hospitalization. The patient had multiple internal injuries and has nursing diagnoses of Hopelessness and Impaired Mobility at time of discharge. The nurse's assessment revealed the patient asking nurses to let him stay in bed and the patient having limited involvement in hygiene and a loss of appetite. The patient has a cast on his nondominant left hand and has reduced movement in the right lower leg, which is splinted. The health care provider has ordered the patient to ambulate 3 times a day. Which of the following is a priority for the rehab nurse? 1. Providing assistance with meals 2 . Teaching patient exercises to strengthen right leg 3. Making preferred hygiene products available to the patient to use 4. Setting times to discuss relationship of hopelessness to injuries

Answer 4. The patient is physically stable, having been discharged from acute care. Ambulation is obviously a desired outcome from rehab, but the patient's hopelessness is a barrier. Focusing on offering interactions that enable the patient to express his concerns and find hope is a priority at this time.

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.) 1. Patient's weight 2. Patient's activity tolerance 3. Patient's level of mobility 4. Recent laboratory values 5. Nutritional intake 6. Safe mobility algorithm

Answer: 1, 2, 3. Before transferring a patient from bed to stretcher, assess height and weight and the patient's activity tolerance, noting for fatigue during previous sitting and standing. Assess the patient's mobility level, using the Banner Mobility Assessment Tool (BMAT) as an option. Nutritional intake and laboratory values will not influence a decision to transfer or the transfer technique. Safe mobility algorithm is for transferring a patient from bed to chair, chair to chair, and chair to exam table and not for transferring a patient from bed to stretcher.

A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a one-person assist in the hospital before transfer. The patient has a history of hypertension. His wife accompanies him at the time of transfer. Which of the following assessment data would you collect for this patient? (Select all that apply.) 1. Condition of surgical wound 2. Patient's expectations of rehabilitation 3. Previous hospitalization experience 4. Vital signs 5. Ability to sit on side of bed unassisted 6. Gait and balance 7. History of recent weight changes 8. Social support from wife

Answer: 1, 2, 4, 5, 6, 8. The patient recently had surgery, and wound healing is a factor to monitor. His expectations of rehabilitation are important for determining motivation to participate in rehab. Vital signs will establish a baseline for his stay in rehab to compare with subsequent measures when he begins exercise training. Even though the patient reportedly ambulates with only one assist, his ability to sit on the side of the bed, and his gait and balance, will be critical for determining how to approach transfer and ambulation. The level of the wife's social support determines to what extent she can coach and assist the patient once he returns home. His history of weight change is not relevant at this time, nor is his previous hospitalization experience.

The effects of immobility on the cardiac system include which of the following? (Select all that apply.) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Irregular heartbeat 5. Orthostatic hypotension

Answer: 1, 2, 5. The three major changes affecting the cardiac system are orthostatic hypotension, increased cardiac workload, and thrombus formation.

Which of the following are examples of a nurse participating in primary care activities? (Select all that apply.) 1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2. Assessing the nutritional status of older adults who come to the community center for lunch 3. Working with patients in a cardiac rehabilitation program 4. Providing home wound care to a patient 5. Teaching a class to parents at the local elementary school about the importance of immunizations

Answer: 1, 2, 5. Primary care activities are focused on health promotion. Health promotion programs contribute to high-quality health care by helping patients acquire healthier lifestyles. Health promotion activities help keep people healthy through exercise, good nutrition, rest, and adoption of positive health attitudes and practices.

Which of the following are common barriers to effective discharge planning? (Select all that apply.) 1. Ineffective communication among providers 2. Lack of role clarity among health care team members 3. Number of hospital beds to manage patient volume 4. Patients' long-term disabilities 5. The patient's cultural background

Answer: 1, 2. Barriers to effective discharge planning include ineffective communication, lack of role clarity among health care team members, and lack of resources. Resources include rehabilitation and long-term care beds, not hospital beds. The presence of long-term disability is not a barrier but a characteristic of some patients who need greater discharge planning. A patient's cultural background is not a barrier unless you do not consider cultural factors in planning for discharge

A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? (Select all that apply.) 1. Move more and sit less throughout the day. 2. Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity. 3. Perform muscle-strengthening activities using light weights on 2 or more days a week. 4. Walk at a vigorous pace with wife at least 150 minutes over five days a week. 5. Focus on balance training

Answer: 1, 3, 4. Adults are recommended to move more and sit less throughout the day. Some physical activity is better than none. For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity aerobic physical activity (which includes vigorous walking). Adults should also do muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more days a week. Balance is also important but more of a focus for older adults.

You are a nurse who is working in an agency that has recently implemented an EHR. Which of the following are acceptable practices for maintaining the security and confidentiality of EHR information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer username and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the EHR) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged into a computer to save time if you only need to step away to administer a medication

Answer: 1, 3, 4. Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record (EHR) include not sharing passwords, not leaving computers with open EHRs unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor.

The nurse is observing the patient for general appearance and behavior. What assessments might indicate that the patient is in pain? (Select all that apply). The patient: 1. is slumped in the bed. 2. responds to questions by making eye contact. 3. is short of breath and breathing rapidly. 4. protects and splints the left arm. 5. is alert and oriented.

Answer: 1, 3, 4. Sometimes obvious signs or symptoms indicate pain (grimacing, splinting painful area), difficulty breathing (shortness of breath, sternal retractions), or anxiety. Set priorities and examine the related physical areas first. Observe whether the patient has a slumped, erect, or bent posture, which reflects mood or pain.

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.

Answer: 1, 3, 4. When assessing older adults, listen patiently and allow for pauses and time for patients to tell their story. Do not just focus on the list of questions on an assessment form. The questions might not be relevant to the patient's problems. Recognize normal changes associated with aging. Older-adult symptoms are often muted or less obvious, vague, or nonspecific compared with younger adults. Maintain a patient-directed gaze. Eye contact shows interest in what the patient is saying.

A patient has been hospitalized with a serious flulike infection and is on bed rest. He is receiving multiple medications through two different IV infusions and is on high-flow oxygen therapy by oxygen mask. Currently the patient's head of bed is elevated to semi-Fowler position. The patient initiates little movement and responds only to being shaken. Vitals signs are temperature, 38.6°C (101.6°F); heart rate, 88 beats/min; blood pressure 140/84 mm Hg; and respirations, 20. Which of the following assessment findings suggest that the patient has a risk for an immobility complication? (Select all that apply.) 1. High-flow oxygen therapy by mask 2. Positioned semi-Fowler 3. Temperature 38.6°C (101.6°F) 4. Receiving multiple medications 5. Initiates little movement 6. Reduced conscious response 7. Bed rest

Answer: 1, 3, 5, 6, 7. The mask creates risk for a medical device-related pressure injury. The elevated body temperature can cause diaphoresis, which, combined with initiation of little movement and reduced consciousness, predispose the patient to a pressure injury. The initiation of little movement and being on bed rest place patient at risk for deep vein thrombosis (DVT), pulmonary complications, and elimination complications.

Which of the following describe characteristics of an integrated health care system? (Select all that apply.) 1. The focus is holistic. 2. Participating hospitals follow the same model of health care delivery. 3. The system coordinates a continuum of services. 4. The focus of health care providers is finding a cure for patients. 5. Members of the health care team link electronically to use the EHR to share the patient's health care record.

Answer: 1, 3, 5. Integrated health care systems are shifting to more holistic approaches to health care. At the core of this shift is provision of a coordinated continuum of services for enhancing the health status of defined populations. There is no single model for an integrated health care system. Two types of integrated health care delivery systems are common: an organizational structure that follows economic imperatives, and a system that supports an organized care delivery approach. Patient-centered medical home care is an example; members of the care team are linked by information technology, electronic health records, and system-best practices to ensure that patients receive care when and where they need it, and how they want it.

A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.) 1. Oxygen saturation of 89% 2. Irregular radial pulse 3. Diminished breath sounds in bilateral bases of lungs 4. Blood pressure 132/84 mm Hg 5. Pain reported at 3 on scale of 0 to 10 following medication 6. Respiratory rate of 26

Answer: 1, 3, 6. Patients who are immobile are at high risk of developing pulmonary complications. Pooling of sections secondary to atelectasis can cause decreased lung sounds. Tachypnea is a common response to dyspnea. Atelectasis can also negatively affect oxygen saturation, as exhibited by the 89% oxygen saturation in this patient

Which of the following are normal findings you should find during a physical exam? (Select all that apply.) 1. Jugular vein flattens when a patient sits up. 2. A swooshing sound is normally heard when auscultating a carotid artery. 3. Upon palpation, a lymph node is normally tender. 4. Normal sitting posture involves some degree of rounding of the shoulders. 5. Normally there is no bulging within the intercostal spaces during breathing.

Answer: 1, 4, 5. During a physical examination you will normally find the jugular vein will flatten when a patient sits up, with no sounds over the carotid artery when auscultated. Normal findings also include nontender lymph nodes, a normal sitting posture involving some degree of rounding of the shoulders, and no bulging within the intercostal spaces during breathing

Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform? 1. Moving from an acute illness to a health promotion, illness prevention model 2. Moving from an illness prevention to a health promotion model 3. Moving from hospital-based to community-based care 4. Moving from an acute illness to a disease management model

Answer: 1. Health care reform also affects how health care is delivered. There is greater emphasis on health promotion, disease prevention, and management of illness.

A nurse is helping a patient perform active assisted ROM in the right elbow. Which statement describes the correct technique? 1. Support elbow by holding distal part of extremity. 2. Grasp joint with fingers to provide support. 3. Have patient move joint independently. 4. Move the joint past the point of resistance. 5. Perform the exercise three times during the session, and gradually build up to more.

Answer: 1. During a range-of-motion (ROM) exercise, supporting the distal part of the extremity is the correct technique. Use a cupped hand and not the fingers to support a joint. Active assisted ROM requires assistance of a care provider. Never move a joint past the point of resistance. Each joint movement needs to be repeated 5 times during a session, with sessions performed 2 to 3 times a day.

A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

Answer: 1. Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is the most appropriate outcome for this patient's restorative care? 1. Patient will be able to walk 200 feet without shortness of breath. 2. Wound will heal without signs of infection. 3. Patient will express concerns related to return to home. 4. Patient will identify strategies to improve sleep habits.

Answer: 1. Restorative interventions focus on returning patients to their previous level of function or helping them to reach a new level of function limited by their illness or disability. The goal of restorative care is to help individuals regain maximal functional status and to enhance quality of life through promotion of independence.

The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient's history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following? 1. Increase the patient's risk for falls and injuries 2. Result in less stress on the patient's joints 3. Decrease the amount of work required for patient movement 4. Allow for mobility in spite of the aging effects on the patient's joints

Answer: 1. The effect of bone loss is weaker bones, causing vertebrae to be softer and long shaft bones to be less resistant to bending, making an individual prone to fractures and muscle injuries. Older adults may walk more slowly and incorrectly and appear less coordinated. Many are afraid of falling. They often take smaller steps and keep their feet closer together, which decreases the base of support and thus alters body balance, increasing fall risk.

The nurse is teaching a patient how to perform a testicular selfexamination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."

Answer: 1. The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless.

Match the assessment activity with the type of assessment. ___1. Assessment conducted at beginning of a nurse's shift ___2. Review of a patient's chief complaint ___3. Completion of admitting history at time of patient admission to a hospital ___4. Completion of the Long Term Care Minimum Data Set during an older adult's admission to a nursing home A. Problem focused B. Comprehensive

Answer: 1A, 2A, 3B, 4B.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves Cranial Nerve Function ___1. XII Hypoglossal ___2. V Trigeminal ___3. VI Adducens ___4. IV Trochlear ___5. X Vagus a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue

Answer: 1e, 2a, 3b, 4d, 5c

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit saturated and trans fats, sodium, red meats, sweets, and sugar-sweetened beverages. 5. Review strategies to encourage the patient to quit smoking

Answer: 2, 3, 4, 5. Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in sodium and fats are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower sodium and fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease.

. A nurse contacts the health care provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the EHR, what should the nurse do? 1. Print out a copy of all telephone orders entered into the EHR in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the health care provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the EHR. 3. Record telephone orders in the EHR but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately but insist that the health care provider come to the patient care unit to personally enter the order(s) into the EHR within the next 24 hours.

Answer: 2. Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.

A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures are appropriate for this patient to prevent complications of bed rest? (Select all that apply.) 1. Administer IV analgesic as ordered. 2. Have patient perform incentive spirometry. 3. Support patient in active assisted ROM exercises of upper extremities. 4. Provide patient a low-calorie diet. 5. Apply SCDs to legs.

Answer: 2, 3, 5. Because the patient is immobilized and has an unstable pelvic fracture, administration of intravenous (IV) analgesics is appropriate for pain, but is not focused on prevention of immobility complications. Use of incentive spirometry prevents pulmonary atelectasis. The patient has no upper extremity limitations, so active assisted range of motion (ROM) is appropriate and preventive. The patient should have compression devices on the legs to reduce risk of deep vein thrombosis (DVT). A low-calorie diet would be improper. Patients require a high-calorie intake when they are immobilized.

A nurse newly hired at a community hospital learns about intentional hourly rounding during orientation. Which of the following are known evidence-based outcomes from intentional rounding? (Select all that apply.) 1. Reduction in nurse staffing requirements 2. Improved patient satisfaction 3. Reduction in patient falls 4. Increased costs 5. Reduction in patient use of nurse call system

Answer: 2, 3, 5. Intentional rounding is an evidence-based practice used in an increasing number of hospitals today. Studies have shown that intentional rounding can reduce patient falls and call light use and improve patient satisfaction scores. Proactive problem solving can occur when using intentional rounding. Education for patients helps them understand the importance of this practice.

The school nurse has been following a 9-year-old student who has shown behavioral problems in class. The student acts out and does not follow teacher instructions. The nurse plans to meet with the student's family to learn more about social determinants of health that might be affecting the student. Which of the following potential social determinants should the nurse assess? (Select all that apply.) 1. The student's seating placement in the classroom 2. The level of support parents offer when the student completes homework 3. The level of violence in the family's neighborhood 4. The age at which the child first began having behavioral problems 5. The cultural values about education held by the family

Answer: 2, 3, 5. Social determinants include social support, exposure to crime and violence, and culture. The nurse should learn the child's age at which behavioral problems appeared, but this is not a social determinant. Seating placement is not a social determinant but could be a factor if the child has visual or other physical problems

A patient has an order for application of compression stockings. Place the following steps for application of the compression stockings in the correct order: 1. Place patient's toes into foot of stocking up to the heel; keep smooth. 2. Use tape measure to measure patient's leg for proper stocking size. 3. Slide stocking up over patient's calf until sock is completely extended. 4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel. 5. Slide remaining portion of stocking over patient's foot, covering toes. Be sure foot fits into toe and heel of stocking.

Answer: 2, 4, 1, 5, 3.

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"

Answer: 2, 4, 1, 5, 3. A patient-centered interview begins with a nurse's self-introduction. It then proceeds to an open-ended question that allows a patient to tell their story about any health concerns. Listening and acknowledging a patient's concerns then allow you to probe for further information. Summarization lets the patient confirm accuracy of your interpretation of data. Finally, you end an interview by telling the patient you are finished and by letting the patient ask any final questions.

A home health nurse is visiting a 62-year-old Hispanic woman diagnosed with type 2 adult-onset diabetes mellitus following a 2-day stay at a local hospital. The physician ordered home health with placement of the patient on a diabetic protocol for education about diabetes mellitus and a new medication and diet counseling. The patient lives with her 73-year-old husband, who has progressive dementia. Their daughter checks on her parents daily, buys groceries, and helps with home maintenance. The nurse conducts an initial history to gather information about the patient's condition. Which of the following data cues combine to reveal a possible health problem? (Select all that apply.) 1. First time hospitalized 2. Unable to describe diabetes 3. Takes antiinflammatory for arthritis 4. Has limited health literacy 5. Husband is able to perform self-bathing 6. Patient unable to identify food sources on prescribed diet 7. Patient has reduced vision and wears glasses 8. Patient prescribed an oral hypoglycemic drug

Answer: 2, 4, 6, 7. The inability to describe her health problem of diabetes mellitus, limited health literacy, reduced vision, and inability to identify appropriate diet food sources suggest that the patient has a problem with knowledge and health management. The nurse will need to explore further what the patient knows and understands, her perceptions about having a new disease, and the daughter's willingness and ability to be a helpful resource.

A nurse manager notes that there is tension and arguing among the staff about the holiday work schedule. The nurse manager has used a new scheduling software program to create the work schedule. What should the nurse manager do? Select all that apply. 1. Give the nursing staff the days off they requested and use temporary staff to fill in schedule gaps. 2. Schedule a nursing staff meeting to discuss the holiday work schedule issue. 3. Tell the staff members that if the arguing continues, they will be terminated. 4. Send a memo to all nursing staff explaining the rationale for the work schedule. 5. Tell the staff to work out the schedule themselves. 6. Get to the root of the problem quickly, especially if it relates to the new software program. 7. Allow and closely monitor shift trading among the nursing staff for the holiday schedule. 8. Encourage overtime workloads in scheduling for those who want to work the holiday.

Answer: 2, 6, 7 Skill: Generate solutions Item type: Extended multiple response Client needs: Management of Care > Manage conflict among clients and health care staff (NCSBN, 2018, p. 8) Rationale: When there are general dissatisfaction and arguing among staff about a staffing schedule, it is important for the nurse manager to meet with all staff, resolve the issue, and get to the root of the problem quickly. Perhaps the new software program made an error in the schedule, which needs investigation. Allowing and closely monitoring shift trading among the nursing staff may be an effective strategy, especially if the nurse manager is using a nurse scheduling software that enables the staff to request shift trades but doesn't confirm the trade requests until the nurse manager has seen, analyzed, and approved them. Filling in with temporary help is not cost effective and disempowers the nurse manager's role. A memo sent around with an explanation does not address the disgruntled staff members. It is not appropriate to terminate employees because they voice an issue with a proposed staffing schedule. Increased overtime work can have negative effects on just about every aspect of the profession. Increased overtime results in nurses who are tired, leads to more errors being made on the job, and promotes burnout.

A nurse is assigned to care for an 82-year-old patient who will be transferred from the hospital to a rehabilitation center. The patient and her husband have selected the rehabilitation center closest to their home. The nurse learns that the patient will be discharged in 3 days and decides to make the referral on the day of discharge. The nurse reviews the recommendations for physical therapy and applies the information to fall prevention strategies in the hospital. What discharge planning action by the nurse has not been addressed correctly? 1. Patient and family involvement in referral 2. Timing of referral 3. Incorporation of referral discipline recommendations into plan of care 4. Determination of discharge date

Answer: 2. The nurse must make the referral as soon as possible. The other elements of discharge planning, including knowing the discharge date, involving the patient and family in decision making, and incorporating the referral discipline's recommendations for the patient's care, are part of discharge planning.

A critical care nurse is using a new research-based intervention to correctly position patients who are on ventilators to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which QSEN competency? 1. Patient-centered care 2. Evidence-based practice 3. Teamwork and collaboration 4. Quality improvement

Answer: 2. The use of a research intervention to improve patient care brings the evidence-based practice gained from the research to the bedside

The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data interpretation 4. Termination

Answer: 2. The working phase of a relationship involves gathering accurate, relevant, and complete information about a patient's condition. It usually begins with open-ended questions

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Reflection 2. Clinical inference 3. Cue 4. Validation

Answer: 2. This nurse is clustering cues that seem to relate together to make inferences and identify emerging patterns. Clinical inference involves interpretation of cues. It is a part of the clinical decision-making process and precedes any clinical judgment or decision about what a patient's problems are

After a recent audit on the unit, the nurse manager noted an increase in medication errors and low patient satisfaction scores since the beginning of the COVID pandemic. As the nurse manager reviews the audit results, the nurse manager identifies some areas where hand-off communication could have been improved. Which of the following are examples of effective hand-off communication? Select all that apply. 1. Nurse A has been using 'qd' when transcribing orders. 2. Nurse B was interrupted during a shift hand-off by the unit clerk to answer a call light and left shift report to care for the client. 3. Nurse C provided a detailed summary of the client's discharge plan to the interprofessional team conference. 4. Nurse D has been using the new version of the hand-off template successfully. 5. Nurse E is the admission nurse in the emergency department and called the receiving unit to notify the nurse manager of a new admission an hour before the transfer. 6. Nurse F called the health care provider to obtain a pain medication order while completing nurse's notes on another client. 7. Nurse G transcribed a health care provider's prescription, which read ".25 mg digoxin PO daily" and sent it to

Answer: 3, 4, 5, 8 Skill: Analyze cues Item type: Extended multiple response Client needs: Management of Care > Provide and receive hand-off of care (report) on assigned clients (NCSBN, 2018, p. 8) Rationale: Interactive communication between departments allows for the opportunity for questioning between the giver and receiver of client information. Using new hand-off templates helps the nurse to organize the information and provides an up-to-date report of the client's care and any recent or anticipated changes. There should be a process for verification of the received information, including repeat-back or read-back, as appropriate. When calling a health care provider, the nurse should focus on just that task and not do something else at the same time. Using technology and providing information in advance of a transfer are helpful in assisting with an effective hand-off process. The nurse should avoid use of abbreviations or terms that can be misinterpreted, such "qd" or not having a 0 before a decimal point (0.25 mg digoxin). Interruptions during hand-offs should be limited or preferably avoided to minimize the possibility that information would fail to be conveyed or would be forgotten.

An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.) 1. Patient's usual exercise pattern at home 2. Time and date of the patient's last bowel movement 3. Preadmission activity tolerance 4. Baseline heart rate and blood pressure 5. Patient's home living situation

Answer: 3, 4. Although all of these questions should be included on the initial assessment for the patient before first ambulation, establishing a baseline activity tolerance and heart rate will help avoid overexerting the patient and help develop expectations (safe target heart rate) that are safe and reasonable as mobility is increased.

A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.) 1. The patient keeps the cane on the left side of the body. 2. The patient slightly leans to one side while walking. 3. The patient keeps two points of support on the floor at all times. 4. After the patient places the cane forward, the patient then moves the right leg forward to the cane. 5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.

Answer: 3, 5. Have a patient keep the cane on the stronger side of the body. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The patient needs to learn that two points of support such as both feet or one foot and the cane are on the floor at all times. The patient moves the weaker leg forward to the cane, so body weight is divided between the cane and the stronger leg.

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 22 breaths/min compared with an average of 16 breaths/min during previous clinic visits. The patient tells the nurse, "It's hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 22 breaths/min and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 breaths/min 5. Patient report of sore throat and hoarseness

Answer: 3, 5. Subjective data are your patients' verbal descriptions of their health problems—in this case hoarseness and sore throat and the statement, "It's hard for me to get a breath." All other data are objective data.

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

Answer: 3, 5. To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery.

Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.) 1. The patient is 167.6 cm (5 feet 6 inches) and weighs 54.5 kg (120 lb). 2. The patient speaks and understands English. 3. The patient is returning to the unit from the recovery room after a procedure requiring conscious sedation. 4. The patient has a history of being able to stand independently. 5. The patient received analgesia for pain 30 minutes ago.

Answer: 3, 5. Although the patient was discharged from the procedure recovery room, the patient did have conscious sedation and is still having effects from an analgesic for pain. These factors will affect whether the patient can safely participate in the transfer; therefore, additional help would be needed to safely transfer the patient from the bed to the stretcher.

Place the following steps in the correct order to show how to transfer a patient with partial weight bearing and sufficient upper body strength to a chair. 1. Spread your feet apart. Flex hips and knees, aligning knees with patient's knees. 2. Instruct patient to use armrests on chair for support and ease into chair. 3. Apply gait belt. 4. Flex hips and knees while lowering patient into chair. 5. Pivot on foot farthest from chair. 6. Hold the gait belt with both hands and fingers pointing up. 7. Maintain stability of patient's weaker leg with your knee if needed. 8. Rock patient up to standing position on count of three while straightening hips and legs.

Answer: 3, 6, 1, 8, 7, 5, 2, 4.

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of 12

Answer: 3. In healthy adults the normal respiratory rate varies from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects.

A patient comes to an urgent care clinic with reports of pain in the right lower calf and ankle after participating in a 5K run. Which of the following assessment questions will determine the effects exercise has had on this patient? 1. Tell me specifically when your pain began. 2. Describe for me the pain you are having. 3. In what way has your daily activity changed since you noticed your pain? 4. How long have you been having the pain?

Answer: 3. The way in which the patient's daily activity has changed focuses on effects of exercise. The other questions are relevant but instead focus on onset and symptoms.

The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? 1. Clinical nurse specialist 2. Nurse administrator 3. Nurse educator 4. Nurse researcher

Answer: 4. Nurse researchers investigate problems to improve nursing care and to further define and expand the scope of nursing practice. They often work in an academic setting, hospital, or independent professional or community service agency

4. Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 45."

Answer: 4. American Cancer Society guidelines state that for people of average risk, beginning at the age of 45, an annual fecal occult blood test is recommended. Flexible sigmoidoscopy is recommended every 5 years in this population. A colonoscopy is used every 10 years if recommended by the health care provider.

Which activity performed by a nurse is related to maintaining competency in nursing practice? 1. Asking another nurse about how to change the settings on a medication pump 2. Regularly attending unit staff meetings 3. Participating as a member of the professional nursing council 4. Attending a review course in preparation for a certification examination

Answer: 4. Maintaining ongoing competency is a nurse's responsibility. Earning certification in a specialty area is one mechanism that demonstrates competency. Specialty certification has been shown to be positively related to patient safety

The nurse is working in a tertiary care setting. Which activity does the nurse perform while providing tertiary care? 1. Conducting blood pressure screenings at a local food bank 2. Administering influenza vaccines for older adults at the local senior center 3. Inserting an indwelling catheter for a patient on a medicalsurgical unit 4. Performing endotracheal suctioning for a patient on a ventilator in the medical ICU

Answer: 4. The suctioning of the patient takes place in the critical care unit. Critical care units provide tertiary care. Tertiary care is specialized consultant care. It is also called acute care. Care at a tertiary facility is often expensive because patients have often waited to seek care until health problems are more severe. Inpatient medical-surgical units provide secondary care. Blood pressure screening and influenza vaccines are preventive care strategies.

The nurse manager meets with the registered nursing staff about an increase in urinary tract infections in patients with a Foley catheter. The staff work together to review the literature on catheter-associated urinary tract infections (CAUTIs), identifies at-risk patients, and establishes new catheter care practices. This is an example of which QSEN competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Quality improvement

Answer: 4. This is an example of the competency of quality improvement. The nurses collect, analyze, and use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

Which of the following statements is true regarding Magnet® status recognition for a hospital? 1. Nursing is run by a Magnet® manager who makes decisions for the nursing units. 2. Nurses in Magnet® hospitals make all of the decisions on the clinical units. 3. Magnet® is a term that is used to describe hospitals that are able to hire the nurses they need. 4. Magnet® is a special designation for hospitals that achieve excellence in nursing practice.

Answer: 4. Magnet® status is a process and review that hospitals go through that shows achievement of excellence in nursing practice. The designation is given by the American Nurses Credentialing Center (ANCC) and focuses on demonstration of high-quality patient care, nursing excellence, and innovations in professional practice.

A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct? 1. Perform auscultation first. 2. Have patient place folded arms under the head. 3. Palpate the patient's painful area first. 4. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.

Answer: 4. When performing an abdominal exam, perform inspection first, followed by auscultation. Have patient relax with arms at the side to relax the abdomen. Palpate the patient's painful area last.

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history? 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery

Answer: 5. The nursing health history has several components. A review of present illness or health concerns includes a question asking the patient what provokes or precipitates symptoms. Gathering a patient's explanation for what might be the cause of symptoms is the appropriate approach. Past health history is the component that includes a medication history and history of allergies. Patient expectations of treatment is another component. A review of family interaction and support is part of the family history component

Place the following steps in the correct order for repositioning a patient in the 30-degree lateral side-lying position using two nurses. 1. Using knee and hip for leverage, nurse rolls patient onto side. 2. Nurse facing patient's back places hands under patient's dependent shoulder and brings shoulder blade forward. 3. Place pillows under semiflexed upper leg level at hip from groin to foot. 4. Flex patient's knee that will not be next to mattress, after being turned. Keep foot on mattress. Nurse places one hand on patient's upper bent leg. 5. Place hands under dependent hip and bring hip slightly forward so angle from hip to mattress is approximately 30 degrees. 6. Position patient on side of bed in opposite direction toward which patient is to be turned, then move upper and lower trunk. 7. Lower head of bed completely or as low as patient can tolerate. One nurse on each side of bed.

Answer: 7, 6, 4, 1, 2, 5, 3. 5.

Mr. When Chang is being admitted to the medical-surgical unit for management of a stage 4 decubitus ulcer on his left hip. Mr. Chang, a 37-year-old engineer, was in a near-fatal motor vehicle accident 3 months ago that precipitated a series of spine surgeries to help correct damage to his spine. He has been bedridden in a long-term care facility since his last surgery 7 weeks ago, and he has developed a stage 4 decubitus ulcer on his left hip. The wound is being treated with a wound vacuum and antibiotic therapy. Bettina is the nursing student who is assigned to Mr. Chang. Bettina enters his room, introduces herself, and explains that she is going to perform an admission health history and physical assessment. 2. Bettina's experience as a nursing student is a valid source of data that provides information about Mr. Chang's illness. A. True B. False

Answer: A Rationale: Nurses obtain data from a variety of sources, including their own nursing experience, that provide information about the patient's current level of wellness and functional status, anticipated prognosis, risk factors, health practices and goals, responses to previous treatment, and patterns of health and illness.

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 2. Abiamu needs to weigh Ms. Ortega's son. Which device should she use to weigh the infant? A. Platform scale B. Sliding scale C. Water chamber D. Bariatric chamber

Answer: A Rationale: To weigh an infant, remove the clothing and weigh in a dry disposable diaper using a basket or platform scale.

Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 3. Boris takes Mr. Scalini's vital signs at 0800. When should Boris chart Mr. Scalini's vital signs? A. At the time of occurrence B. At the end of shift C. Before the lunch break D. At 1200

Answer: A Rationale: Vital signs; pain assessment; administration of medications and treatments; preparation for diagnostic tests or surgery; changes in the patient's status and who was notified; treatment for a sudden change in the patient's status; the patient's response to treatment or intervention; and admission, transfer, discharge, or death of a patient should be documented at the time of occurrence.

Mrs. Elizabeth Repogle is a 92-year-old woman who lives in a long-term care facility. She is healthy, except for mild osteoporosis and a vitamin D deficiency. She takes a vitamin D supplement and has several servings of dairy a day. She also takes a nonsteroidal antiinflammatory drug for the occasional moderate pain that she experiences from the osteoporosis. Diego is the nursing student assigned to Mrs. Repogle. His main goal in caring for her is to make sure that she does not fall and break any bones. Therefore he assists Mrs. Repogle, who is ambulatory, to the bathroom, dining room, and activities room. He just walks beside her in case she becomes unsteady on her feet. 3. Diego performs an assessment of Mrs. Repogle. Which of the following are appropriate questions to ask her to assess her osteoporosis? (Select all that apply.) A. "Does your back hurt when you walk?" B. "Are you still able to walk the length of the hall without discomfort?" C. "How many times a day do you void?" D. "Are you getting enough fruit in your diet?"

Answer: A, B Rationale: Assessment questions for osteoporosis include asking about mobility, endurance, and pain. Elimination is not something that is directly related to osteoporosis. Fruit in the diet is not directly related to osteoporosis.

Mrs. Elizabeth Repogle is a 92-year-old woman who lives in a long-term care facility. She is healthy, except for mild osteoporosis and a vitamin D deficiency. She takes a vitamin D supplement and has several servings of dairy a day. She also takes a nonsteroidal antiinflammatory drug for the occasional moderate pain that she experiences from the osteoporosis. Diego is the nursing student assigned to Mrs. Repogle. His main goal in caring for her is to make sure that she does not fall and break any bones. Therefore he assists Mrs. Repogle, who is ambulatory, to the bathroom, dining room, and activities room. He just walks beside her in case she becomes unsteady on her feet. 2. Diego teaches Mrs. Repogle about the causes and management of osteoporosis. Which of the following are causes of osteoporosis? (Select all that apply.) A. Physical inactivity B. Hormonal changes C. Increased osteoclastic activity D. Stooped posture

Answer: A, B, C Rationale: The causes of osteoporosis are physical inactivity, hormonal changes, and increased osteoclastic activity. Stooped posture is a symptom of osteoporosis.

Mr. When Chang is being admitted to the medical-surgical unit for management of a stage 4 decubitus ulcer on his left hip. Mr. Chang, a 37-year-old engineer, was in a near-fatal motor vehicle accident 3 months ago that precipitated a series of spine surgeries to help correct damage to his spine. He has been bedridden in a long-term care facility since his last surgery 7 weeks ago, and he has developed a stage 4 decubitus ulcer on his left hip. The wound is being treated with a wound vacuum and antibiotic therapy. Bettina is the nursing student who is assigned to Mr. Chang. Bettina enters his room, introduces herself, and explains that she is going to perform an admission health history and physical assessment. 3. Which of the following are examples of back channeling techniques that Bettina may use during the patient interview with Mr. Chang? (Select all that apply.) A. "Go on." B. "I see." C. "Where does it hurt?" D. "All right." E. "Why are you here?"

Answer: A, B, D Rationale: Back channeling techniques such as "go on," "I see," and "all right" reinforce the nurse's interest in what the patient has to say and encourage the patient to give more details. "Where does it hurt?" and "Why are you here?" are examples of open-ended questions.

Mr. Scott Silliman is a 53-year-old Caucasian male who sustained multiple injuries as a result of a motor vehicle accident (MVA). He was admitted to the emergency department (ED) and, once stable, was transferred to the medical-surgical unit for management of several broken ribs, concussion, and nerve damage to his right leg that has made walking difficult. He is on bed rest until physical therapy can assess him to determine his mobility status. Erin is the nursing student assigned to Mr. Silliman. She enters his room to perform a physical assessment. 2. Erin assesses Mr. Silliman for a possible thrombus. Which factors together form Virchow's triad? (Select all that apply.) A. Damage to the vessel wall B. Alterations in blood flow C. Damage to the nerve root D. Alterations in blood constituents E. Damage to muscle fibers

Answer: A, B, D Rationale: Virchow's triad contributes to venous thrombus formation. The three factors of Virchow's triad are damage to the vessel wall, alterations in blood flow, and alterations in blood constituents.

Mr. When Chang is being admitted to the medical-surgical unit for management of a stage 4 decubitus ulcer on his left hip. Mr. Chang, a 37-year-old engineer, was in a near-fatal motor vehicle accident 3 months ago that precipitated a series of spine surgeries to help correct damage to his spine. He has been bedridden in a long-term care facility since his last surgery 7 weeks ago, and he has developed a stage 4 decubitus ulcer on his left hip. The wound is being treated with a wound vacuum and antibiotic therapy. Bettina is the nursing student who is assigned to Mr. Chang. Bettina enters his room, introduces herself, and explains that she is going to perform an admission health history and physical assessment. 1. Bettina asks Mr. Chang many questions to determine his health patterns. Which of the following are examples of Gordon's model of 11 functional health patterns that Bettina may address in her assessment? (Select all that apply.) A. Sleep-rest B. Pain C. Role-relationship D. Sexuality-reproductive E. Elimination

Answer: A, C, D, E Rationale: Gordon's model of 11 functional-health patterns includes health perception-health management, nutritional-metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception-self-concept, role-relationship, sexuality-reproductive, coping-stress tolerance, and value-belief. Pain is not one of Gordon's models of 11 functional health patterns.

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 3. Abiamu performs an assessment of Ms. Ortega's cardiac system. List the six anatomical sites for assessment of cardiac function, starting on the patient's upper right side and moving in a clockwise direction.

Answer: Aortic, pulmonic, second pulmonic area, tricuspid, mitral, and epigastric Rationale: The six anatomical sites for assessment of cardiac function starting on the patient's upper right side and moving in a clockwise direction are aortic, pulmonic, second pulmonic area, tricuspid, mitral, and epigastric.

Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 2. Boris charts Mr. Scalini's pain assessment in Mr. Scalini's chart. Which of the following is a correct example of charting as it appears in the chart? A. "Patient appears to be free from pain." B. "Patient states a 0 on a pain-rating scale of 1 to 10." C. "Patient seems to be resting comfortably." D. "Patient seems to have pain at the incision site."

Answer: B Rationale: A factual record such as a patient chart should include descriptive, objective information about what a nurse sees, hears, feels, and smells. Vague terms such as appears and seems state an opinion and not fact. The patient's complaint of pain using the pain-rating scale is a descriptive piece of subjective information that is permissible in the patient's chart.

Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 4. Boris charts Mr. Scanlini's vital signs and intake and output on a flow sheet. Documenting on a flow sheet ensures duplication of data as required by The Joint Commission. A. True B. False

Answer: B Rationale: Documenting on a flow sheet prevents duplication of data. The Joint Commission does not require duplication of data.

Mrs. Elizabeth Repogle is a 92-year-old woman who lives in a long-term care facility. She is healthy, except for mild osteoporosis and a vitamin D deficiency. She takes a vitamin D supplement and has several servings of dairy a day. She also takes a nonsteroidal antiinflammatory drug for the occasional moderate pain that she experiences from the osteoporosis. Diego is the nursing student assigned to Mrs. Repogle. His main goal in caring for her is to make sure that she does not fall and break any bones. Therefore he assists Mrs. Repogle, who is ambulatory, to the bathroom, dining room, and activities room. He just walks beside her in case she becomes unsteady on her feet. 1. Diego reviews Mrs. Repogle's plan of care to ensure that no changes are needed. He knows that osteoporosis changes the biochemical makeup of the bones, which causes a reduction in bone density or mass. A. True B. False

Answer: B Rationale: In osteoporosis the bone remains biochemically normal but has difficulty maintaining integrity and support.

Mr. Scott Silliman is a 53-year-old Caucasian male who sustained multiple injuries as a result of a motor vehicle accident (MVA). He was admitted to the emergency department (ED) and, once stable, was transferred to the medical-surgical unit for management of several broken ribs, concussion, and nerve damage to his right leg that has made walking difficult. He is on bed rest until physical therapy can assess him to determine his mobility status. Erin is the nursing student assigned to Mr. Silliman. She enters his room to perform a physical assessment. 1. Erin performs a neurological assessment on Mr. Silliman. When assessing his legs, she notices that he is not able to dorsiflex and invert his right foot. Which condition may Mr. Silliman have? A. Pigeon toes B. Scoliosis C. Footdrop D. Bowlegs

Answer: C Rationale: Footdrop is the inability to dorsiflex and invert the foot because of peroneal nerve damage.

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 1. Abiamu enters Ms. Ortega's room to perform a physical assessment. Rank in order the four techniques used in a physical examination. A. Palpation B. Auscultation C. Inspection D. Percussion

Answer: C, A, D, B Rationale: The order of the four techniques used in physical examination is inspection, palpation, percussion, and auscultation.

Boris is a nursing student on the medical-surgical unit who is assigned a new admission from the postanesthesia care unit (PACU), Mr. Rudolpho Scalini. Mr. Scalini is 54 years old and status post-right total hip replacement (THR). He is an owner of a local Italian restaurant chain and is 5'6" and 220 pounds. Mr. Scalini's hip replacement was precipitated by his obesity and refusal to engage in a regular exercise program. Boris conducts his admission assessment of Mr. Scalini and charts his findings in the electronic health record (EHR). 1. Boris completes Mr. Scalini's admission paperwork. Which of the following establishes reimbursement to the hospital for Mr. Scalini's care? A. Patient care plan B. Joint Commission standards C. ICNP diagnoses D. Diagnosis-related groups

Answer: D Rationale: Diagnosis-related groups enable hospitals to be reimbursed a predetermined dollar amount by Medicare.

Ms. Ortega is a 16-year-old teen mother admitted to the mother-baby unit after the delivery of her second child. Her pregnancy was a difficult one; she was placed on bed rest for the last 2 months because of pregnancy-induced hypertension (PIH) to reduce the workload of her heart to help sustain her pregnancy. Ms. Ortega gave birth to healthy baby boy whom she is learning to breastfeed. Abiamu is the nursing student assigned to Ms. Ortega and her infant. 4. When auscultating Ms. Ortega's heart, Abiamu notices that the heart fails to beat at regular successive intervals. This cardiac abnormality is referred to as a __________________.

Answer: Dysrhythmia Rationale: A dysrhythmia, which may be life-threatening, is the failure of the heart to beat at regular successive intervals.

Mr. Scott Silliman is a 53-year-old Caucasian male who sustained multiple injuries as a result of a motor vehicle accident (MVA). He was admitted to the emergency department (ED) and, once stable, was transferred to the medical-surgical unit for management of several broken ribs, concussion, and nerve damage to his right leg that has made walking difficult. He is on bed rest until physical therapy can assess him to determine his mobility status. Erin is the nursing student assigned to Mr. Silliman. She enters his room to perform a physical assessment. 3. Erin assesses Mr. Silliman's legs and notices that the calf and thigh of the right leg are a little smaller than those of the left leg. Mr. Silliman's immobility since the accident has caused ___________ _____________ in his right leg.

Answer: Muscle atrophy Rationale: Muscle atrophy is the loss of muscle tone and joint stiffness as a result of immobilization.

A nurse inspects a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter with inflammation. The nurse gently applies pressure around the wound, with the patient acknowledging pain. The nurse asks the patient to rate the level of pain on a scale from 0 to 10. A final assessment includes reviewing the electronic health record for how frequently the patient was turned in the last 12 hours. Fill in the spaces below to identify the following concepts: assessment activity or cue. The nurse inspects (a. _____) a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. _____) with inflammation (c. _____). The nurse gently applies pressure (d. ____) around the wound, with the patient acknowledging pain (e. _____). The nurse asks the patient to rate the level of pain on a scale (f. _____) from 0 to 10. A final assessment includes reviewing the electronic record (g. _____) for how frequently the patient was turned in the last 12 hours.

Answer: Nurse inspects (a. assessment activity) a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. cue) with inflammation (c. cue). The nurse gently applies pressure (d. assessment activity) around the wound, with the patient acknowledging pain (e. cue). The nurse asks the patient to rate the level of pain on a scale (f. assessment activity) from 0 to 10. A final assessment includes reviewing the electronic record (g. assessment activity) for how frequently the patient was turned in the last 12 hours.

A nurse receives a hand-off report for three assigned patients. Using a nursing task list on the EHR, the nurse identifies the care procedures scheduled for the patients. One patient is on the second day after surgery and is stable. Another patient is developing a fever, and diagnostic tests are being conducted to determine the cause. The third patient just returned from surgery and is still on every30-minutes vital signs. Discuss the ways this nurse can use time management to organize assessment of these patients.

Answer: The nurse should apply these approaches for time management for assessment: list the care activities that need to be done, including assessment; prioritize these activities; estimate the time needed for each activity; spend the time consciously; cautiously spend the time for unscheduled activities, and be willing to say "no."

The nurse is assigned to provide care for the following clients. Client #1: A 56-year-old man who had a total knee replacement 8 hours ago and whose affected extremity is internally rotated Client #2: A 72-year-old woman who has Parkinson disease, experiences mild dementia, and is receiving continuous intravenous fluids for dehydration Client #3: A 60-year-old female with chronic obstructive pulmonary disease who is reporting hemoptysis Client #4: A 40-year-old patient who had a craniotomy 24 hours ago and has become lethargic and confused Client #5: A 33-year-old patient who had a flare-up of ulcerative colitis with electrolyte depletion and is being discharged tomorrow. Complete the following sentences by choosing the most likely options for the missing information from the lists of options provided. The nurse should assess first _____1_____ because this client is at risk for _____2_____. After attending to the priority client's needs, the second client the nurse would assess is _____1_____ because the client is at risk for _____2_____. Options for 1 Options for 2 Client #1 Hypokalemia Client #2 Respiratory failure Client #3 Pulmonary edema Client #4

Answer: The nurse should assess first client #3 because this client is at risk for pulmonary edema. After attending to the priority client's needs, the second client the nurse would assess is client #4 because the client is at risk for increased intracranial pressure. Skill: Prioritize hypotheses Item type: Cloze Client needs: Management of Care > Prioritize the delivery of client care (NCSBN, 2018, p. 8) Rationale: Excessive pink, frothy sputum is common with pulmonary edema, along with other clinical findings such as extreme anxiety, tachycardia, and difficulty breathing. Lung damage caused by severe infection or smoking is associated with development of pulmonary edema in clients with severe lung disease, such as COPD. This is a rapidly emerging respiratory condition, which makes this client the first priority to assess. The client who has a change in level of consciousness after a craniotomy is a priority because of the potential development of increased intracranial pressure. Because joint dislocation is rare after a total knee replacement, there are no special positioning precautions required to prevent adduction. The operative leg is best left in a neutral position, thus avoiding both internal and external rotation. The client with Parkinson disease and dementia has a chronic illness. The IV fluids need monitoring, but this client is not a priority. The client who is going to be discharged is not the priority client for the nurse to assess.

Contemporary nursing requires that the nurse have knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.) 1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion 5. Genetic counselor

Answers: 1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion Each of these roles or skills includes activities for the professional nurse. Each of these is used in direct care or is part of the professionalism that guides nursing practice.

A nurse wants to work in a setting in which it is possible to have a dramatic impact on the cost of health care. What type of setting should the nurse choose to work in? Chronic disease clinic Emergency department Hospital intensive care School-based practice

Chronic disease clinic The most dramatic reductions in this cost could be realized by keeping those with chronic illnesses out of the hospital and free of complications. Working in an emergency department, intensive care unit, or school-based practice would not have this same impact.

The nurse manager observes a new nurse caring for a patient and evaluating how well the patient understood information about an upcoming diagnostic test. The nurse manager interprets this as which role? A.Advocate B.Counselor C.Manager D.Teacher

D. Teacher The teacher provides information to patients about a multitude of things, such as diagnostic exams, conditions, medication regimens, and healthy lifestyles. Inherent in this role is evaluating the patient's understanding and tailoring this information to the patient's learning styles and understanding. Advocates protect the patient, often by speaking on the patient's behalf. Counselor is not a nursing role. Managers organize patient care.

A nurse and health care provider are talking in the hallway about a patient's condition. The health care provider says that the patient needs an x-ray. Which action by the nurse is most appropriate? Document the order and facilitate the patient having the x-ray. Explain that you will call x-ray when the health care provider inputs the order. Inform the health care provider that verbal orders are prohibited now. Repeat the order to the health care provider and document it in the chart.

Explain that you will call x-ray when the health care provider inputs the order. Verbal orders should only be taken during an emergency situation or when it is physically difficult for the health care provider to write or put in the order himself or herself, such as during a sterile procedure. Because neither is the case here, the nurse should explain that as soon as the order is properly put into the system, he or she will facilitate the study. The nurse should not document the order or say that verbal orders are prohibited because there are circumstances in which they are still appropriate.

A nurse is writing a telephone order for medication. Which written order does the nurse interpret as written appropriately? Furosemide 10.0 mg b.i.d. Furosemide 10 mg bid PO Furosemide 10 mg two times a day orally Furosemide 10 mg 2×/day by mouth

Furosemide 10 mg two times a day orally The clearest example of a well-written medication order is the one in which all items are spelled out and the numerical (dose) value is written properly. It should be "furosemide (Lasix) 10 mg two times a day orally." Medication orders need to be completely clear. The option of 2×/day might be misread if written sloppily. The option of 10.0 has a trailing zero, which should not be used (easy to mistake as 100). The abbreviation "b.i.d." also should not be used. The option with "bid" contains the abbreviation "PO."

The staff nurse working in a hospital is familiar with The Joint Commission (TJC) patient safety goals. Which of the following are 2019 patient safety goals that the nurse will incorporate into patient care? (Select all that apply.) Implement new provider orders in a timely fashion. Improve the effectiveness of communication among caregivers. Label medications that are not labeled. Reduce the risk of health care-associated infections. Use at least two unique ways to identify patients.

Improve the effectiveness of communication among caregivers. Label medications that are not labeled. Reduce the risk of health care-associated infections. Box 22.1 is the complete list of TJC patient safety goals, which include improving the effectiveness of communication among caregivers, label medications that are not labeled, reducing the risk of health care-associated infections, and using two ways to identify patients. Implementing new orders in a timely fashion is important but is not one of the 2019 TJC patient safety goals.

A staff nurse has joined the Continuous Quality Improvement Team and asks what root cause analysis is. What does the chair of the committee tell this nurse? It finds the one main cause for an error that occurred. It helps reduce processes to their main, or root, activities. It identifies all the main causative factors leading to errors. It provides identified root processes to reduce errors.

It identifies all the main causative factors leading to errors. Root cause analysis is a process to investigate and characterize the root causes of events that occur. In the case of errors, many factors often affect the outcome. It does not identify root processes. There is usually no one main cause for errors. It is not used to reduce processes to their main, or root, activities.

An experienced nurse is precepting a new graduate. Prior to charting, the preceptor instructs the new nurse to do which of the following? Abbreviate as much as possible to keep records short. Do not use any abbreviations at all in patients' charts. Look up the facility's list of "do not use" abbreviations. Use only abbreviations seen in other nurses' charting.

Look up the facility's list of "do not use" abbreviations. Each facility should have a list of abbreviations that are not allowed, which should include but not replace the list compiled by The Joint Commission. The new nurse should be instructed to look at this list up and become familiar with it. Although abbreviations are allowed, the nurse should only use facility-approved abbreviations. The nurse should not just copy what is seen in others' charting. The new nurse should not abbreviate as much as possible but should only use facility-approved abbreviations.

A student nurse protests about writing "endless" care plans. The faculty explains how this teaches one of the nursing roles in addition to preparing the student to care for patients, and that all hospitals must demonstrate the use of the nursing process. Which nursing role is the faculty referring to? Advocate Colleague Manager Teacher

Manager Organizing nursing care so that other nurses can continue caring for the patient in one's absence is the essence of the earliest version of the nurse manager role. In addition to helping the student prepare to care for a particular patient, writing down directions (or entering the information into a computer) for patient care ensures consistency among the staff. The teacher provides patients with information. The advocate protects patients and, on occasion, speaks for them. The colleague works within interdisciplinary relationships for better patient care; nursing care plans are not used by other disciplines.

A nurse has finished getting shift report. Which patient should the nurse see first? Patient just transferred from the emergency department Patient who needs to get out of bed and ambulate Pneumonia patient getting respiratory treatment Postoperative patient requesting pain medication

Patient just transferred from the emergency department Hand-offs are particularly dangerous times during a health care stay. The nurse should see this patient first; hopefully, the ED nurse is still with the patient, waiting to give a face-to-face report. Otherwise, the nurse should assess this patient, review the orders, facilitate their input into the system, and call the ED nurse for questions. The nurse should see the ED patient first. The patient who needs to ambulate can wait, or the nurse could delegate a nursing assistant to help this patient. The pneumonia patient is with another professional (respiratory therapy). The postoperative patient requesting pain medications needs to be seen soon, but the nurse could either delegate this task to another nurse or get the pain medication as quickly as possible after seeing the new patient.

As a result of a quality improvement (QI) project, a key nursing process has been changed on an inpatient unit. Which action by the QI team and/or nursing manager is most important at this time? Disband the QI work team as their work is done. Gather data on the next item to investigate. Prevent the return to previous work methods. Write up and publish the results of the process.

Prevent the return to previous work methods. Change is difficult for most people, and backsliding can occur easily because the old way of doing things is much easier than remembering all the new steps in the new process. The QI team or management should have a process in place to monitor the staff and react quickly to any backsliding. Publishing results is an important way to disseminate knowledge, but it is far more important to maintain the new practices until they become ingrained. The work of the team may or may not be complete; instituting measures to prevent backsliding to the old way of doing things is more important. Gathering data for new projects is not as important as maintaining the new process.

A nurse looking for a job wants a workplace in which the nurse has 24-hour responsibility for patient care for a specific group of patients and wants to develop meaningful relationships with patients and families. Which pattern of nursing care should this nurse look for? Functional nursing Patient-focused care Primary nursing Team nursing

Primary nursing Functional nursing divides nursing care into specific tasks, which are then assigned to various levels of caregivers. Patient-focused care uses fewer people to care for patients by cross-training some of them to take on tasks normally performed by other departments. Primary nursing is a pattern in which an RN assumes responsibility for patients on a 24-hour-a-day basis and cares for those patients when on duty. Team nursing uses a group of care providers to care for a patient group. The team often consists of one RN, one or two LPNs, and one or two nursing assistants.

The nurse is caring for a newly admitted client with a history of glaucoma and type 2 diabetes. The client has a 2-year history of colon cancer and has received chemotherapy and radiation therapy in the past, along with a colon resection a year ago. One month ago carpal tunnel release surgery was performed in outpatient surgery. The client is scheduled for another colon resection due to the rapid growth of the tumor. The following are the client's admission orders: Health History Start IV at 100 mL/hr with normal saline Latanoprost 0.005% one drop at bedtime in both eyes Timolol .5% one drop in left eye q12h Metformin 500 mg, PO, bid Glyburide 5 mg PO, qd MS 10 mg/5 mL, PO for pain q4-6 hr prn Regular diet NPO after midnight Highlight the orders that the nurse should question and contact the health care provider right away for clarification.

Start IV at 100 mL/hr with normal saline Latanoprost 0.005% one drop at bedtime in both eyes Timolol .5% one drop in left eye q12h Metformin 500 mg PO bid Glyburide 5 mg PO qd MS 10 mg/5 mL PO for pain q4-6 hr prn Regular diet NPO after midnight Skill: Recognize cues Item type: Enhanced hot spot Client needs: Management of Care > Use approved abbreviations and standard terminology when documenting care (NCSBN, 2018, p. 8) Rationale: The nurse should use approved abbreviations to prevent medication errors and promote medication safety. -With latanoprost 0.005% one drop at bedtime in both eyes ordered as a medication treating glaucoma, the nurse needs to determine whether the drop should be placed only in the affected left eye and not both eyes. -Timolol 0.5% one drop in left eye q12h should have a 0 before the decimal point because it is often misread without the 0. The nurse should check that the medication is given only to the affected left eye and not both eyes. -The use of the "qd" abbreviation is not approved and should be written out as "daily." -MS, which can be misinterpreted as morphine sulfate or magnesium sulfate, needs to be written out completely.

A nurse is preparing to provide feedback to a new graduate who has been on the unit for half of the regular orientation period. Which action by the nurse demonstrates the best example that the feedback has been constructive? The new graduate stresses, "I really like working on this unit". The nurse shares that, "This is what you need to do to manage your time effectively". The nurse ends the discussion by stating, "You still have time to make the necessary changes". The nurse asks the new graduate to, "Tell me how you think you are doing regarding patient care".

The nurse asks the new graduate to, "Tell me how you think you are doing regarding patient care". The nurse has demonstrated an understanding of providing effective constructive feedback by actively listening to the new graduate as he/she self-reflects on their perception of their performance. While a positive factor, the new graduate's favorable perception of the unit doesn't reflect on personal performance. The nurse should avoid giving personal advice regarding the new graduate's time management skills. The new graduate should be encouraged to self-reflect on possible changes in behavior. The statement regarding still having time to make changes could easily be interrupted as being intimidating.