Unit 6

A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction? a. "I should call the doctor if I have incontinence at home." b. "I will avoid driving until I get approval from my doctor." c. "I should schedule yearly appointments for prostate examinations." d. "I will increase fiber and fluids in my diet to prevent constipation."

"I should call the doctor if I have incontinence at home."

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

Insert a urinary retention catheter.

The pediatric nurse understands that nonpharmacologic strategies for pain management: a. May reduce pain perception. b. Make pharmacologic strategies unnecessary. c. Usually take too long to implement. d. Trick children into believing they do not have pain

May reduce pain perception.

A patient with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse's best action? a. Instruct the client to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

Measure the calf circumference and compare the measurement with the right calf circumference measurement.

Which key feature is associated with a stage 2 pressure ulcer? 1 Presence of nonintact skin 2 Development of sinus tracts 3 Damage to the subcutaneous tissues 4 Appearance of a reddened area over a bony prominence

Presence of nonintact skin

A 62-yr-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

The patient's blood pressure is 92/52 mm Hg.

A 7-year-old child sustains a fractured femur in a bicycle accident. The admission x-ray films reveal evidence of fractures of other long bones in various stages of healing. Which would the nurse suspect as the cause of the fracture? 1 Child abuse 2 Vitamin D deficiency 3 Osteogenesis imperfecta 4 Inadequate calcium intake

Child abuse

When giving home care instructions to a patient who has comminuted left forearm fractures and a longarm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

Call the health care provider for numbness of the hand.

The day after having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take? a. Explain the reasons for the pain. b. Administer prescribed analgesics. c. Reposition the patient to assure good alignment. d. Inform the patient that this pain will diminish over time.

Administer prescribed analgesics.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

Capillary refill to the fingers is prolonged.

A patient with Parkinson's disease has bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

Suggest that the patient rock from side to side to initiate leg movement.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

"Check and clean the pin insertion sites daily."

A client with foot ulcers is admitted to the hospital. The nurse manager would delegate the task of maintaining hygiene to which staff members to maximize efficient use of human resources? Select all that apply. One, some, or all responses may be correct. 1 Registered nurse (RN) 2 Patient care associate (PCA) 3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN) 5 Unlicensed nursing practitioner (UNP)

2 Patient care associate (PCA) 5 Unlicensed nursing practitioner (UNP)

Which information would the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply. One, some, or all responses may be correct. 1 Potential drug-drug interactions 2 Skill to care for the surgical wound 3 Safe and effective use of medications 4 List of appropriate community resources 5 Need to report any change in the surgical area

2 Skill to care for the surgical wound 3 Safe and effective use of medications 4 List of appropriate community resources

The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to: a. Administer naloxone (Narcan). b. Discontinue the IV infusion. c. Discontinue morphine until the child is fully awake. d. Stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

Administer naloxone (Narcan).

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action? 1 Obtain vital signs. 2 Administer oxygen. 3 Notify the health care provider. 4 Auscultate the client's lung sounds.

Administer oxygen.

The nurse uses the palms of the hands when handling a wet cast to: a. Assess dryness of the cast. b. Facilitate easy turning. c. Keep the patient's limb balanced. d. Avoid indenting the cast.

Avoid indenting the cast.

The nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result would confirm the diagnosis? 1 Digital rectal examination 2 Serum phosphatase level 3 Biopsy of prostatic tissue 4 Massage of prostatic fluid

Biopsy of prostatic tissue

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Antibiotics are infused continuously through the bladder irrigation. d. Bladder irrigation prevents obstruction of the catheter after surgery.

Bladder irrigation prevents obstruction of the catheter after surgery.

After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? a. Elevated temperature and pulse b. Bladder spasms and urine output c. Respiratory rate and lung crackles d. No prescription for antihypertensive drugs

Bladder spasms and urine output

A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse's best action? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.

Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns.

A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which pain assessment tool should the nurse use to assess this child for the presence of pain? a. FACES pain rating tool c. Oucher scale b. Numeric scale d. FLACC tool.

FLACC tool.

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

Decreased subcutaneous fat

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

Decreasing pruritus

An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation. He has been on round-the-clock opioid doses q 4 hours. What is the nurse's first action? a. Call the rapid response team to care for the patient immediately. b. Discontinue the opioids on the medication administration record. c. Assess the patient's blood pressure and pain level. d. Start a second intravenous line with a large bore catheter.

Discontinue the opioids on the medication administration record.

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

Ensure the weight for the traction is hanging freely

What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? a. Risk for injury related to poor blood clotting b. Fatigue related to decreased cellular oxygenation c. Disturbed body image related to skin color changes d. Imbalanced nutrition, less than body requirements related to anorexia

Fatigue related to decreased cellular oxygenation

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? 1 Avoid massaging the client's legs. 2 Frequently reposition the client on a scheduled basis. 3 Increase the fiber content in the client's food. 4 Encourage the client to participate in weight-bearing exercises.

Frequently reposition the client on a scheduled basis.

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

Herbs, vitamins, and tai chi

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

IV Dilaudid q 4 hours prn, hydrocodone 5/500 PO q 6 hours prn, and acetaminophen

In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.

Instruct the patient to cough and deep breathe

The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

Mild temperature elevation

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. b. Assess for contractures. c. Check peripheral pulses. d. Monitor for hip dislocation.

a. Assess for hip pain.

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse cleans the ulcer with half-strength peroxide. b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

The new nurse cleans the ulcer with half-strength peroxide.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.

Abdomen is distended and bowel sounds are absent.

While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age

Advancing age

Mobility for the patient changes throughout the life span. What is the term that best describes this process? a. Aging and illness b. Illness and disease c. Health and wellness d. Growth and development

d. Growth and development

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take? a. Discuss alternative methods of sexual expression. b. Teach about medication for erectile dysfunction (ED). c. Clarify that TURP does not commonly affect erection. d. Offer reassurance that fertility is not affected by TURP.

Clarify that TURP does not commonly affect erection.

Which client would the nurse suspect may have Parkinson's disease? 1 Client A 2 Client B 3 Client C 4 Client D

Client A

A client with Parkinsonism takes an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complained of some numbness in the left hand. Which intervention would the nurse implement for this client? 1 Refer the client to the primary health care provider, only if other neurological deficits are present. 2 Ask the primary health care provider to increase the client's dosage of the anticholinergic medication. 3 Stress the importance of having the client call the primary health care provider as soon as possible. 4 Make immediate arrangements for further medical evaluation by the client's primary health care provider.

Make immediate arrangements for further medical evaluation by the client's primary health care provider.

A nurse is gathering history on a school-age child admitted for a migraine headache. The child states, I have been getting a migraine every 2 or 3 months for the last year. The nurse documents this as which type of pain? a. Acute c. Recurrent b. Chronic d. Subacute

Recurrent

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.

The patient takes oral hypoglycemic agents daily.

Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

a. Simple

The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy to a. restrict oral fluid intake. b. do pelvic muscle exercises. c. perform intermittent self-catheterization. d. use belladonna and opium suppositories.

do pelvic muscle exercises.

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate? a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

"It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

Assess for child abuse. Fractures in infants are often nonaccidental.

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

Elevate casted arm when resting and when sitting up.

Which nursing action is the priority when the nurse discovers in an admission assessment that a client has a stage 1 pressure ulcer? 1 Turn and reposition the client every 2 hours. 2 Cover the ulcer with an occlusive, transparent dressing. 3 Clean the ulcer with hydrogen peroxide and leave it open to the air. 4 Provide the client with a diet high in vitamin C, zinc, and protein.

Turn and reposition the client every 2 hours.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information indicates a need for change in the medication or dosage? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

Uncontrolled head movement

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic? a. Eschar c. Maceration b. Slough c. Maceration d. Undermining

Undermining

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

Use a cervical collar to stabilize the spine.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. d. Place an armchair at the patient's bedside.

The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion d. Increased calcium deposition in the bones

a. Demineralization, calcium loss

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

a. Elevate the ankle above heart level.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

b. "I don't bother with sunscreen on overcast days."

Which medications are the most effective choices for treating pain associated with inflammation in children (Select all that apply)? a. Morphine b. Acetaminophen (Tylenol) c. Ibuprofen (Advil) d. Ketorolac (Toradol) e. Aspirin

c. Ibuprofen (Advil) d. Ketorolac (Toradol)

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)? a. Palpable distal pulse b. Capillary refill to extremity of <3 seconds c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity

c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

c. "Monitor spots for color change."

Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant's c. Russell d. Buck's extension

c. Russell

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain

c. Separation of the proximal wound edges

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A beta-hemolytic streptococci c. Staphylococcus aureus d. E. Coli

c. Staphylococcus aureus

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. blood in the urine. b. lower back or hip pain. c. force of urinary stream. d. erectile dysfunction (ED).

c. force of urinary stream.

What would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. "Hot spots" felt on cast surface

d. "Hot spots" felt on cast surface

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

d. 200 mL sanguineous fluid in the wound drain

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

d. Apply sunscreen 30 minutes prior to exposure.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

d. Turning the patient at least every 2 hours

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

for at least 3 weeks.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

how and when to cut the immobilizing wires.

The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP) a. that urine will appear bloody for several days. b. how to care for an indwelling urinary catheter. c. that symptom improvement takes 2 to 3 weeks. d. about complications associated with urethral stenting.

how to care for an indwelling urinary catheter.

A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate-specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

prostate-specific antigen (PSA) testing.

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

risk for infection related to disruption of skin integrity.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

Imbalanced nutrition: less than body requirements

While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"

"Have you noticed any blood in your stool?"

A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate? a. "Have you taken any over-the-counter (OTC) medications recently?" b. "I will talk to the doctor about a prostate specific antigen (PSA) test." c. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."

"Have you taken any over-the-counter (OTC) medications recently?"

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" Which response by the nurse is most appropriate? 1 "What makes you think you have cancer?" 2 "I don't know if you do; let's talk about it." 3 "Why don't you discuss this with your primary health care provider?" 4 "You needn't worry now; we won't know the answer for a few days."

"I don't know if you do; let's talk about it."

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the O2 saturation. d. Observe for facial asymmetry.

Check the O2 saturation.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Delegate the transfer to nursing assistive personnel (NAP). d. Decrease the pain medication before getting the patient up.

Check the patient's prescribed weight-bearing status.

When a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures, which actions would the nurse take first? 1 Establish an airway and stabilize the cervical spine. 2 Assess heart sounds and find carotid and femoral pulses. 3 Check for alertness, orientation, and pupil reaction to light. 4 Remove clothing to enable further assessment of injuries.

Establish an airway and stabilize the cervical spine.

A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: a. 4% Liposomal Lidocaine (LMX) 15 minutes before the procedure. b. A transdermal fentanyl (Duragesic) patch immediately before the procedure. c. Eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure. d. EMLA 30 minutes before the procedure

Eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure.

Kyle, age 6 months, is brought to the clinic. His parent says, I think he hurts. He cries and rolls his head from side to side a lot. This most likely suggests which feature of pain? a. Type b. Severity c. Duration d. Location

Location

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

b. Document the assessment.

An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast: a. Is less expensive. b. Dries rapidly. c. Molds closely to body parts. d. Has a smooth exterior.

b. Dries rapidly.

A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of what type of pain? a. Neuropathic pain b. Nociceptive pain c. Chronic pain d. Mixed pain syndrome

b. Nociceptive pain

A cancer patient's susceptibility to the syndrome of inappropriate antidiuretic hormone (SIADH) can be suspected with which of the following laboratory results? a. Serum potassium of 5.2 mmol/L b. Serum sodium of 120 mmol/L c. Hematocrit of 40% d. Blood urea nitrogen (BUN) of 10 mg/dL

b. Serum sodium of 120 mmol/L

When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

b. antiparkinsonian drugs.

The health care provider prescribes finasteride for a client with benign prostatic hyperplasia. Which information would the nurse provide to the client? 1 Male pattern baldness can occur. 2 Results can be expected in 4 to 6 weeks. 3 The medication relaxes the muscles in the bladder neck. 4 A condom should be worn during intercourse with a pregnant female.

A condom should be worn during intercourse with a pregnant female.

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

A patient who has a wound with purulent drainage and dry brown areas

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

Administer prescribed PRN O2 at 4 L/min.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Administer prescribed PRN hydrocodone 30 minutes before the change. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change

Administer prescribed PRN hydrocodone 30 minutes before the change.

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

Apply a thin coat to affected areas; avoid the face and groin.

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating

The patient advances the left leg and both crutches together and then advances the right leg

Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)? a. The patient has noticed a decrease in energy level for a few years. b. The patient's symptoms have increased steadily over the past few years. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient has had a gradual decrease in the force of his urinary stream.

The patient has had a gradual decrease in the force of his urinary stream.

The nurse is monitoring a patient for side effects associated with opioid analgesics. Which side effects should the nurse expect to monitor for (Select all that apply) ? a. Diarrhea b. Respiratory depression c. Hypertension d. Pruritus e. Sweating

b. Respiratory depression d. Pruritus e. Sweating

An appropriate tool to assess pain in a 3-year-old child is the (Select all that apply): a. Visual Analog Scale (VAS) b. Adolescent and pediatric pain tool c. Oucher tool d. Poker Chip Tool e. FACES pain rating scale

c. Oucher tool d. Poker Chip Tool e. FACES pain rating scale

What percentage of hip fractures is the result of falls? a. 50% b. 80% c. 90% d. 100%

c. 90%

A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellowgreen semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing b. Nonadherent dressing c. Hydrocolloid dressing d. Transparent film dressing

c. Hydrocolloid dressing

The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

d. transrectal ultrasonography (TRUS).

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. have the patient lift the buttocks slightly by using a trapeze over the bed. d. turn the patient partially to each side with the assistance of another nurse.

have the patient lift the buttocks slightly by using a trapeze over the bed.

The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

his interest in sexual activity may decrease while he is taking the medication.

The nurse is caring for a patient who is to be discharged from the hospital 4 days after the insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

"I can sleep in any position that is comfortable for me."

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

"I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can get the cast wet as long as I dry it right away with a hairdryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

"I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. "Patients must have a trapeze over the bed to move properly." b. "Patients should move themselves in bed to prevent immobility." c. "Patients should always have a two-person assist to move in d. "Patients must be moved correctly in bed to prevent shearing."

"Patients must be moved correctly in bed to prevent shearing."

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? a. "Patients with impaired bed mobility have an increased risk for pressure ulcers." b. "Patients with impaired bed mobility like to have extra visitors." c. "Patients with impaired bed mobility need to have a mechanical soft diet." d. "Patients with impaired bed mobility are prone to constipation."

"Patients with impaired bed mobility have an increased risk for pressure ulcers."

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response? a. "Walk at least 5 miles every day for exercise." b. "Wear proper fitting shoes to prevent tripping." c. "Talk with your physician about a calcium supplement." d. "Stand up slowly so you don't feel faint."

"Talk with your physician about a calcium supplement."

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

"Tell me what you know about your options for treatment."

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" The nurse's most helpful response would be which of the following? a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." b. "That is correct, because the face and arms are exposed more often to the sun." c. "That is not correct. Melanoma occurs on the top of the head in men but is rare in women." d. "That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

"That is not correct. Melanoma is more commonly found on the torso or the lower legs of women."

A patient is not certain whether she and her family should participate in a genetic screening plan. She asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in males more frequently than in females. What is the nurse's best response? a. "The disease tends to show up in males because they do not have a second X chromosome to balance the expression of the gene." b. "One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the gene." c. "Females are known to have more effective DNA repair mechanisms than males, thus negating the damage caused by the recessive gene." d. "Expression of genes from the male's Y chromosome does not occur in females, so they are essentially immune to the effects of the gene."

"The disease tends to show up in males because they do not have a second X chromosome to balance the expression of the gene."

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response? a. "Your iron level is low. This is known as anemia." b. "Your immobility in the hospital is known as deconditioning." c. "Your poor appetite is known as malnutrition." d. "Your medications have caused drug induced weakness."

"Your immobility in the hospital is known as deconditioning."

The father of a child who is dying of cancer asks the nurse whether he should tell his 7-year-old son that his sister is dying. What is the most appropriate response by the nurse? 1 "He can't comprehend the real meaning of death, so don't tell him until the last minute." 2 "Your son probably fears separation most and wants to know that you will care for him, rather than what will happen to his sister." 3 "You should talk this over with your health care provider, who probably knows best what's happening in terms of your daughter's prognosis." 4 "Your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's death."

"Your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's death."

Which findings would the nurse expect when completing an admission physical for a client with a diagnosis of Parkinson disease? Select all that apply. One, some, or all responses may be correct. 1 Muscle rigidity 2 Blank facial expression 3 Leaning toward the affected side 4 Intention tremors with movement 5 Hyperextension of the affected extremity

1 Muscle rigidity 2 Blank facial expression

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

Assess the left axilla and change absorbent dressings as needed.

In which developmental stage is the child first able to localize pain and describe both the amount and the intensity of the pain felt? a. Toddler stage c. School-age stage b. Preschool stage d. Adolescent stage

Preschool stage

An appropriate nursing intervention when caring for a child in traction is to: a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity 3 times a day. d. Keep child in one position to maintain good alignment.

Assess for tightness, weakness, or contractures in uninvolved joints and muscles.

A young girl has just injured her ankle at school. In addition to calling the child's parents, the most appropriate immediate action by the school nurse is to: a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a comfortable position. d. Obtain parental permission for administration of acetaminophen or aspirin.

Apply ice.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

Ask the patient about abdominal discomfort.

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly.

Change the patient's position every 1 to 2 hours.

Which myth may interfere with the treatment of pain in infants and children? a. Infants may have sleep difficulties after a painful event. b. Children and infants are more susceptible to respiratory depression from narcotics. c. Pain in children is multidimensional and subjective. d. A childs cognitive level does not influence the pain experience.

Children and infants are more susceptible to respiratory depression from narcotics.

The nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? 1 Client A 2 Client B 3 Client C 4 Client D

Client B

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun to care for the client. Which is the best nursing intervention in preparing for the client's discharge? 1 Contact the client's health care provider to ask to substitute a liquid form of medications for the pill form. 2 Teach the client and family members to crush the pills and administer them with applesauce. 3 Contact the client's health care provider to discuss use of transdermal medications for pain control. 4 Teach the client and family members about addiction that may occur as a result of regular opioid use.

Contact the client's health care provider to discuss use of transdermal medications for pain control.

Which hormonal deficiency would increase the client's risk for fractures? 1 Growth hormone 2 Follicle-stimulating hormone 3 Thyroid-stimulating hormone 4 Adrenocorticotropic hormone

Growth hormone

Which nursing intervention promotes perfusion and healing of the surgical wound for an older adult? 1 Minimize the use of tape on the skin. 2 Keep the client adequately hydrated. 3 Change the dressings as soon as they get wet. 4 Provide rest for the client throughout the day.

Keep the client adequately hydrated.

When pain is assessed in an infant, it is inappropriate for the nurse to assess for: a. Facial expressions of pain. c. Crying. b. Localization of pain. d. Thrashing of extremities.

Localization of pain.

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

Maintaining the patient's blood glucose within a normal range

After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

Manually instill and then withdraw 50 mL of saline into the catheter.

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

Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy

What medication is the most effective choice for treating pain associated with sickle cell crisis in a newly admitted 5-year-old child? a. Morphine c. Ibuprofen b. Acetaminophen d. Midazolam

Morphine

Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine b. Morphine c. Methadone d. Meperidine

Morphine

The nurse caring for the child in pain understands that distraction: a. Can give total pain relief to the child. b. Is effective when the child is in severe pain. c. Is the best method for pain relief. d. Must be developmentally appropriate to refocus attention.

Must be developmentally appropriate to refocus attention.

Physiologic measurements in childrens pain assessment are: a. The best indicator of pain in children of all ages. b. Essential to determine whether a child is telling the truth about pain. c. Of most value when children also report having pain. d. Of limited value as sole indicator of pain.

Of limited value as sole indicator of pain.

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

Patient has been incontinent of urine and stool.

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep

Prioritization and administration of nursing care throughout the day

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

Prolonged stress response and a cascade of harmful effects system-wide

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment

Protection from excessive ultraviolet (UV) exposure

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to perform Kegel exercises. b. Report any complaints of pain or spasms to the nurse. c. Monitor for increases in bleeding or presence of clots. d. Increase the flow rate of the irrigation if clots are noted.

Report any complaints of pain or spasms to the nurse.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

Reposition the patient every 1 to 2 hours.

A child is upset because, when the cast is removed from her leg, the skin surface is caked withdesquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub the leg. c. Apply powder to absorb material. d. Carefully pick material off of the leg.

Soak in a bathtub.

Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage a decreased evening intake of fluid. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day.

Teach the patient how to use the Credé method.

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching? a. The UAP apply a cold pack to the scrotum for a patient with mumps orchitis. b. The UAP help a patient who has had a prostatectomy to put on antiembolism hose. c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. d. The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.

The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter.

Which assessment indicates to a nurse that a 2-year-old child is in need of pain medication? a. The child is lying rigidly in bed and not moving. b. The childs current vital signs are consistent with vital signs over the past 4 hours. c. The child becomes quiet when held and cuddled. d. The child has just returned from the recovery room

The child is lying rigidly in bed and not moving.

When assessing pain in any child, the nurse should consider that: a. Any pain assessment tool can be used to assess pain in children. b. Children as young as 1-year-old use words to express pain. c. The child's behavioral, physiologic, and verbal responses are valuable when assessing pain. d. Pain assessment tools are minimally effective for communicating about pain.

The child's behavioral, physiologic, and verbal responses are valuable when assessing pain.

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

The family member dries the wound using a hair dryer on a low setting.

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

Use pillows to elevate the ankle above the heart.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull on shoes and socks. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

The patient leans over to pull on shoes and socks.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who reports increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

Which nursing intervention is appropriate to assess for neurovascular competency in a child who felloff the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity. b. The length, diameter, and shape of the extremity. c. The amount of swelling noted in the extremity and pain intensity. d. The skin color, temperature, movement, sensation, and capillary refill of the extremity.

The skin color, temperature, movement, sensation, and capillary refill of the extremity.

The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

Using skin protection during sun exposure while at the beach

Which dietary recommendations should a nurse make to an adolescent patient to manage constipation related to opioid analgesic administration (Select all that apply)? a. Bran cereal b. Decrease fluid intake c. Prune juice d. Cheese e. Vegetables

a. Bran cereal c. Prune juice e. Vegetables

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

a. Low serum albumin level

A 19-year-old male has sustained a transection of C-7 in a motor vehicle crash rendering him a quadriplegic. He describes his pain as burning, sharp, and shooting. What type of pain is this patient describing? a. Neuropathic pain b. Ghost pain c. Mixed pain syndrome d. Nociceptive pain

a. Neuropathic pain

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continue to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

a. Notify the health care provider.

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. c over the cast with a small blanket to absorb the dampness.

avoid handling the cast using fingertips

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL d. White blood cells 11,900/μL

b. Albumin level 2.2 g/dL

A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to a. vaccinate the patient with sipuleucel-T (Provenge). b. provide the patient with information about cryotherapy. c. teach the patient about placement of intraurethral stents. d. schedule the patient for annual prostate-specific antigen testing.

schedule the patient for annual prostate-specific antigen testing.