Adult Care 1 Exam 1

asymptomatic

no symptoms or signs shown

lateral position

side lying shoulder--could be left or right side

Medical asepsis:

clean technique such as hand hygiene, barrierr techniques, routine environmental cleaning.

Virulence

the ability to produce disease

Topic Route of Meds:

skin, nasal, eye, ear, vaginal, rectal

Anerobic bacteria

small amount to none oxygen needed for this bacteria.

Surgical asepsis:

sterile technique such as sterile field and gloves, and used forr procedures requiring intentionap perforation of skin.

Federal and state law requires

that consumers of health care have access to interpreter services

Etiology

the cause of the patient's problem. It's always related to something (R/T)-pathophysiology, treatment related, situational, and maturational. DO NOT include medical diagonsis.

Sterilization

the complete elimination all mircoogranisms INCLUDE spores

infection

the invasion of a susceptible host by pathogens or mircooragnisms, resulting in disease.

defining characteristics

what are the evidence of the problem

symptomatic

with symptoms

Prone postion

lies on the abdomen

colonization

occurs when a mircoorganism invades the host but does not cause infection

Temporary Tubes

-Nasogastric Tube (NG) -Small Bore Feeding Tube -Dobhoff (weighted) -Nasojejunostomy tube (NJ)

Nursing Diagnosis

-Ndx for communication: difficulty with communication- lacking skills in attending, listening, responding, or self-expression; inability to articulate, inappropriate verbalization; difficulty forming words; difficulty with comprehension

Professional Nursing Relationships

-Nurse-family relationships -Nurse -health care team relationships -Nurse- community relationships

Adapt Communication Techniques

-Patients who cannot speak clearly -Cognitive Impairment -Hearing impairment -Visual impairment -Unresponsive -Patients who do not speak English (or your language)

SBAR

-Situation, Background, Assessment, Recommendation -Provides a framework for a conversation among health care providers that fosters patient safety. -Consistent communication practices minimize risk with hand-off communication

Implementation

-Therapeutic communication techniques invoke specific responses that encourage expressions of feelings and ideas that convey acceptance and respect: *active listening- attentive to what patient is saying both verbally and nonverbally; use SOLER: sit facing pt, observe open posture, lean toward patient, establish and maintain intermittent eye contact, relax -Techniques- sharing: observation, empathy, hope, humor, and feelings; use touch/silence; provide info, clarify, focus, paraphrasing, validation, asking relevant questions, summarizing, self-disclosure, confrontation -Nontherapeutic Communication Techniques: asking personal questions, give personal opinions, changing subject, automatic responses, false reassurance sympathy, asking for explanations, approval/disapproval, defensive responses, passive/aggressive responses, arguing

Nursing Process: Assessment

-Through patient's eyes: Gather information, synthesize, apply critical thinking -Physical & emotional factors -Developmental factors -Sociocultural factor -Gender

Sublingual Med Administration:

-Under the tongue -Medication should not be swallowed -NO eating or drink anything until the medication is fully dissolved

Nasal Sprays

-Upright position with head slightly hyperextended -Spray during inhalation

Forms of Communication

-Verbal communication: vocabulary, denotative and connotative meaning, pacing, intonation, clarity & brevity, timing and relevance -Nonverbal: personal appearance, posture and gait, facial expressions, eye contact, gestures, sounds, territoriality & personal space -Metacommunication: a broad term that refers to all factors that influence communication. Awareness of influencing factors helps people better understand what is communicated

Oral Medication through an Enteral Tube:

-Verify whther the location of the tube (stomach or jejunum) --through x-ray, pH strips for NGT AND NJT. -Compatibility of location with medication. -Flush tube with at least 15ml sterile ater BEFORE and AFTER giving medication -Clamp enteral tube for at least for 30-60 mintues after giving medicine. -if liquid preparation is NOT available: crush tablets or simple open gelatin capsulues an dilute in sterile water/ DO NOT use tap water

Oral Medication Administration Key Points:

-Wear Gloves if medications are no packed -DO NOT remove wrapper until in patient's room -Administer medications on time: 30 MINS before or after scheduled time. -Discard medication, and repeat again if medication falls on the floor. -Make sure that patient has swallowed medications -Do not leave meds at bedside for pateint to take later.

intramuscular injection

-angle: 90 degrees -assess the muscle before giving the injection. -patient must be relaxed

Vulnerable zone (special care needed)

-face, neck, front of body

Zones of touch social (permission not needed)

-hands, arms, shoulders, back

Social Zone (9-12 feet)

-making rounds with a physician -sitting at the head of a conference table -conducting a family support group

Consent Zone (permission needed)

-mouth, wrists, feet

Physical surroundings in which communication takes place

-privacy level -noise level -comfort and safety level -distraction level

Personal Zone (18 inches-4 feet)

-sitting at a patient's bedside -Taking a patient's nursing history -teaching an individual patient -exchanging information at change of shift

Public zone (12 feet and Greater)

-speaking at a community forum -testifying at a legislative hearing -lecturing to a class students

intradermal injections

-used for skin testing (TB, allergy testing) -angle: 5 to 15 degrees with bevel up -site: inner forearm and upper back -a small bleb will form as you inject

Nurse Responsibilities--Meds

1. Assess whether the client can tolerate the meds 2. Administer meds accurrately and timely 3. Monitor for side effects 4. Know contraindications 5. Pateint teaching 6. Practice the "SIX rights" 7. Evalution (patient's response)

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

1. Hot baths 2. Heavy meals 5. Bending down to the floor

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

1. Include what mobility is impaired.

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail.

1. Perform hand hygiene.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 5. Encourage the client to assist as possible.

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

1. Place high-topped shoes on the client while in bed.

The Six "RIGHTS"

1. right meds 2. right dose 3. right patient 4. right route 5. right time 6. right documentation

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

2. Be certain the client does not hit the head on anything.

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

3. A registered nurse

While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion.

3. Have the client brush the hair and teeth.

During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain.

3. Healthy pregnant women should exercise at least 30 minutes on most if not all days.

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

3. Toward the far corner of the foot of the bed

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.

4. Hold the box as close to the body as possible.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.

4. No solo lifting of clients is permitted in the facility.

The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed her hands and donned sterile gloves to set up her sterile field. Which action would indicate break in sterile technique? A. Touching protective eyewear B. Staying with the sterile field/table once it's opened C. Touching sterile equipment on the sterile field D. Poruing sterile water into basin on the sterile field

A. Touching protective eyewear This is the only option that is not sterile

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain with baseline pain B. body language is incongruent with reports of pain relief C. family members report that pain has subsided D. vital signs have returned to baseline

A. you compare assessed pain with baseline pain. You evaluate by comparing what the patient's pain was before they took the medication verus after they took the medication

1. The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient needs to be evaluated immediately and may need intubation and mechanical ventilation. b. The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis but urine output has been low. c. The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable. d. This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour.

ANS: D, B, C, A The order of the nurses statements follows the SBAR format. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC:

6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patients bedding is changed when it becomes damp. c. Patient understands the need for increased fluid intake. d. Patients skin remains cool and dry throughout hospitalization.

ANS: A This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved. DIF: Cognitive Level: Apply (application) REF: 7 TOP: Nursing Process: Planning MSC:

2. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled dose was due. What type of problem does this represent? a. "Right time" b. "Right dose" c. "Right route" d. "Right medication"

ANS: A "Right time" is correct because the medication was given more than 30 minutes after the scheduled dose was due. "Dose" is incorrect because the dose is not related to the time the medication administration is scheduled. "Route" is incorrect because the route is not affected. "Medication" is incorrect because the medication ordered will not change. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 11 TOP: NURSING PROCESS: Implementation

Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior? a. The nurse aide is calling the older adult patient "honey." b. The nurse aide is facing the older adult patient when talking. c. The nurse aide cleans the older adult patient's glasses. d. The nurse aide allows time for the older adult patient to respond.

ANS: A Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Avoid terms of endearment such as "honey," "dear," "grandma," or "sweetheart." Facing an older adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older adult patients and should be encouraged, not stopped.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure

ANS: A In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient, but it is not the R in SOLAR. Reminisce is a therapeutic communication technique, especially when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many kinds of hope, and that meaning and personal growth can come from illness experiences. However, false reassurance can block communication.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR

ANS: A In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation.

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.

ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.

1. Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? a. Institutional policies b. Stability of the patient c. State nurse practice act d. LPN/LVN teaching abilities e. Experience of the LPN/LVN

ANS: A, B, C, E The nurse should assess the experience of LPN/LVNs when delegating. In addition, state nurse practice acts and institutional policies must be considered. In general, LPN/LVN scope of practice includes caring for patients who are stable, while registered nurses should provide most of the care for unstable patients. Since LPN/LVN scope of practice does not include patient education, this will not be part of the delegation process. DIF: Cognitive Level: Apply (application) REF: 14 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

1. When giving medications, the nurse will follow the rights of medication administration. The rights include the right documentation, the right reason, the right response, and the patient's right to refuse. Which of these are additional rights? (Select all that apply.) a. Right drug b. Right route c. Right dose d. Right diagnosis e. Right time f. Right patient

ANS: A, B, C, E, F Additional rights of medication administration must always include the right drug, right dose, right time, right route, and right patient. The right diagnosis is incorrect. DIF: COGNITIVE LEVEL: Remembering (Knowledge) REF: p. 9 TOP: NURSING PROCESS: Implementation

17. The nurse is providing education to nursing staff on quality care initiatives. Which statement would be the most accurate description of the impact of health care financing on quality care? a. Hospitals are reimbursed for all costs incurred if care is documented electronically. b. Payment for patient care is primarily based on clinical outcomes and patient satisfaction. c. If a patient develops a catheter-related infection, the hospital receives additional funding. d. Because hospitals are accountable for overall care, it is not nursings responsibility to monitor care delivered by others.

ANS: B Payment for health care services programs reimburses hospitals for their performance on overall quality-of- care measures. These measures include clinical outcomes and patient satisfaction. Nurses are responsible for coordinating complex aspects of patient care, including the care delivered by others, and identifying issues that are associated with poor quality care. Payment for care can be withheld if something happens to the patient tha is considered preventable (e.g., acquiring a catheter-related urinary tract infection). DIF: Cognitive Level: Apply (application) REF: 4 TOP: Nursing Process: Implementation MSC:

A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.

ANS: B Allowing time for the patient to respond will facilitate communication, especially for an older confused patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired or cognitively impaired patients.

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Pre-interaction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.

An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print.

ANS: B Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Intimate b. Personal c. Social d. Public

ANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary

ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication.

Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed

ANS: B, C, E, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations.

8. The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problems

ANS: C During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The other responses are examples of the planning, intervention, and evaluation phases of the nursing process. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: Nursing Process: Assessment MSC:

A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend

ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient.

Which person is the best referral for a patient who speaks a foreign language? a. A family member b. A speech therapist c. An interpreter d. A mental health nurse specialist

ANS: C Interpreters are often necessary for patients who speak a foreign language. A family member can lead to legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or highly anxious patients to communicate more effectively.

The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately.

ANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues.

8. The nurse is performing an assessment of a newly admitted patient. Which is an example of subjective data? a. Blood pressure 158/96 mm Hg b. Weight 255 pounds c. The patient reports that he uses the herbal product ginkgo. d. The patient's laboratory work includes a complete blood count and urinalysis.

ANS: C Subjective data include information shared through the spoken word by any reliable source, such as the patient. Objective data may be defined as any information gathered through the senses or that which is seen, heard, felt, or smelled. A patient's blood pressure, weight, and laboratory tests are all examples of objective data. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 6 TOP: NURSING PROCESS: Assessment

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed.

ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R).

7. When the nurse considers the timing of a drug dose, which factor is appropriate to consider when deciding when to give a drug? a. The patient's ability to swallow b. The patient's height c. The patient's last meal d. The patient's allergies

ANS: C The nurse must consider specific pharmacokinetic/pharmacodynamic drug properties that may be affected by the timing of the last meal. The patient's ability to swallow, height, and allergies are not factors to consider regarding the timing of the drug's administration. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 12 TOP: NURSING PROCESS: Assessment

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship.

15. The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility b. A residential care facility c. A transitional care facility d. An intermediate care facility

ANS: C Transitional care settings are appropriate for patients who need continued rehabilitation before discharge to home or to long-term care settings. The patient is no longer in need of the more continuous assessment and care given in acute care settings. There is no indication that the patient will need the permanent and ongoing medical and nursing services available in intermediate or skilled care. The patient is not yet independent enough to transfer to a residential care facility. DIF: Cognitive Level: Apply (application) REF: eTable 1-1 | eTable 1-2 | eTable 1-3 TOP: Nursing Process: Planning MSC:

Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression

ANS: C, D, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards.

The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious.

ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, a tracheostomy, and anxiety all contribute to communication concerns.

18. The nurse documenting the patients progress in the care plan in the electronic health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category? a. Patient-centered care b. Quality improvement c. Evidence-based practice d. Informatics and technology

ANS: D The nurse is displaying competency in the QSEN area of informatics and technology. Using a computerized information system to document patient needs and progress and communicate vital information regarding the patient with health care team members provides evidence that nursing practice standards related to the nursing process have been maintained during the care of the patient. DIF: Cognitive Level: Apply (application) REF: 5 TOP: Nursing Process: Implementation MSC:

A nurse uses SBAR during hand-offs. The purpose of SBAR is to a. Use common courtesy. b. Establish trustworthiness. c. Promote autonomy. d. Standardize communication.

ANS: D When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, a risk of miscommunication arises. Accurate communication is essential to prevent errors. SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

This pain is less than 6 months and considered protective., prevention of harm.

Acute Pain

A nurse is administering a liquid medication to an infant. Where will the nurse place the medication to prevent aspiration? A) Between the gum and the cheek B) In front of the teeth and gums C) On the front of the tongue D) Under the tongue

Ans: A Feedback: A dropper is used to give infants or very young children liquid medications while holding them in a sitting or semisitting position. The medication is placed between the gum and the cheek to prevent aspiration.

Of the following individuals, who can best determine the experience of pain? A) The person who has the pain B) The person's immediate family C) The nurse caring for the client D) The physician diagnosing the cause

Ans: A Feedback: According to McCaffery, an expert on pain, "Pain is whatever the experiencing person says it is, existing whenever he (or she) says it does." The only one who can be a real authority on whether and how a person experiences pain is that individual.

Pet therapy is commonly used in long-term facilities for distraction. If a client is experiencing pain and the pain is temporarily decreased while petting a visiting dog or cat, this is an example of which type of distraction technique? A) Tactile kinesthetic distraction B) Visual distraction C) Auditory distraction D) Project distraction

Ans: A Feedback: Examples of tactile kinesthetic distraction include holding or stroking a loved one, pet, or toy; rocking; and slow rhythmic breathing. Project distraction includes playing a challenging game or performing meaningful work. Visual distraction can be accomplished through reading or watching television. Auditory distraction may occur when one listens to music.

The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process? A) Prodromal stage B) Incubation period C) Full stage of illness D) Convalescent period

Ans: A Feedback: When given during the prodromal stage of certain viruses, antiviral medications can shorten the full stage of the illness.

A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made? A) The pubic area for growth of hair B) The head for nits on hair shafts C) The nails for evidence of cleanliness D) The body for evidence of abuse

Ans: B Feedback: Infestation with lice is called pediculosis. Pediculosis capitis infests the hair and scalp. Lice lay eggs, called nits, on the hair shafts. Nits are white or light gray and look like dandruff, but cannot be brushed or shaken off the hair.

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of which of the following pain syndromes? A) Complex regional pain syndrome B) Postherpetic neuralgia C) Trigeminal neuralgia D) Diabetic neuropathy

Ans: C Feedback: A symptom of trigeminal neuralgia is paroxysms of lightning-like stabs of in tense pain in the distribution of one or more divisions of the trigeminal nerve, the fifth cranial nerve. Pain is usually experienced in the mouth, gums, lips, nose, cheek, chin, and surface of the head and may be triggered by everyday activities like talking, eating, shaving, or brushing one's teeth.

A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection? A) Stress may adversely affect normal defense mechanisms. B) White blood cells provide resistance to certain pathogens. C) Intact skin and mucous membranes protect against microbial invasion. D) Age, race, sex, and hereditary factors influence susceptibility to infection.

Ans: C Feedback: Intact skin and mucous membranes provide resistance to certain pathogens. A major burn of 40% of the body provides multiple portals of entry for pathogens.

A nurse has completed morning care for a client. There is no visible soiling on her hands. What type of technique is recommended by the CDC for hand hygiene? A) Do not wash hands, apply clean gloves. B) Wash hands with soap and water. C) Clean hands with an alcohol-based handrub. D) Wash hands with soap and water, follow with handrub.

Ans: C Feedback: The CDC recommends that a health care worker whose hands are visibly soiled or contaminated with blood or body fluids wash the hands with soap and water. If the hands are not visibly soiled, an alcohol-based handrub can be used.

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect? A) Peak level B) Trough level C) Half-life D) Therapeutic range

Ans: D Feedback: A drug's therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. The peak level, or highest plasma concentration, of the drug should be measured when absorption is complete. The peak level may be affected by factors that affect drug absorption as well as the route of administration. The trough level is the point when the drug is at its lowest concentration, and this specimen is usually drawn in the 30- minute interval before the next dose. A drug's half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of the following would the nurse expect to find in the client? A) Diffuse scaling of the epidermis B) Itching and flaking of whitish scales C) Premature loss of hair D) Inflammation related to bites along the hairline

Ans: D Feedback: The nurse would find inflamed bites along the hairline in the client with pediculosis infestation. Diffuse scaling of the epidermis with itching and flaking of whitish scales is seen in clients who have dandruff. Hair loss is not a manifestation of pediculosis capitis.

A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which of the following is the most suitable angle when administering an intradermal injection? A) 180-degree angle B) 90-degree angle C) 45-degree angle D) 10-degree angle

Ans: D Feedback: When administering an intradermal injection, the nurse should hold the syringe almost parallel to the skin at a 10-degree angle with the bevel pointing upward. This facilitates delivering the medication between the layers of the skin and advances the needle to the desired depth. A nurse administers a subcutaneous injection at a 45-degree angle or a 90- degree angle to reach the subcutaneous level of tissue, depending on the length of the needle. The nurse will not be able to insert the injection if it is held at a 180-degree angle.

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? A. Provide her the opportunity to practice drawing up insulin B. Coach her to give herself positive messages about her ability to do this C. Bring her written material that clearly describes the steps of insulin administration D. Use therapeutic communication to help her express her feeling about giving herself an injection

B. Coach her to give herself positive messages about her ability to do this

The nurse is caring for a group of medical surgical patients. The patient most at risk for developing an infection is the patient who--- A. Is in observation chest pain B. Is recovering from a right total hip arthroplasty C. Has been admitted with dehydration D. Has been admitted for stablization of atrial fibrillation

B. Is recovering from a right total hip arthroplasty. This is because the patient's skin has been opened

When a smiling and cooperative patient complains of discomfort, nurse caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature B. Patients are the best judges of their pain C. Regular use of narcotic analgesics leads to drug addiction D. Amount of pain reflective of actual tissue damage.

B. Patients are the best judges of their pain.

What is the most effective way to control transmission of infection? A. Isolation precautions B. Identifying the infectious agent C. Hand Hygiene Practices D. Vaccinations

C. Hand hygeine practices

During the initial interview, you notice that the patient is griminacing and will not make eye contact with you. You want to get more information. Which question is most appropriate to help your assessment of the patient? A. Do you hurt? B. Do you feel like you're going to vomit? C. How are you feeling now? D. Do you need pain medication?

C. How are you feeling now? Open ended question can help them open up about what is going throught their head.

A self sufficient bedridden patient is unable to reach all body parts will need type of bath? A. Complete bed bath B. Shower C. Partial bed bath D. Sponge Bath

C. Partial bed bath Because they are still capable of doing some things on their own. You do some, they do some.

When working with an older adult, the nurse remembers to avoid: A. Touching the patient. B. Allowing the patient to reminisce. C. Shifting quickly from subject to subject. D. Asking the patient how he or she feels.

C. Shifting quickly from subject to subject.

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find the dressing is saturated with purulent drainage. Which action would be best on your part? A. Reinforce dressing with a clean, dry dressing and call the health care provider B. Remove wet. dressing and apply new dressing using sterile procedure C. Put on gloves before removing the old dressing; then obtain a wound culture D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

D. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

IM injections: Z-track method

Zig zag path that seals the needle track: -displaces the SQ tissue -medication cannot escape from muscle tissue -protects SQ tissue from irritating and discoloring medications

Hand Hygiene

before, after, and between direct contact with patient

sim's position

left side with the right knee drawn up toward the chest-- good for rectal procedure.

supine position

lies on the back

Immunocompromised

means having an imparied immune system

During the nursing process of Planning and Implementation, you want to make sure that the goals and outcomes are:

measurable, achieveable, and individualized

What is the fifth vital sign?

pain

Pain is whatever the_______

patient says it is.

Aerobic bacteria

requires oxygen for survival and for multipication sufficency to cause a diease

Nurse-Patient Relationship

- Caring relationships are the foundation of clinical nursing practice -therapeutic relationships promote a psychological climate that facilitates positive change and growth 1. Preinteraction phase- occurs before meeting the patient 2. Orientation phase- when the nurse and patient meet & get to know each other 3. Working phase- when the nurse and patient work together to solve problems and accomplish goals ( Plan of Care) 4. Termination Phase- occurs at her end of a relationship

Motivational Interviewing

- Technique holds promise for encouraging patients to share their thoughts, beliefs, fears, and concerns with the aim of changing their behavior -Interviewing is delivered in a nonjudgmental, guided communication approach

Buccal Med Administration:

-Against the mucous membranes -Alternate cheeks to avoid mucosal irritation -Do not chew or swallow medication -Do not take with any liquids

Intimate Zone

-genitalia, rectum

The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

3. Reduce the movement of the joint just until the point of slight resistance.

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

Identify behaviors that foster the development of trust. (Select all that apply.) A. Answer the call light promptly. B. Call the patient by first name unless requested otherwise. C. Do all the care as quickly as possible and leave the room so the patient can rest. D. Answer questions honestly. E. Demonstrate competence when doing treatments.

A. Answer the call light promptly. D. Answer questions honestly. E. Demonstrate competence when doing treatments.

The nurse is admitting a patient with an infectious disease process. What question would be appropriate for a nurse to ask this patient? A. Do you have a chronic disease, and how long have you had it? B. Do you have any childern living in the home? C. Did someone get you sick? D. Do you have any cultural or religious beliefs that will influence your care?

A. Do you have a chronic disease, and how long have you had it?

What factors can influence pain?

Age, fatigue, genes, neurologoical function. Anxiety, coping style, the level of pain tolerance, culutural meaning of pain

Transfer Techniques

Always assess the patient's ability to move or help with movement BUT always encourage them to do stuff on there own as well.

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A. Turning on the television to her favorite show B. Pulling the curtain to provide privacy C. Offering to discuss information about her condition D. Asking her why she is crying E. Sitting quietly by her bed and hold her hand

B. Pulling the curtain to provide privacy C. Offering to discuss information about her condition E. Sitting quietly by her bed and hold her hand

Which statement by the patient is an indication to use the Z-track method? A. "I'm really afraid that a big needle will hurt" B. "The last shot like that turned my skin colors" C. "I am allergic to many meds" D. "my legs are too obese for the needle to go through"

B. "The last show like that turned my skin colors"

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A. Say nothing and walk away. Find a different nurse to help you. B. "When you brush me off like that, it takes me even longer to do my job." C. "Why do you always put me down like that?" D. "I guess I just enjoy having you make fun of me."

B. "When you brush me off like that, it takes me even longer to do my job."

Which of the following statements would be most likely to block communication? A. "You look kind of tired today." B. "Why do you always put so much salt on your food?" C. "It sounds like this has been a hard time for you." D. "If you use your oxygen when you walk, you may be able to walk farther."

B. "Why do you always put so much salt on your food?"

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A. Providing information B. Clarifying C. Focusing D. Paraphrasing

B. Clarifying

The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease? A. Wear a gown, gloves, face mask, and goggles for interactions with the patient B. Use a dedicated blood pressure cuff that stays in the room and is used for the patient only C. Place the patient in a room with negative airflow D. Transport the patient quickly when going to the radiology department.

B. use a dedicated blood pressure cuff that stays in the room and is used for that patient only.

This pain is greater than 6 months, no longer protective, could be noncancer or cancer

Chronic Pain

Nutrition assesment should include:

Diet History, Sociculutual, food perfernces, socioeconomic status, medications/vitamins, drug use/alcohol consumption

Assess and examine patient's condition

During a medication error, what's the FIRST thing a nurse should do?

Fowler's Position

Elevated

Sharp pain, localized and distinct sensations

Fast myelinated A delta fibers

Active listening

being attentive to what a patient is saying both verbally and nonverbally

What no to do as a nurse while speaking to a patient:

Give false reassurance-"everything will be ok" Pass judgement Giving unsolicited advice Sympathy Argue

Putting on PPE:

Gown Mask Eyewear Gloves

Medical Diagnosis:

Identifies and treats diseases and conditions/always stays the same as long as the disease is present.

Levels of communication:

Intrapersonal communication: self talk Interpresonal communication: talking to patient/families/co-workers/physicans/ etc.. Small-group communication: an example is when it's time for rounds/discussing ethics with familiy members, when a patient passes away. Public communication: presentations with an audience Electronic communication: emailing, texting, calling, etc..

While helping a patient with perineal care for a female always remember that:

Its front to back and separate labia.

Which group of people do not accept blood products or transfusions?

Jehovah Witnesses

Which drugs have to counted and locked up in a secured cabinet or container? This drugs must also be recored when used, wasted, and amount remaining. -You need a second RN witness to prove the disposal of unused drug

Narcotics

abnormal processing of sensory input by peripheral or CNS and responds to adjuvant analgesics

Neuropathic

Pain that has normal processing of stimuli and responds to opioid and nonopioid

Nociceptive

Direct Care

interactions with patients

Routes of Administration Meds:

Oral: sublingual, buccal Topical: direct, body cavioty, (otic, opthalmic) Parenteral: Intradermal, Subcutaneous Intramuscular, Intravenous

Indirect Care

Performed away from the patient but on behalf of the patient

Communication is affected by:

Personal Perception Culture 5 senses Developmental Stages

SMART GOALS

S: SPECIFIC M: MEASURABLE A: ATTAINABLE R: REALTED TO DIAGNOSIS T: TIMED

PPE removal:

STEP 1: Remove one glove by grasping cuff anf pulling gloves inside out over hand. Discard glove. With ungloved hand tuck finger inside cuff of remaining glove and pull it off, inside out. STEP 2: Remove eyewear/face shield or goggles STEP 3: Untie waist and neck strings of gown. Discard in trash. Roll gown into itself. STEP 4: Remove mask (unless in airbone isolation). DO NOT touch surface of the mask. Perform hand hygiene.

Partial Bed Bath

Self-sufficient, bed ridden

SBAR- NURSE/ PHYSICIAN COMMUNICATION

Situtation Background Assessment Recommendation

Topical Medications for Elderly:

Skin is thinner, so remove patches slowly, to avoid tearing of skin. Absorption is more rapid with elderly. Apply lotions and creams gently to avoid bruising.

Poorly localized pain, burning, persistent pain

Slow small unmyelinated C fibers

Oral Route of Meds Administration:

Solid Forms: Tablets, Capsules, Caplet, Enteric Coated, Sustained Release Liquid Forms: Elixir Other Forms: Aerosol

Pain is always measured in what way?

Subjective

Now order

Which medication order is given when a medication is needed right away, but not STAT ?

PRN order

Which medication order is given when the patient require it?

Chain of Infection

The start of the infection is at infectious agent. Reservior-where the microoraganisms survive and multiple. Portal of exit: skin/mucous/GI tract/respiratory tract/blood/urinary tract. Mode of transmission: unwashed hands of providers Portal of entry: this is the same as portal of exit Host: Nuritional status/chronic disease/trauma/smoking

While helping a patient with perineal care for a male always remember that:

Tip to shaft & Retract foreskin to clean and return to natural position.

Prescriptions order

Which medication order is to be taken outside of the hospital?

Complete Bed Bath

Unconcious, paralyzed

Single- one time order

Which medication order is given one time ONLY for a specific reason

STAT order

Which medication order is given or carried out IMMEDIATELY in an emergency?

Standing or routine order

Which type of medication order is administered until the dosage is change or another medication is prescribed?

Disinfection

eliminates many and all mircoorganisms, EXCEPT bacterial spores

Mutual respect and trust

enable clarification and unambiguous communication. Establishing a relationship and face-to-face communication are important for teamwork

Nursing Diagnosis:

identifies the response to health and illnesses/can change day to day.

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

1. Decrease in blood pressure when moving from supine to standing

Transdermal Patches

1. Prep Skin 2. Use sterile technique for open wounds 3. Remove old patch before applying new. 4. Ask about patches during the medication history 5. Apply a label to the patch with date/time and your initials

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.

1. slightly higher.

Collecting a Physical Exam

1. vital signs, height, weight 2. inspection 3. palpation 4. percussion 5. auscultation 6. patient's behavior 7. diagnostic and lab data 8. standarized risk assessment

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

3. Measure the calf and compare to the opposite calf.

3. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patients input. The patient states, How is this different from what the doctor does? Which response would be most appropriate for the nurse to make? a. The role of the nurse is to administer medications and other treatments prescribed by your doctor. b. The nurses job is to help the doctor by collecting information and communicating any problems that occur. c. Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor. d. In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.

ANS: D This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing role but do not accurately describe the nurses role in the health care system. DIF: Cognitive Level: Understand (comprehension) REF: 3 TOP: Nursing Process: Implementation MSC:

4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus. Which statement best illustrates an outcome criterion for this patient? a. The patient will follow instructions. b. The patient will not experience complications. c. The patient will adhere to the new insulin treatment regimen. d. The patient will demonstrate correct blood glucose testing technique.

ANS: D "Demonstrating correct blood glucose testing technique" is a specific and measurable outcome criterion. "Following instructions" and "not experiencing complications" are not specific criteria. "Adhering to new regimen" would be difficult to measure. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 8 TOP: NURSING PROCESS: Planning

Which misconception is common in clients in pain? A) "I will get addicted to pain medications." B) "I need to ask for pain medications." C) "The nurses are here to help relieve the pain." D) "I do not have to fight the pain without help."

Ans: A Feedback: Many misconceptions interfere with the client's ability to communicate pain. A common misconception is that "if I ask for something for pain, I may become addicted to the medication."

What is the name of the process by which a drug moves through the body and is eventually eliminated? A) Pharmacology B) Pharmacotherapeutics C) Pharmacokinetics D) Pharmacodynamics

Ans: C Feedback: Pharmacokinetics is the process by which a drug moves through the body and is eventually eliminated.

A patient has just undergone an appendectomy. When dicussing with the patient several pain relief interventions, the most appropriate recommendation would be: A. Adjunctive therapy B. Nonopioids C. NSAIDs D. PCA pain management

D. PCA pain management PCA is the only that can give the patient opioid meds

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? A. Summarize what you have talked about in the previous sessions B. Review his medical record and talk to other nurses about how he is reacting C. Explore his feelings about losing his leg D. Talk with him about his favorite hobbies

D. Talk with him about his favorite hobbies

When assessing a patient's skin, the nurse needs to know that- A. Restricted movement can increase blood circulation B. Paralyzed patients have normal sensory function C. Dry Skin can lead to rapid skin healing D. Moisture on the skin can lead to skin maceration

D. moisture on the skin can lead to skin maceration. You need to always make sure patient's skin is clean and dry.

Provider

Who writes medications orders/checks accuracy of dosing and medication?

Topical Medications:

-Always wear gloves! -Assess sites where previous medication was applied: Irritation or skin breakdown/rotate sites to prevent skin irriation.

Elements of Professional Communication

-Appearance, demeanor, and behavior -Courtesy -Use of names -Trustworthiness -Autonomy & responsibility -Assertiveness

Nasal Drops

-Before administration: blow nose gently to clear mucus and secretion. -Supine position with head tilted back -Avoid contamination: keep dropper away from the nares

Communication & Interpersonal Relationships

-Communication establishes caring, healing relationship -Ability to relate to others important for interpersonal communication -Communication includes: posture, expressions, attitudes, words, gestures, have ability to hurt or heal

Developing Communication Skills

-Critical thinking -Perseverance & Creativity -Self-confidence -Humility -Integrity -thinking influenced by perception: 5 senses, culture & education -Perceptual bias -Emotional intelligence

Permanent Tubes

-Gastrostromy Tubes -PEG or G-tube -Jejunostomy tubes

Planning

-Goals and outcomes: specific and measurable (must have time frame- long or short term goal)) -Setting of priorities -Teamwork and collaboration

intimate Zone (0-8 inches)

-Holding crying infant -performing physical assessment -bathing, grooming, dressing, feeding, and toileting a patient

Levels of Communication

-Intrapersonal: within individual; self-talk -Interpersonal: one-to-one interaction between 2 people -Transpersonal: Interaction that occurs within a person's own spiritual domain -Small Group: ex: breast feeding group, interactions within a small number of people -Public: interactions with an audience -Electronic

Therapeutic Communication

-Promotes personal growth & attainment of patients health-related goals -Occurs within a healing relationship between nurse and patient: empathy, healing, hope to patients, active listening, open-ended questions, no- false reassurance

Topical Route: Rectal Suppository

-Provide for privacy -Explain procedure to client -Place client in Sim's position -Apply clean gloves -Lubricate the tip, round end inserted first

Interpersonal Variables: Circular Transactional Model Components

-Referent -Sender and receiver -Message -Channels -Feedback: message that receiver returns; indicates whether the receiver understood the meaning of the sender's message -Environment

Parenteral Route

-Syringes -Needles -Vitals -Mixing medications -Administering injections

Considerations Prior to Meds Administratation:

1. Past Medical History 2. Allgeries 3. Medication History 4. Diet History 5. Patient's current condition- anything thats gonna affect their mental or physical status 6. Attitudes-fearful of adverse effects, refusal, etc.. 7. Learning needs-Questions that patients ask about meds/teach patient about how to the medication/

Essential Componenets of Medication order:

1. Patients name 2. Medical Record Number 3. Date and Time of Order 4. Name of Medication 5. Dosage of medication 6. Route 7. Frequency of administration 8. Provider's signature

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

1. Institute an exercise plan that includes weight-bearing activities.

Health History Sequence

1. biographical data 2. chief complaint 3. present health/history of present illness 4. past history 5. family history 6. review of symptoms 7. acitivies of daily living 8. health promotion

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

2. Move the cane forward while the body weight is between both legs. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

2. Orthopneic position across the overbed table

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

2. Palpate for bladder fullness.

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

3. Lock the brakes on the bed.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

3. Range-of-motion exercises to prevent worsening of contractures

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

3. The client who fell from a house, sustaining a fractured tibia

What does the nurse do to verify an order for a medication listed on a medication administration record (MAR)? A) Compare it with the original physician's order. B) Ask another nurse what the drug is. C) Look up the drug in a textbook. D) Call the pharmacist for verification.

Ans: A Feedback: In many institutions, the medication order is copied onto the client's medication record. The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original physician's order.

A client has an order for a narcotic analgesic every three to four hours and he received his last dose three hours earlier. Which of the following actions is most appropriate for the nurse to take in response to the client's request for pain medication on his first postoperative day? A) Provide the client with pain medication B) Tell the client that the pain cannot be severe C) Document and ask the client to wait one hour D) Contact the physician for a change in medication

Ans: A Feedback: Inadequate or poor pain assessment is a leading factor in poor pain control, because the health care professional may not know a client has pain. The nurse must provide the next dose of pain medication.

7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? a. To determine if interventions have been effective in meeting patient outcomes b. To document the nursing care plan in the progress notes of the medical record c. To decide whether the patients health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory

ANS: A Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: Nursing Process: Evaluation MSC:

5. Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed with hypertension? a. Providing education on keeping a journal of blood pressure readings b. Setting goals and outcome criteria with the patient's input c. Recording a drug history regarding over-the-counter medications used at home d. Formulating nursing diagnoses regarding deficient knowledge related to the new treatment regimen

ANS: A Education is an intervention that occurs during the implementation phase. Setting goals and outcomes reflects the planning phase. Recording a drug history reflects the assessment phase. Formulating nursing diagnoses reflects analysis of data as part of planning. DIF: COGNITIVE LEVEL: Applying (Application) REF: pp. 8-9 TOP: NURSING PROCESS: Implementation

The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations.

ANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique.

Nurses who make the best communicators a. Develop critical thinking skills. b. Like different kinds of people. c. Learn effective psychomotor skills. d. Maintain perceptual biases.

ANS: A Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques and communication involves more than psychomotor skills. Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators.

A nurse has seen several clients at a community health center. Which of the clients would be most at risk for developing an infection? A) An older adult with several chronic illnesses B) An infant who has just received first immunizations C) An adolescent who had a basketball physical D) A middle-aged adult with joint pain and stiffness

Ans: A Feedback: Many factors affect the risk for infection, including age, sex, race, and heredity. Neonates and older adults, especially those who have preexisting illnesses, appear to be more vulnerable to infection.

Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve such things as setting the tone for the relationship by adopting a warm, empathetic, caring manner; recognizing that the initial relationship is often superficial, uncertain, and tentative; or expecting the patient to test the nurse's competence and commitment. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. This phase can involve such things as encouraging and helping the patient express feelings about his or her health, encouraging and helping the patient with self-exploration, or providing information needed to understand and change behavior. The termination phase occurs during the ending of the relationship. This phase can involve such things as reminding the patient that termination is near, evaluating goal achievement with the patient, or reminiscing about the relationship with the patient.

2. The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication c. Identifies the patient by the room number on the door d. Checks lab test results before administering a diuretic e. Gives the patient a list of current medications upon discharge

ANS: A, B, D, E National Patient Safety Goals have been established to promote safe delivery of care. The nurse should use at least two reliable ways to identify the patient such as asking the patients full name and date of birth before medication administration. Other actions that improve patient safety include performing hand hygiene, disposing of unlabeled medications, completing appropriate assessments before administering medications, and giving a list of the current medicines to the patient and caregiver before discharge. DIF: Cognitive Level: Apply (application) REF: 15 TOP: Nursing Process: Implementation MSC:

16. A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose appropriate foods. b. Help the patient with a daily bath and oral care. c. Check the patients feet for signs of breakdown. d. Teach the patient how to monitor blood glucose.

ANS: B Assisting with patient hygiene is included in home health-aide education and scope of practice. Assessment of the patient and instructing the patient in new skills, such as diet and blood glucose monitoring, are complex skills that are included in registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 14 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC:

1. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. The nursing process is a scientific-based method of diagnosing the patients health care problems. b. The nursing process is a problem-solving tool used to identify and treat patients health care needs. c. The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans. d. The nursing process is used primarily to explain nursing interventions to other health care professionals.

ANS: B The nursing process is a problem-solving approach to the identification and treatment of patients problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing theory or explain nursing interventions to other health care professionals. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: Nursing Process: Implementation MSC:

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit

ANS: B A patient with impaired verbal communication has defining characteristics such as an inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending. Hopelessness implies that the patient has no hope for the future. Hearing loss is not a nursing diagnosis. Just because a patient has garbled speech does not mean that a hearing loss has occurred; a physical problem such as a stroke could cause the garbled speech. Self-care deficit does not apply in this situation because this usually relates to bathing, grooming, etc.

A college-aged student has influenza. At what stage of the infection is the student most infectious? A) Incubation period B) Prodromal stage C) Full stage of illness D) Convalescent period

Ans: B Feedback: A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific. During this phase, the person often does not realize that he or she is contagious. As a result, the infection spreads.

A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong.

ANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe.

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."

ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic.

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group

ANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process.

5. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leaving my children with my parents. Which action should the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Gather more data about the patients feelings about the child-care arrangements. d. Call the patients parents to determine whether adequate child care is being provided.

ANS: C Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurses first action should be to obtain more information. The other actions may be appropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Apply (application) REF: 6 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:

11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? a. Monitor for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. c. Obtain the patients blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready to increase the activity level.

ANS: C UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse education and scope of practice and cannot be delegated. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

6. The medication order reads, "Give ondansetron (Zofran) 4 mg, 30 minutes before beginning chemotherapy to prevent nausea." The nurse notes that the route is missing from the order. What is the nurse's best action? a. Give the medication intravenously because the patient might vomit. b. Give the medication orally because the tablets are available in 4-mg doses. c. Contact the prescriber to clarify the route of the medication ordered. d. Hold the medication until the prescriber returns to make rounds.

ANS: C A complete medication order includes the route of administration. If a medication order does not include the route, the nurse must ask the prescriber to clarify it. The intravenous and oral routes are not interchangeable. Holding the medication until the prescriber returns would mean that the patient would not receive a needed medication. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 12 TOP: NURSING PROCESS: Implementation

12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patients urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit

ANS: C Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP. The other assignments made by the RN are appropriate. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

ANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them.

4. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independently

ANS: C The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Apply (application) REF: 7 TOP: Nursing Process: Diagnosis MSC:

9. Which nursing diagnosis statement is written correctly? a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altered urinary elimination related to urinary tract infection

ANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patients response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The response beginning Risk for impaired tissue integrity uses the defining characteristic as the etiology. DIF: Cognitive Level: Understand (comprehension) REF: 7 TOP: Nursing Process: Diagnosis MSC:

2. Place the phases of the nursing process in the correct order, with 1 as the first phase and 5 as the last phase. (Select all that apply.) a. Planning b. Evaluation c. Assessment d. Implementation e. Nursing Diagnoses

ANS: C, E, A, D, B The nursing process is an ongoing process that begins with assessing and continues with diagnosing, planning, implementing, and evaluating. DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 4 TOP: NURSING PROCESS: General

2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. Inferences from clinical research studies are used as a guide. b. Patient care is based on clinical judgment, experience, and traditions. c. Data are evaluated to show that the patient outcomes are consistently met. d. Recommendations are based on research, clinical expertise, and patient preferences.

ANS: D Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical judgment based on the nurses clinical experience is part of EBP, but clinical decision making should also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects. DIF: Cognitive Level: Remember (knowledge) REF: 11 TOP: Nursing Process: Planning MSC:

13. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.

ANS: D The education and scope of practice of the LPN/LVN include activities such as obtaining glucose testing using a finger stick. Patient teaching and the initial assessment and development of the plan of care are nursing actions that require registered nurse education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 15 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:

14. A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the services that the patient receives in the hospital and at home.

ANS: D The role of the case manager is to coordinate the patients care through multiple settings and levels of care to allow the maximal patient benefit at the least cost. The case manager does not provide direct care in either the acute or home setting. The case manager coordinates and advocates for care but does not determine what medical care is needed; that would be completed by the health care provider or other provider. DIF: Cognitive Level: Apply (application) REF: 15 TOP: Nursing Process: Implementation MSC:

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.

ANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message.

1. The nurse is writing a nursing diagnosis for a plan of care for a patient who has been newly diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing diagnosis? a. Anxiety b. Anxiety related to new drug therapy c. Anxiety related to anxious feelings about drug therapy, as evidenced by statements such as "I'm upset about having to test my blood sugars." d. Anxiety related to new drug therapy, as evidenced by statements such as "I'm upset about having to test my blood sugars."

ANS: D Formulation of nursing diagnoses is usually a three-step process. "Anxiety" is missing the "related to" and "as evidenced by" portions of defining characteristics. "Anxiety related to new drug therapy" is missing the "as evidenced by" portion of defining characteristics. The statement beginning "Anxiety related to anxious feelings" is incorrect because the "related to" section is simply a restatement of the problem "anxiety," not a separate factor related to the response. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 7 TOP: NURSING PROCESS: Nursing Diagnosis

3. The nurse has been monitoring the patient's progress on a new drug regimen since the first dose and documenting the patient's therapeutic response to the medication. Which phase of the nursing process do these actions illustrate? a. Nursing diagnosis b. Planning c. Implementation d. Evaluation

ANS: D Monitoring the patient's progress, including the patient's response to the medication, is part of the evaluation phase. Planning, implementation, and nursing diagnosis are not illustrated by this example. DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: pp. 13-14 TOP: NURSING PROCESS: Evaluation

Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation.

ANS: D Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power." Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions

10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symptoms of the problem

ANS: D When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The subjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. DIF: Cognitive Level: Remember (knowledge) REF: 8 TOP: Nursing Process: Diagnosis MSC:

A client in the emergency department is diagnosed with a myocardial infarction (heart attack). The client describes pain in his left arm and shoulder. What name is given to this type of pain? A) Cutaneous pain B) Referred pain C) Allodynia D) Nociceptive

Ans: B Feedback: Referred pain is pain that is perceived in an area distant from the point of origin. Pain associated with a myocardial infarction is frequently referred to the neck, shoulder, or arm.

Which of the following clients would be classified as having chronic pain? A) A client with rheumatoid arthritis B) A client with pneumonia C) A client with controlled hypertension D) A client with the flu

Ans: A Feedback: Chronic pain is pain that may be limited, intermittent, or persistent but that lasts beyond the normal healing period. Acute pain is generally rapid in onset and varies in intensity from mild to severe. After its underlying cause is resolved, acute pain disappears. It should end once healing occurs.

A homeless person uses the soap and towels in a public restroom to wash up. This is an example of which type of factor affecting personal hygiene practices? A) Socioeconomic class B) Culture C) Developmental level D) Health state

Ans: A Feedback: A person's socioeconomic class and financial resources often define the hygiene options available to him or her. Access to assistive services, such as shelters, may be limited for some clients. For example, homeless people, who often carry all their belongings in a car or shopping cart, may welcome the warm running water and soap available in roadside or public restrooms.

The nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse notes that the client's respiratory rate is 10 breaths per minute. The client is somnolent, with minimal response to physical stimulation. The nurse should prepare to administer which of the following medications? A) Intravenous naloxone (Narcan) B) Intravenous flumazenil (Romazicon) C) Oral modafinil (Provigil) D) Nebulized albuterol (Proventil)

Ans: A Feedback: Albuterol is a bronchodilator and not appropriate for this clinical situation.

A nurse is providing perineal care to a female client. In which direction would the nurse move the washcloth? A) From the pubic area toward the anal area B) From the anal area to the pubic area C) From side to side within the labia D) The direction does not make any difference

Ans: A Feedback: Always proceed from the least contaminated area to the most contaminated area. For a female client, spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over to the genital area.

Which client would be most likely to have decreased anxiety about, and response to, pain as a result of past experiences? A) One who had pain but got adequate relief B) One who had pain but did not get relief C) One who has had chronic pain for years D) One who has had multiple pain experiences

Ans: A Feedback: An individual's experience of pain in the past, and the qualities of that experience, profoundly affect new pain experiences. Some clients have experienced severe acute or chronic pain in the past but received immediate and adequate pain relief. These clients are generally unafraid of pain and initiate appropriate requests for assistance.

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which of the following actions is correct? A) Remove the antiembolism stockings during the bath. B) Leave the antiembolism stockings in place, but be sure to remove all wrinkles. C) Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse. D) Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.

Ans: A Feedback: Antiembolism stockings should be removed periodically to allow for assessment.

A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the following techniques should the nurse employ when providing this care? A) Use an antifungal powder on the client's feet if necessary. B) Carefully remove any corns or calluses that are present. C) Soak the client's feet for 15 to 20 minutes prior to cleansing. D) Avoid using soaps or commercial cleansers whenever possible.

Ans: A Feedback: Antifungal foot powders may be used when indicated, and it is appropriate to use soap and/or cleansers when providing foot care. Corns and calluses should not be removed, and the nurse should avoid soaking the client's feet.

Which statement accurately describes pain experienced by the older adult? A) Boredom and depression may affect an older person's perception of pain. B) Residents in long-term care facilities have a minimal level of pain. C) The older client has decreased sensitivity to pain. D) A heightened pain tolerance occurs in the older adult.

Ans: A Feedback: Boredom, loneliness, and depression may affect an older person's perception and report of pain. One myth held by many to be true is that older clients have a decreased sensitivity to pain and therefore a heightened pain tolerance. Numerous older adult clients residing in long-term care facilities have significant pain that negatively affects their quality of life.

A nurse is brushing the hair of a client admitted to the health care facility following a fracture in the hand. The nurse implements this action based on the understanding that brushing the hair achieves which of the following? A) Facilitates oil distribution B) Cleans hair and scalp C) Removes excess oil D) Cleans the hair of dirt

Ans: A Feedback: Brushing the hair facilitates oil distribution along the hair shaft more effectively than combing, as well as massages the scalp and stimulates circulation. Shampooing cleans the hair and scalp, helps get rid of excess oil, and cleans the hair of dirt. It provides a relaxing, soothing experience for the client.

The nurse and nursing aid are providing perineal care for an incontinent client. What information is important for the nurse to consider when providing perineal care? A) Apply moisture barriers to the skin of the perineal area. B) Provide excessive hydration to the skin of the perineal area. C) Wash the perineal area frequently with soap and water. D) Aggressively cleanse the perineal area with a washcloth or towel.

Ans: A Feedback: Care to the perineal area for an incontinent client includes the use of moisture barriers, skin cleansers, and moisturizers and the avoidance of soap or friction. Measures should be followed to reduce overhydration because this will increase the risk for perineal damage and skin breakdown.

The medical chart of a newly admitted client notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's wound culture and sensitivity. How should the nurse respond to this situation? A) Withhold the medication until the potential drug allergy has been addressed by the care team. B) Administer the medication and increase the frequency of assessments in the hours that follow. C) Substitute an antibiotic with similar action, but which is from a different drug family. D) Discuss the severity, signs and symptoms of the drug allergy with the client in order to ascertain the risks of administration.

Ans: A Feedback: Client safety is paramount, and the nurse has a responsibility to ensure that a potential threat of harm is identified and dealt with promptly. It is beyond the nurse's scope of practice to independently substitute another drug, and it would be unsafe to administer the drug in light of this revelation. The nurse would not administer the drug even if the client stated that his or her allergy is mild.

What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled for effective hand hygiene? A) 20 seconds B) 30 seconds C) 1 minute D) 5 minutes

Ans: A Feedback: Effective handwashing requires at least a 20-second scrub with plain soap or disinfectant and warm water. Hands that are visibly soiled need a longer scrub.

Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant. What is an appropriate consideration when assisting the client with morning hygiene? A) Provide the client with an electric shaver. B) Provide the client with a firm bristled toothbrush. C) Do not allow the client to shower. D) Avoid massaging the client's back with lotion.

Ans: A Feedback: Electric shavers are recommended when a client is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the client is more prone to bleeding, and the firm bristles may lead to bleeding. The client should be allowed to shower, unless there are other contraindications. A back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.

The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle baby powder in the perineal area. Which of the following actions is correct? A) Inform the client that baby powder is not used because it may become a medium for bacterial growth. B) Carefully apply baby powder to skin folds only. C) Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder. D) Apply a generous amount of baby powder to all areas where skin touches skin.

Ans: A Feedback: Failing to pull the foreskin back into place may cause tissue damage to the penis.

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which of the following techniques for cleaning the penis is correct? A) Retract the foreskin while washing the penis; then, immediately pull the foreskin back into place. B) Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry; then, replace the foreskin in its original position. C) Avoid retraction of the foreskin because injury and scarring could occur. D) Soak the end of the penis in warm water before cleaning the shaft of the penis.

Ans: A Feedback: Failing to pull the foreskin back into place may cause tissue damage to the penis.

Which client is most likely to require hospitalization related to problems associated with the feet? A) A client with peripheral vascular disease B) A client with osteoporosis C) A client with asthma D) A client with diabetes insipidus

Ans: A Feedback: Foot problems, particularly common in people with diabetes and peripheral vascular disease, often require hospitalization.

A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA) infection after hospitalization for hip replacement surgery. What name is given to this type of infection? A) Nosocomial B) Viral C) Iatrogenic D) Antimicrobial

Ans: A Feedback: For various reasons and sometimes despite best efforts, certain clients in health agencies develop infections that were not noted to be present on admission. The term nosocomial infection is used to describe a hospital-acquired infection.

The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route? A) Flush the tube with water between each drug administered. B) Position the client supine prior to administering the drug. C) Administer the medication at a cold temperature. D) If connected to suction, do not reconnect to suction for five minutes after drug administration.

Ans: A Feedback: Guidelines to consider when administering a drug via nasogastric tube include positioning the client with the head of the bed elevated, administering the medication at room temperature for the client's comfort, flushing the tube with water between each drug administered, and avoiding the use of suction for 20 to 30 minutes after the drug is administered.

A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow? A) Standard precautions B) Droplet precautions C) Contact precautions D) Airborne precautions

Ans: A Feedback: Health care personnel follow standard precautions whenever there is the potential for contact with the following: blood; body fluids except sweat, regardless of whether they contain visible blood; non-intact skin; and mucous membranes. Standard precautions are measures for reducing the risk of microorganism transmission from both recognized and unrecognized sources of infection. The other three precautions are transmission-based precautions, which are measures for controlling the spread of infectious agents from clients known to be, or suspected of being, infected with highly transmissible or epidemiologically important pathogens.

A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate? A) A reservoir B) An infectious agent C) A portal of exit D) A portal of entry

Ans: A Feedback: Humans may act as reservoirs for an infectious agent and not exhibit any manifestations of the disease. They are considered carriers and can transmit the disease. In this case, the woman is the reservoir for the HIV virus.

What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high? A) Liquid or bar hand soap B) Cold water C) Hot water D) Antimicrobial products

Ans: D Feedback: Using handwashing products that contain an antimicrobial or antibacterial ingredient is recommended in any setting where the risk of infection is high. When present in certain concentrations, these agents can kill bacteria or suppress their growth.

The nurse assists the client to the bathroom sink to perform morning care. The nurse observes the client wash his face, arms, abdomen, and legs. The nurse washes the client's back and rectal area and applies soap to the back. The client brushes his teeth and ambulates to a chair in his room with assistance. How will the nurse describe the morning care on the client's chart? A) Partial care B) As-needed care C) Self-care D) Complete care

Ans: A Feedback: Morning care is categorized as self-care, partial care, or complete care. Clients identified as partial care most often receive morning care at the bedside, or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach. Clients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. Clients identified as complete care require nursing assistance with all aspects of personal hygiene. In additional to scheduled care, the nurse will offer care as needed.

A nurse is performing a sterile dressing change. If new sterile items or supplies are needed, how can they be added to the sterile field? A) With sterile forceps or hands wearing sterile gloves B) By carefully handling them with clean hands C) With clean forceps that touch only the outermost part of the item D) By clean hands wearing clean latex gloves

Ans: A Feedback: Once a sterile field is established, objects on a field may only be handled by using sterile forceps or with hands wearing sterile gloves. The other choices would contaminate the sterile field.

A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called "the kissing disease." The nurse explains that the organisms causing this disease were transmitted by: A) direct contact. B) indirect contact. C) airborne route. D) vectors.

Ans: A Feedback: Organisms can enter the body by way of the contact route, either directly or indirectly. Direct contact involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual intercourse. Mononucleosis can be spread through direct contact with saliva, mucus from the nose and throat, and sometimes tears.

Why is acute pain said to be protective in nature? A) It warns an individual of tissue damage or disease. B) It enables the person to increase personal strength. C) As a subjective experience, it serves no purpose. D) As an objective experience, it aids diagnosis.

Ans: A Feedback: Pain is a subjective experience. Acute pain, lasting from a few minutes to less than six months, warns an individual of tissue damage or organic disease. After its underlying cause is resolved, acute pain disappears.

While conducting an oral assessment, a nurse notices the client's gums are red and swollen, some teeth are loose, and blood and pus can be expressed when the gums are palpated. What condition do these symptoms indicate? A) Periodontitis B) Plaque C) Halitosis D) Caries

Ans: A Feedback: Periodontitis is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; and loose teeth.

An older adult resident of a long-term care facility has recurring problems with dry skin. Which of the following strategies should the nursing staff utilize in order to help meet the resident's hygiene needs while preventing skin dryness? A) Use a nonsoap cleaning agent. B) Use organic soap and shampoo. C) Bathe the client more often, but without using soap or shampoo. D) Provide the client with bed baths rather than tub baths.

Ans: A Feedback: Soap cleans the skin, but while it removes dirt from the surface, it affects the lipids that are present on the skin, and the skin pH. This contributes to drier skin, damaging the barrier function of the skin. The substitution of a nonsoap, emollient cleaning agent is an easy way to prevent drying and damage to the skin. An organic soap is not necessarily less drying to the skin. It would be inappropriate to forego the use of any cleaning products whatsoever. Providing a bed bath rather than a tub bath will not necessarily minimize dry skin.

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following? A) Somatic pain B) Cutaneous pain C) Visceral pain D) Phantom pain

Ans: A Feedback: Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the client.

Which of the following statements about glove use and hand hygiene is true? A) Artificial fingernails should not be worn by staff involved in direct client care. B) Nonsterile gloves can be decontaminated with alcohol-based hand rub, but must be changed between clients. C) Use of alcohol-based hand rubs is appropriate after using the restroom. D) The use of sterile gloves reduces the need for hand hygiene.

Ans: A Feedback: The CDC Guideline for Hand Hygiene in Health-Care Settings (2002) specifies that health care personnel involved in patient care should not wear artificial nails because they are more likely to be associated with higher bacterial counts.

A nurse is assessing a client during a health care camp. The nurse observes that the client has poor hygiene and an itchy, infected scalp. Which of the following should the nurse ask the client to do? A) Wash hair daily B) Use dry shampoo C) Use oil-based shampoo D) Use anti-lice shampoo

Ans: A Feedback: The client with a scalp infection should be advised to shampoo her hair daily with a mild shampoo. For occasional use, the nurse will use dry shampoos, which are applied to the hair as a powder. Other options include aerosol spray or foam. Anti-lice shampoos or oil-based shampoos are not used for fear of aggravating the infection.

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention? A) Gate control theory B) Neuromodulation C) Large/small fiber theory D) Prostaglandin stimulation

Ans: A Feedback: The gate control theory of pain describes the transmission of painful stimuli. Nursing interventions, such as massage or a warm compress to a painful lower back, stimulate large nerve fibers to close the gate, thus blocking nerve impulses from that area.

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client? A) Manipulation of the client's ear to straighten the auditory canal B) Dilution of the medication drops before instilling in the client's ear C) Position in which the client remains until medication reaches the eardrum D) Amount of time before instilling medication in the client's opposite ear

Ans: A Feedback: The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription, and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum, and the amount of time before instilling medication in the client's opposite ear, does not differ with the age of the client.

A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which of the following precautions should the nurse take when storing narcotic medications? A) In a double-locked drawer B) In a single container C) In a self-contained packet D) In disguised containers

Ans: A Feedback: The nurse should place narcotic drugs in a double-locked drawer. Narcotics are controlled substances, meaning that federal laws regulate their possession and administration. Health care facilities keep narcotics in a double-locked drawer, box, or room on the nursing unit. A narcotic drug may not be placed in a single container, self-contained packet, or in disguised containers.

A nurse is assessing a mentally challenged, adult client who is in pain after a fall. Which of the following scales should the nurse use to assess the client's pain? A) Pain Assessment in Advanced Dementia (PAINAD) B) Wong-Baker Faces scale C) Linear Scale D) Numeric Scale

Ans: A Feedback: The nurse should use the Pain Assessment in Advanced Dementia (PAINAD) scale, which was developed for cognitively impaired clients. The Wong-Baker FACES scale is best for children and clients who are culturally diverse. Nurses generally use a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult clients who can express their pain intensity in words, numbers, or linear fashion with the help of the respective scales.

Which of the following clients receives a drug that requires parenteral route? A) A woman who has been ordered intravenous antibiotics B) A woman who takes a diuretic pill each morning C) A man with emphysema who uses nebulized bronchodilators D) A man who has an antifungal ointment applied to his skin rash daily

Ans: A Feedback: The parenteral route includes such methods as intravenous administration and injections. Pills are given by an oral route and a nebulizer is administered by the pulmonary route. An ointment is a topical medication.

The nurse has just completed programming of a patient-controlled analgesia (PCA) pump using prescribed parameters. Which of the following actions should you take next? A) Verify the settings with another nurse. B) Document implementation of the PCA on the client's chart. C) Attach the PCA pump tubing to the client's intravenous access device. D) Check the pump's electrical cords for cracks, splits, or fraying.

Ans: A Feedback: This action should be performed before programming is initiated.

The nurse talks with a client who states, "My primary care provider wants me to try a TENS unit for my pain. How can electricity decrease my pain?" Which of the following responses is most appropriate? A) "The mild electrical impulses block the pain signal before it can reach the brain." B) "The electrode patches generate heat and decrease muscle tension." C) "The machine tricks the mind into believing the pain does not exist." D) "The electricity produces numbness and alters tissue sensitivity."

Ans: A Feedback: This statement explains the use of cold therapy for pain.

A nurse is converting the dosage of a medication to a different unit in the metric system. The medication label specifies the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse give? A) 1 B) 2 C) 5 D) 10

Ans: A Feedback: To convert in the metric system from a smaller unit to a larger unit, move the decimal point three places to the right. As 0.5 g = 500 mg, the nurse would administer one tablet.

An older adult client with Parkinson's disease is unable to take care of himself. The client frequently soils his bed and is unable to clean himself independently. How should the nurse in this case ensure the client's perineal care? A) Cleanse to remove secretions from less-soiled to more-soiled areas. B) Cleanse using a cotton cloth and warm water. C) Use tissue rolls to clean the client's perineal area. D) Provide the client with a bed pan or a jar to collect the urine.

Ans: A Feedback: To ensure proper perineal care, the nurse should cleanse to remove secretions and excretions from less-soiled to moresoiled areas. The nurse must also prevent direct contact with and any secretions or excretions by wearing clean gloves. The nurse should not use cotton cloth or tissues to clean the perineal area because that might lead to skin impairment. Older adult clients have sensitive skin, which may be easily impaired when cleaning. Because the client cannot do anything independently, providing him with a bed pan or a jar will not help.

A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure? A) Use sterile gloves to handle the entire drape surface. B) Fold the lower edges of the drape over the sterile-gloved hands. C) Touch only the outer two inches of the drape when not wearing sterile gloves. D) When reaching over the drape do not allow clothing to touch the drape.

Ans: A Feedback: Using sterile gloves allows the nurse to handle the entire drape surface. The nurse should fold the lower edges of the drape over the sterile-gloved hands for protection when positioning. When not wearing sterile gloves, the nurse should touch only the outer one inch (2.5 cm) of the drape, and the nurse should not reach over the drape because this would contaminate a sterile area.

A client with an upper respiratory infection (common cold) tells the nurse, "I am so angry with the nurse practitioner because he would not give me any antibiotics." What would be the most accurate response by the nurse? A) "Antibiotics have no effect on viruses." B) "Let me talk to him and see what we can do." C) "Why do you think you need an antibiotic?" D) "I know what you mean; you need an antibiotic."

Ans: A Feedback: Viruses are the smallest of all microorganisms. Viruses, including the common cold and AIDS, cause many infections. Antibiotics have no effect on viruses.

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? A) "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." B) "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." C) "Client bathes more often than necessary and consequently experiences dry skin." D) "Client's level of personal hygiene is acceptable and age-appropriate."

Ans: A Feedback: When documenting the nursing history, it is best to be specific, clearly describing the client's typical hygiene practices and any complaints. Judgments regarding cause and effect are likely premature in this context and may be inaccurate.

A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration? A) Ensures that the right medication is given at the right time by the right route B) Complies with the medical order and ensures that the right dose is given C) Ensures that the medication has been administered to the right client D) Demonstrates timely administration and compliance with the medical order

Ans: A Feedback: When preparing the medications for administration, the nurse reads and compares the label on the medication with the MAR at least three times. This is to ensure that the right medication is given at the correct time, and by the correct route. The nurse calculates the doses to comply with the medical order and ensure that the right dose is given. Before administration, the nurse identifies the client by checking the wristband or asking the client's name. This is to ensure that the medication is given to the right person. The nurse should plan to administer the medications within 30 to 60 minutes of their scheduled time, which demonstrates timely administration and compliance with the medical order.

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of which of the following? A) Allergic reaction B) Side effect C) Toxicity D) Antagonism

Ans: A Feedback: With urticaria, hives, wheezing, and dyspnea are the symptoms of severe allergic reaction, which is due to an anaphylactic reaction. Minor adverse effects are called side effects. Many side effects are essentially harmless and can be ignored. Toxicity results from overdosage or buildup of medication in the blood due to impaired metabolism and excretion. Antagonism is a drug interaction by which drug effects decrease.

Which of the following clients ia at an increased risk for oral problems? Select all that apply. A) Comatose client B) Confused client C) Depressed client D) Client undergoing chemotherapy E) Hypertensive client

Ans: A, B, C, D Feedback: Clients at increased risk for oral problems include those who are seriously ill, comatose, dehydrated, confused, depressed, or paralyzed. Clients who are mouth breathers, those who can have no oral intake of nutrition or fluids, those with nasogastric tubes or oral airways in place, and those who have had oral surgery are also at increased risk. Variables known to cause oral problems include deficient self-care abilities, poor nutrition or excessive intake of refined sugars, family history of periodontal disease, or ingestion of chemotherapeutic agents that produce oral lesions.

The Joint Commission supports the client's right to pain management, and published standards for assessment and management of pain in hospitals, ambulatory care settings, and home care settings (Joint Commission, 2008b). Which of the following are recommended guidelines for pain management? Select all that apply. A) Teach all clients to use a pain rating scale. B) Determine a pain-rating goal with each client. C) Use pharmacologic pain relief measures first. D) Manipulate factors that affect the pain experience. E) Keep the primary care provider in charge of all pain relief measures.

Ans: A, B, D Feedback: The Joint Commission recommendations include teaching all clients to use a pain-rating scale and determining a painrating goal with each client. Nursing interventions to achieve this goal include establishing a trusting nurse-patient relationship; manipulating factors that affect the pain experience; initiating nonpharmacologic pain relief measures; managing pharmacologic interventions; reviewing additional pain control measures; ensuring ethical and legal responsibility to relieve pain; and educating the client about pain.

The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which of the following represent these five rights? Select all that apply. A) Medication B) Client C) Prescribing physician D) Pharmacy E) Dosage F) Route

Ans: A, B, E, F Feedback: To prevent medication errors, always ensure that the: (1) Right medication is given to the (2) right client in the (3) right dosage through the (4) right route at the (5) right time.

What care should the nurse take when providing foot care for a client with peripheral vascular disease? Select all that apply. A) Use an emery board to file toe nail edges B) Cut the toenails short C) Cut the nail in one piece D) Avoid cutting into calluses E) Cut the nails straight across

Ans: A, D, E Feedback: The nurse caring for the client with peripheral vascular disease should use an emery board to file nail edges. These clients may have thick distorted nails that may be difficult to cut, but can be safely filed. The nurse should avoid cutting the nails too short or cutting into calluses to prevent trauma. The nurse should cut the nails straight across if possible, and cut in a few small pieces rather than one piece to prevent injury or skin breakdown.

A nurse is assessing the vital signs of a client who is moaning due to the acute onset of pain. What would be the expected objective findings? A) Decreased pulse and respirations B) Increased pulse and blood pressure C) Increased temperature D) No change from client's norms

Ans: B Feedback: A client who is in acute pain will most often also have an increased pulse and blood pressure.

Which client would benefit from a p.r.n. drug regimen? A) One who had thoracic surgery 12 hours ago B) One who had thoracic surgery four days ago C) One who has intractable pain D) One who has chronic pain

Ans: B Feedback: A p.r.n. drug regimen has not proven effective for people experiencing acute pain, such as in the early postoperative period. It is not adequate for clients with intractable or chronic pain. However, later in the postoperative period, it may be acceptable to relieve occasional pain episodes.

A physician has ordered that a medication be given "stat" for a client who is having an anaphylactic drug reaction. At what time would the nurse administer the medication? A) At the next scheduled medication time B) Immediately after the order is noted C) Not until verifying it with the client D) Whenever the client asks for it

Ans: B Feedback: A stat order is a single order, and it is carried out immediately. This is a legal order. The nurse would not wait until the next scheduled medication time or verify the order with the client. With a p.r.n. order, the client receives medication when it is requested or required.

Which client would be most at risk for alterations in oral health? A) Infant who is breast-fed B) Man with a nasogastric tube C) Woman who is pregnant D) Healthy young adult

Ans: B Feedback: A variety of illnesses and habits may increase the risk for oral health problems, including poor nutrition, treatment with chemotherapy, those who are NPO, and those who have nasogastric tubes or oral airways in place.

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? A) Recap the needle; place it in a puncture-resistant container. B) Do not recap the needle; place it in a puncture-resistant container. C) Break off the needle, place it in the barrel, and throw it in the trash. D) Take off the needle and throw the syringe in the client's trash can.

Ans: B Feedback: After use, needles and syringes are placed in a puncture-resistant container without being recapped. This prevents needlestick injuries, because most occur during recapping.

A client who is taking an oral narcotic for pain relief tells the nurse he is constipated. What is this common response to narcotics called? A) Therapeutic effect B) Adverse effect C) Toxic effect D) Idiosyncratic effect

Ans: B Feedback: Although therapeutic effect is the desired outcome of medication administration, sometimes adverse effects occur. Adverse effects (such as constipation from narcotics) often are predictable and can usually be tolerated. Toxic effects (toxicities) are specific groups of symptoms related to drug therapy that carry risk for permanent damage or death. An idiosyncratic effect(sometimes called paradoxical effect) is any unusual or peculiar response to a drug that may manifest itself by over-response, under-response, or even the opposite of the expected response.

A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears it could recur and become chronic. What is a characteristic of chronic pain? A) Chronic pain will lead to psychological imbalance. B) Chronic pain has far-reaching effects on the client. C) Chronic pain can be severe in its initial stages. D) Chronic pain eases with healing and eventually disappears.

Ans: B Feedback: Chronic pain has far-reaching effects on the client because the discomfort lasts longer than six months. Chronic pain is not as severe in the initial stage as acute pain, but does not disappear eventually with pain medication. Chronic pain need not always lead to psychological imbalance.

Besides controlling pain of the post-abdominal surgery client with narcotics, the nurse suggests to the client that he ... A) focus on pain relief B) use distraction C) describe the pain D) think about the next dose

Ans: B Feedback: Distraction is useful when clients are undergoing brief periods of sharp, intense pain, such as dressing changes, wound débridement, biopsy, or incident pain from shifting positions.

Which statement is true of health care personnel and good hand hygiene? A) Hand hygiene is carefully followed. B) Compliance is difficult to achieve. C) Only nurses need to practice hand hygiene. D) Wearing gloves reduces the need for hand hygiene.

Ans: B Feedback: Even though health care personnel know the importance of good hand hygiene, most studies report that compliance with this simple preventive measure is difficult to achieve. Despite intensive educational efforts, good hand hygiene is practiced infrequently.

Which of the following is a correct guideline to follow when providing a bed bath for a client? A) When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye. B) Fold the washcloth like a mitt on your hand so that there are no loose ends. C) Clean the perineal area before cleaning the gluteal area. D) Change the bath water after washing each body part.

Ans: B Feedback: Fold the washcloth like a mitt on your hand so that there are no loose ends. Moving from the inner to the outer aspect of the eye prevents carrying debris toward the nasolacrimal duct. The gluteal area should be cleaned first and the bath water and towels should be changed before cleaning the perineal area. It is not necessary to change the bath water after washing every body part.

A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend? A) Mandating antibiotics for all nursing home residents B) Have written, infection-prevention practices for all employees C) Requiring all employees to have monthly screenings for skin flora D) Restricting visitors and community activities for residents

Ans: B Feedback: Health care agencies, including hospitals and nursing homes, have found several measures to be successful in reducing the incidence of nosocomial infections. One of these measures is having written, infection-prevention practices for all personnel. Adherence to hand hygiene recommendations and infection-control precaution techniques can prevent many nosocomial infections.

Medications administered that are renal toxic should have frequent assessments of which blood values? A) AST and ALT B) BUN and creatinine C) WBC and platelets D) RBC and differential

Ans: B Feedback: If medications are known to cause kidney dysfunction, kidney function tests (serum creatinine, blood urea nitrogen) should be frequent.

A nurse is required to clean the open wounds of a client who has been involved in an automobile accident. What intervention would the nurse need to perform when cleaning open wounds to protect himself from infection? A) Wash hands with alcohol-based hand wash. B) Wear a pair of sterile latex gloves. C) Use sterilizing acid to clean the injury. D) Use sterile solutions such as normal saline.

Ans: B Feedback: In order to protect themselves from infections when dealing with open wounds, nurses should wear sterile latex gloves when cleaning the open wounds of a client. Latex gloves allow the nurse to handle sterile equipment and supplies without contaminating them during the treatment, and the gloves also protect the nurse from the infection caused by the injury. Though washing hands with an alcohol-based hand wash helps kill the microorganisms, it will not protect the nurse from being infected during the cleaning of the wound. Sterilizing acid is used to sterilize heat-sensitive instruments. Sterilizing solutions such as normal saline are used to avoid contamination.

A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed? A) "I will wash my hands before and after going to the bathroom." B) "I don't wear a condom when I have sex, but I know my partners." C) "I always eat fruits and vegetables, and I sleep eight hours a night." D) "When I have an infection, I rest and take my medications."

Ans: B Feedback: Sensible nutrition, adequate rest and exercise, and good personal hygiene habits can help maintain optimum body function and immune response. Unsafe sex practices are potentially dangerous and provide an opportunity for pathogens to enter a host and cause an infection.

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection? A) Virus B) Bacteria C) Fungi D) Spores

Ans: B Feedback: Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi. Bacteria are the most significant and most commonly observed infection-causing agents in health care institutions.

What would a nurse instruct a client to do after administration of a sublingual medication? A) "Take a big drink of water and swallow the pill." B) "Try not to swallow while the pill dissolves." C) "Swallow frequently to get the best benefit." D) "Chew the pill so it will dissolve faster."

Ans: B Feedback: Sublingual and buccal medications should not be swallowed, but rather held in place so that complete absorption takes place.

A nurse is teaching an older adult at home about taking newly prescribed medications. Which information would be included? A) "You can identify your medications by their color." B) "I have written the names of your drugs with times to take them." C) "You won't forget a medication if you count them every day." D) "Don't worry if the label comes off; just look at the shapes."

Ans: B Feedback: Teach clients the names of drugs rather than distinguishing drugs by color. Manufacturers may vary the color of generic drugs, and the visual changes associated with aging may make it more difficult to identify medications by color. Medications should not be identified by counting or by shapes.

A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the nurse to do what? A) Remove ingrown toenails B) Cut the nail straight across C) Protect the foot from blisters D) Soak the foot in witch hazel

Ans: B Feedback: The feet of older adults require special attention, because foot problems may relate to reduced peripheral blood flow. Poor circulation makes the feet more vulnerable to infection and skin breakdown, particularly after trauma. By cutting the nail straight across, the nurse can protect the toes from trauma.

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client? A) "Only take morphine when you have the most severe pain." B) "Increase fluids and high-fiber foods, and use a mild laxative." C) "Administer an enema to yourself every third day." D) "Constipation is nothing to worry about; take your medicine."

Ans: B Feedback: The most common side effects associated with opioids (e.g., morphine) are sedation, nausea, and constipation. If constipation persists, it usually responds to treatment with increased fluids and fiber, and use of a mild laxative.

A middle-age client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client? A) Does your diet include red meat and poultry products? B) Does your pain level change after taking medications? C) Are your family members aware of your pain? D) Have you thought of the effects of your condition on your family?

Ans: B Feedback: The nurse should ask direct and specific questions about the nature of the pain and whether it changes with medication, as this helps the nurse to quickly gather objective data about the client's pain. The nurse should avoid asking irrelevant and closed-ended questions, such as whether the client's diet includes red meat and poultry products, or whether the client has thought about the effects of his condition on his family. These types of questions do not add any value to pain assessment, but could make the client feel more depressed and uncomfortable.

What are the general nursing care guidelines that the nurse should follow when caring for clients in a health care facility? A) Avoid physical contact with the infected client. B) Avoid jewelry with prongs or protruding stones. C) Isolate the client and keep the room door closed. D) Shake linens properly when changing the beds.

Ans: B Feedback: The nurse should avoid wearing artificial nails, colored nail polish, and jewelry with prongs or protruding stones to avoid the spread of pathogens. The nurse should avoid physical contact with the infected client only when the disease is known to be transmitted through physical contact. The nurse can practice isolation of the client if instructed by the physician, but need not keep the room door closed. The nurse should avoid shaking linens when changing the beds because this causes spread of dust and pathogens.

A nurse is showing an older adult client the correct method of self-administering an insulin injection at home. Which of the following points should the nurse tell the client in order to avoid lipoatrophy and lipohypertrophy? A) Change the needle daily with each injection. B) Rotate the site with each injection. C) Apply local anesthetic to the injection site. D) Massage the injection site for 10 minutes.

Ans: B Feedback: The nurse should tell the client to rotate the injection site each time an insulin injection is administered to prevent lipoatrophy and lipohypertrophy. In case of an insulin injection, the needle need not be changed daily but rather after a specific period specified by the manufacturer on the injection. Local anesthetic need not be applied to the injection site when administering insulin as the needle used causes very little discomfort. There is also no need to massage the injection site when insulin is administered. Massaging is contraindicated when heparin is administered, because this can increase the tendency for local bleeding.

Which medication system allows for client independence? A) Unit dose system B) Self-administered medication system C) Automated medication-dispensing system D) Bar Code Medication Administration

Ans: B Feedback: The self-administered system allows the client independence and responsibility. It also allows nursing supervision, education, and evaluation for client compliance and safety medication management prior to facility discharge.

On the first postoperative day, the client is assisted to the bathroom. It is important for the nurse to do what? A) Allow the client privacy B) Assess the client's safety C) Assess the client's pain D) Allow sufficient time

Ans: B Feedback: Toileting often is associated with falls; the nurse must ensure the client's safety.

A nurse is ordered to apply a transcutaneous electrical nerve stimulation (TENS) unit to a client recovering from abdominal surgery. Which of the following is a consideration when using this device? A) TENS is an invasive technique for providing pain relief. B) TENS involves the electrical stimulation of large-diameter fibers to inhibit the transmission of painful impulses carried over small-diameter fibers. C) TENS is most beneficial when used to treat pain that is generalized. D) A TENS unit is applied intermittently throughout the day and should not be worn for extended periods of time.

Ans: B Feedback: Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique for providing pain relief that involves the electrical stimulation of large-diameter fibers to inhibit the transmission of painful impulses carried over small-diameter fibers. It is most beneficial when the pain is localized and the unit can be worn for extended periods of time.

A nurse is providing oral care to a client with dentures. What action would the nurse do first? A) Assess the mouth and gums. B) Don gloves. C) Wash the client's face. D) Apply lubricant.

Ans: B Feedback: When providing oral care and denture care, the nurse would be exposed to body fluids. The nurse should always don gloves if exposure to body fluids will occur.

Which of the following are characteristics of the stage of infection known as full stage of illness? Select all that apply. A) It is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. B) Specific signs and symptoms are present. C) The organisms are growing and multiplying. D) The signs and symptoms disappear, and the person returns to a healthy state. E) Early signs and symptoms of disease are present, but these are often vague and nonspecific.

Ans: B, C Feedback: The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The presence of specific signs and symptoms indicates the full stage of illness, and the type of infection determines the length of the illness and the severity of the manifestations. The convalescent period is the recovery period from the infection; the signs and symptoms disappear, and the person returns to a healthy state. A person is most infectious during the prodromal stage, in which early signs and symptoms of disease are present, but are often vague and nonspecific (ranging from fatigue and malaise to a lowgrade fever).

What is the term used to describe a pharmaceutical agent that relieves pain? A) Antacid B) Antihistamine C) Analgesic D) Antibiotic

Ans: C Feedback: An analgesic is a pharmaceutical agent that relieves pain. Analgesics reduce the perception of pain and alter responses to discomfort.

Which of the following most accurately defines an infection? A) An illness resulting from living in an unclean environment B) The result of lack of knowledge about food preparation C) A disease resulting from pathogens in or on the body D) An acute or chronic illness resulting from traumatic injury

Ans: C Feedback: An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body.

The latest CDC guidelines designate standard precautions for all substances except which of the following? A) Urine B) Blood C) Sweat D) Vomitus

Ans: C Feedback: Current CDC guidelines define standard precautions as those used in the care of all hospitalized individuals, regardless of their diagnosis or possible infection status. They apply to blood, all body secretions and excretions (except sweat), nonintact skin, and mucous membranes.

An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed? A) The use of gloves eliminates the need for hand hygiene. B) The use of hand hygiene eliminates the need for gloves. C) Hand hygiene must be performed after contact with inanimate objects near the client. D) Hand lotions should not be used after hand hygiene.

Ans: C Feedback: Hand hygiene must be performed when moving from a contaminated body site to a clean body site during client care, and after contact with inanimate objects near the client. Using gloves does not eliminate the need for hand hygiene and, in some cases, gloves must still be used after hand hygiene. Lotions may be used to prevent irritation.

Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup with clean water. What rationale supports placing dentures in water? A) None; they should be placed in saline B) To increase comfort when replaced in the mouth C) To prevent drying and warping of plastic D) To ensure the dentures are not thrown away

Ans: C Feedback: If a client removes dentures while sleeping, they should be stored in water in a disposable denture cup to prevent drying and warping of plastic materials.

A female client in a reproductive health clinic tells the nurse practitioner that she douches every day. Should the nurse tell the client to continue this practice? A) Yes, this helps prevent vaginal odor. B) Yes, this decreases vaginal secretions. C) No, douching removes normal bacteria. D) No, douching may increase secretions.

Ans: C Feedback: In normal healthy women, daily douching is believed to be unnecessary because it removes normal bacterial flora from the vagina. Douching has been linked to bacterial vaginosis, pelvic inflammatory disease, higher rates of HIV transmission, tubal pregnancies, chlamydial infection, and cervical cancer.

A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment? A) Shaking the contents of the ointment B) Applying inunction with a cotton ball C) Rubbing the ointment into the skin D) Warming the inunction before application

Ans: C Feedback: In order to promote absorption, the nurse should rub the ointment into the client's skin. Shaking the contents would mix the contents uniformly, whereas applying the with a cotton ball would distribute the substance over a wide area. Warming the ointment before application would provide comfort.

A client with allergy has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which of the following injection routes is most suitable for allergy testing? A) Subcutaneous B) Intramuscular C) Intradermal D) Intravenous

Ans: C Feedback: Intradermal injection routes are commonly used for tuberculin tests and allergy testing because they are administered between the layers of the skin. A subcutaneous injection is not suitable because it is administered more deeply than an intradermal injection; whereas, an intramuscular injection is administered in one muscle or muscle group. Intravenous injection is also not suitable because it is instilled into veins.

The mother of a child 2 years of age tells the nurse she always cleans the child's ears with a hairpin. What would the nurse tell the mother? A) "That's not good. Use a Q-tip or your finger instead." B) "You really like to keep your child clean. Good for you!" C) "That is dangerous; you might puncture the eardrum." D) "Show me exactly how you use the hairpin."

Ans: C Feedback: Little intervention is needed for routine hygiene of the ear. Using bobby pins, hairpins, paper clips, or fingernails to remove wax from the ear is extremely dangerous because these may injure or puncture the eardrum.

A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error? A) Report the incident to the physician. B) Report the incident to the supervising nurse. C) Check the client's condition. D) Fill in the accident report sheet.

Ans: C Feedback: On detection of the medication error, the nurse should immediately check the client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintain the client's safety. As soon as the nurse recognizes an error, he or she should check the client's condition and report the mistake to the prescriber and supervising nurse immediately. Health care agencies have a form for reporting medication errors called an incident sheet or accident sheet.

A mother calls the nurse practitioner to say, "I don't know what is wrong with my baby. He cried all night and kept pulling at his ear." How would the nurse respond? A) "Oh, he probably was just hungry and wet. Did you feed him?" B) "Babies at that age cry at night. Think nothing of it." C) "That means his ear hurt. Bring him in to be checked." D) "That probably means he had a tummy ache. How is he now?"

Ans: C Feedback: Pain is frustrating for children because they are unable to understand the concept and cause of pain, and may have difficulty describing it. Crying and touching/grabbing the painful body part are observations that may indicate pain in a child.

Of all possible nursing interventions to break the chain of infection, which is the most effective? A) Administering medications B) Providing good skin care C) Practicing hand hygiene D) Wearing gloves at all times

Ans: C Feedback: Practicing hand hygiene is the most effective way to help prevent the spread of organisms. Nurses need to focus on this simple procedure that can interrupt the cycle of infection.

A nurse is assisting a client to shave his beard. Which of the following statements accurately describes a recommended step in this process? A) Cover the client with a blanket. B) Fill a basin with cool water. C) Apply cream to area to be shaved in a layer about 1/2-inch thick. D) Shave against the direction of hair growth in upward, short strokes

Ans: C Feedback: Steps in the procedure include: Cover patient's chest with a towel or waterproof pad. Fill bath basin with warm (43ºC to 46ºC [110ºF to 115ºF]) water. Put on gloves. Moisten the area to be shaved with a washcloth. Dispense shaving cream into palm of hand. Apply cream to area to be shaved in a layer about 1/2-inch thick. With one hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin shaving. If shaving the face, shave with the direction of hair growth in downward, short strokes. If shaving a leg, shave against the hair in upward, short strokes. If shaving an underarm, pull skin taut and use short, upward strokes.

Which of the following is an example of the body's defense against infection? A) Racial characteristics B) Body shape and size C) Immune response D) Level of susceptibility

Ans: C Feedback: The body has various defenses against infection, including normal flora and the inflammatory response. One of the most effective is the immune response, which involves specific reactions in the body as it responds to an invading foreign protein, such as bacteria. The foreign material is called an antigen, and the body commonly responds by producing an antibody. Race, body size and shape, and level of susceptibility do not affect defense against infection.

A physician writes an order for ampicillin 1 gram every 6 hours for a client. What is missing in this order? A) Time B) Amount C) Route D) Frequency

Ans: C Feedback: The medication order does not identify a route.

A nurse is assessing a client with arthritis. Which of the following should the nurse consider in the initial assessment of the client? A) Blood group B) Anxiety level C) Pain level D) Glucose level

Ans: C Feedback: The nurse should first assess the client's pain level since the client has arthritis. Anxiety level, blood group, and glucose level are not vital signs which will help the nurse assess the client's pain during the initial assessment.

A nurse is caring for a client with a serious bacterial infection. The client is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses? A) High Risk for Infection B) Excess Fluid Volume C) Risk for Imbalanced Body Temperature D) Risk for Latex Allergy Response

Ans: C Feedback: The response of the body to an infectious process (fever), as well as dehydration, would support the nursing diagnosis of Risk for Imbalanced Body Temperature for this client.

A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs? A) Other people B) Food C) Soil D) Animals

Ans: C Feedback: The soil can act as a reservoir; the organisms that cause gas gangrene and tetanus are examples of pathogens whose reservoir is soil. Nurses can serve as reservoirs and inadvertently transfer pathogenic organisms to clients. For example, a nurse with artificial nails may harbor a large number and variety of microbes under the nails. Undercooked ground beef, tomatoes, and bagged spinach are reservoirs that have been identified as responsible for recent outbreaks of E. coli infections. The rabies virus is an example of a pathogen whose reservoir is various animals, notably dogs, squirrels, bats, and raccoons.

A physician has ordered peak and trough levels of a medication. When would the nurse schedule the trough level specimen? A) Before administering the first dose B) Immediately after the first dose C) 30 minutes before the next dose D) 24 hours after the last dose

Ans: C Feedback: The trough level is the point when the drug is at its lowest concentration, and the specimen is usually drawn in the 30- minute interval before the next dose. The peak level, in contrast, is the highest plasma concentration of the drug.

A student nurse is administering medications through a nasogastric tube connected to continuous suction. How will the student do this accurately? A) Briefly disconnect tubing from the suction to administer medications, then reconnect. B) Realize this can't be done, and document information. C) Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30 minutes. D) Leave the suction alone and give medications orally or rectally.

Ans: C Feedback: To administer medications to clients with a nasogastric tube connected to continuous suction, disconnect the tubing from the suction, administer the medications one at a time, and then clamp the tubing for 20 to 30 minutes after administration to allow absorption.

A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene? A) "Perhaps you don't recognize your bad body odor." B) "You must eat a lot of greasy foods to have this acne." C) "Tell me about what you do to take care of your skin." D) "Why do you only take a bath once a week?"

Ans: C Feedback: When skin problems are present, the nurse asks the client about usual personal hygiene practices and documents the client's responses. The questions should be open-ended and nonthreatening.

A nurse is teaching an alert client how to use a PCA system in the home. How will she explain to the client what he must do to self-manage pain? A) "You don't have to do anything. The machine does it all." B) "I will teach your family what they need to do." C) "When you push the button, you will get the medicine." D) "The medicine is going into your body all the time."

Ans: C Feedback: When the sensation of pain occurs, the client pushes a button that activates the PCA device to deliver a small preset bolus dose of the analgesic. A lockout interval (usually 5 to 10 minutes) prevents reactivation of the pump and administration of another dose during that period of time. Other safeguards also limit the possibility of overmedication.

What type of bath is preferred to decrease the inflammation after rectal surgery? A) Bed bath B) Tub bath C) Whirlpool bath D) Sitz bath

Ans: D Feedback: A sitz bath can be helpful in soaking a client's pelvic area in warm water to decrease inflammation after childbirth or rectal surgery, or to decrease inflammation of hemorrhoids.

A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an infection, what is the most likely means of transmission from the woman to the man? A) Direct contact B) Indirect contact C) Vectors D) Airborne route

Ans: D Feedback: An organism may be transmitted from its reservoir by various means or routes. Microorganisms can be spread through the airborne route when an infected host coughs, sneezes, or talks or when the organism becomes attached to dust particles.

What is the correct rationale for using body substance precautions? A) The risk of transmitting HIV in sputum and urine is nonexistent. B) Disease-specific isolation procedures are adequate protection. C) Only actively infected clients are considered contagious. D) All body substances are considered potentially infectious.

Ans: D Feedback: Body substance precautions are an extension of universal precautions. These precautions consider all body substances potentially infectious, regardless of a person's diagnosis. The consistent use of barriers whenever health care personnel have contact with moist body substances, mucous membranes, and nonintact skin is highly recommended.

The nurse is caring for a client with terminal bone cancer. The client states, My pain is getting worse and worse, and the morphine doesn't help anymore. The nurse determines the client's pain is which of the following? A) Acute B) Chronic malignant C) Diffuse D) Intractable

Ans: D Feedback: Chronic malignant pain is acute pain episodes, persistent chronic pain, or both, associated with a progressive malignanttype process.

A client who has breast cancer is said to be in remission. What does this term signify? A) The client is experiencing symptoms of the disease. B) The client has end-stage cancer. C) The client is experiencing unremitting pain. D) The disease is present but the client is not experiencing symptoms.

Ans: D Feedback: Commonly, people with chronic pain experience periods of remission (when the disease is present but the person does not experience symptoms) or exacerbation (the symptoms reappear).

How may a nurse demonstrate cultural competence when responding to clients in pain? A) Treat every client exactly the same, regardless of culture. B) Be knowledgeable and skilled in medication administration. C) Know the action and side effects of all pain medications. D) Avoid stereotyping responses to pain by clients.

Ans: D Feedback: Culture influences an individual's response to pain. It is particularly important to avoid stereotyping responses to pain because the nurse frequently encounters clients who are in pain or anticipating it will develop. A form of pain expression that is frowned upon in one culture may be desirable in another cultural group.

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain? A) Narcotics B) Sedatives C) A-delta fibers D) Endorphins

Ans: D Feedback: Endorphins, which are opioid neuromodulators, are produced at neural synapses at various points in the CNS pathway. They have prolonged analgesic effects and produce euphoria. It is suggested that they may be released when measures such as skin stimulation and relaxation techniques are used.

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets? A) To prevent absorption in the mouth B) To prevent absorption in the esophagus C) To facilitate absorption in the stomach D) To prevent gastric irritation

Ans: D Feedback: Enteric-coated tablets are covered with a hard surface to impede absorption until the tablet has left the stomach. Entericcoated tablets should not be chewed or crushed because the active ingredient of the drug is irritating to the gastric mucosa.

A clinic nurse is preparing for a tuberculosis screening. Knowing the injections will be administered intradermally, what size needles and syringes will the nurse prepare? A) 10-mL syringe, 3-inch 18-gauge needle B) 5-mL syringe, 2-inch 20-gauge needle C) Insulin syringe, 1-inch 16-gauge needle D) Tuberculin syringe, 1/2-inch 26-gauge needle

Ans: D Feedback: Equipment used for an intradermal injection includes a tuberculin syringe calibrated in tenths and hundredths of a milliliter. A quarter-inch to half-inch 26- or 27-gauge needle is used.

A nurse is conducting an interview for a health history. In addition to asking the client about medications being taken, what else should be asked to assess the risk for drug interactions? A) The effects of prescribed medications B) Type and amount of foods eaten C) Daily amount of intake and output D) Use of herbal supplements

Ans: D Feedback: Herbal remedies can interact with prescribed medications. When asking a client if he or she is taking any medications, the nurse should specifically ask if herbal supplements are also being used.

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas.

Ans: D Feedback: Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

The following procedures have been ordered and implemented for a hospitalized client. Which procedure carries the greatest risk for a nosocomial infection? A) Enema B) Intramuscular injections C) Heat lamp D) Urinary catheterization

Ans: D Feedback: Most nosocomial infections are caused by bacteria. Urinary tract infections, pneumonia, and bloodstream infections are the three most common nosocomial infections, most of which can be traced to an invasive device (e.g., a urinary catheter).

A nurse is bunching the tissue of a client when administering a subcutaneous injection to that client. The nurse knows that which of the following is the reason for bunching when injecting subcutaneously? A) To prevent needle-stick injuries B) To ensure the accuracy of landmarking C) To facilitate blood circulation at injection site D) To avoid instilling medication within the muscle

Ans: D Feedback: Nurses bunch tissue between the thumb and fingers before administering the injection to avoid instilling medication within the muscle. Bunching does not prevent needle-stick injuries, it does not facilitate blood circulation at the injection site, nor does it ensure the accuracy of landmarking.

Which of the following factors does not affect personal hygiene practices? A) Culture B) Income level C) Health state D) Gender

Ans: D Feedback: Personal hygiene practices vary widely among individuals and are affected by culture, socioeconomic status, spiritual practices, developmental level, health state, and personal preferences.

Which clent would be at greatest risk for injury to the skin and mucous membranes? A) Infant 10 days old with no health problems B) adolescent 17 years of age with asthma C) Man 44 years of age with hemorrhoids D) Man 77 years of age with diabetes

Ans: D Feedback: Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissue, and illness conditions. In this question, the older man with diabetes would be most at risk.

A student has been assigned to provide hygiene care to four clients. Which one would require special consideration for perineal care? A) Middle-aged man with a nasogastric tube B) Young adult man who has had a hernia repair C) Young woman who has had cosmetic surgery D) Middle-age woman with a Foley catheter

Ans: D Feedback: The dark, warm, moist perineal and vaginal areas favor bacterial growth. Variables known to create a need for special care include an indwelling Foley catheter. The client who cannot clean the perineal area needs the nurse's assistance for personal hygiene.

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges? A) All needles for parenteral injection are the same gauge. B) The gauge will depend on the length of the needle. C) Ask the client what size needle is preferred. D) Gauges range from 18 to 30, with 18 being the largest.

Ans: D Feedback: The gauge is determined by the diameter of the needle and ranges from 18 to 30. As the diameter of the needle increases, the gauge number decreases (an 18-gauge needle is, therefore, larger than a 30-gauge needle). A viscous medication requires a larger-gauge needle for injection.

A nurse is caring for a client with acute back pain. When should the nurse assess the client's pain? A) Six hours after administering a prescribed analgesic B) After the client is discharged from the health care facility C) Once per day when the pain is a potential problem D) Whenever the vital signs are measured and documented

Ans: D Feedback: The nurse should assess the client's pain whenever the nurse measures and documents vital signs. When administering a prescribed analgesic, the nurse should assess pain before implementing a pain-management intervention, and again 30 minutes later. The nurse should assess the client's pain when the client is admitted to, not discharged from, the health care facility. Similarly, the nurse should assess pain once per shift when pain is an actual or potential problem.

Which of the following questions asked by the nurse when taking a client's health history would collect data about infection control? A) Tell me what you eat in each 24-hour period. B) Do you sleep well and wake up feeling healthy? C) What were the causes of death for your family members? D) When did you complete your immunizations?

Ans: D Feedback: The nurse's role in infection control includes early detection and surveillance. When taking a health history, the nurse asks about immunization status and previous/recurring infections. The other questions are appropriate in a health history, but are not specific to infections.

A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order? A) Ask the physician to repeat the dosage. B) Ask the physician to spell out the medication name. C) Ask a second nurse to listen for accuracy. D) Ask the physician to write out the order.

Ans: D Feedback: To maintain the accuracy of a verbal order, the nurse should tactfully ask the physician for a written order. When obtaining phone orders, it is important to repeat the dosages of medications and to spell medication names for confirmation of accuracy. Some nurses may ask a second nurse to listen to a telephone order on an extension.

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A. Referent B. Channel C. Environment D. Feedback

D. Feedback

A nurse is educating a rural community group on how to avoid contracting West Nile virus by using approved insect repellant and wearing proper coverings when outdoors. By what means is the pathogen involved in West Nile virus transmitted? A) Direct contact B) Indirect contact C) Airborne route D) Vectors

Ans: D Feedback: Vectors, such as mosquitoes, ticks, and lice, are nonhuman carriers that transmit organisms from one host to another, that is, by injecting salivary fluid when a human bite occurs.

A client has a severe abdominal injury with damage to the liver and colon from a motorcycle crash. What type of pain will predominate? A) Psychogenic pain B) Neuropathic pain C) Cutaneous pain D) Visceral pain

Ans: D Feedback: Visceral pain is poorly localized and originates in body organs in the thorax, cranium, and abdomen. The pain occurs as organs stretch abnormally and become distended, ischemic, or inflamed.

A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being worst pain. What characteristic of pain is the nurse assessing? A) Duration B) Location C) Chronology D) Intensity

Ans: D Feedback: When a nurse asks a client to rate his pain on a scale of 0 to 10, the intensity of the pain is being assessed. Duration is how long the pain has lasted, and location is the site of the pain.

A student nurse is performing a urinary catheterization for the first time and inadvertently contaminates the catheter by touching the bed linens. What should the nurse do to maintain surgical asepsis for this procedure? A) Nothing, because the client is on antibiotics. B) Complete the procedure and then report what happened. C) Apologize to the client and complete the procedure. D) Gather new sterile supplies and start over.

Ans: D Feedback: When following surgical asepsis, areas are considered contaminated if they are touched by any object that is also not sterile. One of the most important aspects of medical and surgical asepsis is that the effectiveness of both depends on faithful and conscientious practice by those carrying them out.

A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which of the following instructions are stated on the label of a vial container? A) Type of needle to be used for withdrawal B) Directions for administering the drug C) Best site for administering the drug D) Amount of diluent to be added

Ans: D Feedback: When reconstitution is necessary, the drug label lists instructions such as the amount of diluent to be added and the type of diluent to be used, but not the type of needle. The label states the dosage per volume after reconstitution, not the best site for administering the drug after the reconstitution. It also states the directions for storing the drug, not the directions for administering the drug to a client.

When the nurse takes the patient's nursing history, he or she sits: A. Next to the patient. B. 4 to 12 feet from the patient. C. 18 inches to 4 feet from the patient. D. 12 inches to 3 feet from the patient.

C. 18 inches to 4 feet from the patient.

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A. Use therapeutic communication to assess for increased anxiety B. Sit down and position yourself closer so you are at eye level C. Deflect your eyes downward to show respect D. Continue to maintain eye contact

C. Deflect your eyes downward to show respect

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A. Leave the room quietly since she evidently does not want to be bothered right now B. Repeat the question in a loud voice, speaking very slowly C. Move to her bedside, get her attention, and repeat the question while facing her D. Bring her a communication board so she can express her needs

C. Move to her bedside, get her attention, and repeat the question while facing her

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A. Uses a dictionary to give directions for medication administration B. Explains the directions to the patient's 14-year-old daughter C. Obtains an interpreter to facilitate communication of medication information D. Uses a picture board and visual aids to communicate medication administration information

C. Obtains an interpreter to facilitate communication of medication information

A patient's plan of care includes the goals of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of shift, the patient suffers a fall. The nurse should revise the plan of care first by: A. asking patient to assist the patient with ambulation B. disregard all previous nursing DX and establish a new plan of care C. reassess the patient and mobility status D. continue with the plan of care and keep the same goals

C. Reassess the patient and mobility status

After assessing the patient and idenitifying the need for headache relief, you administers acetaminophen (Tylenol) for the patient's headache pain. What is your next priority action for this patient? A. Eliminiate Acute Pain from the nursing care plan B. Revise the plan for care C. Reassess the patient's plain level in 30 mins D. Discontinue the care plan

C. Reassess the patient's pain level in 30 mins Reassesing the patient after everytime they get medication is important.

In providing oral care to an unconscious patient, it is important for the nurse to- A. Moisten the mouth using floride containing tooth gel B. Hold the patient's mouth open with the patient's finger C. Rinse the mouth and immediately suction the oral cavity. D. Use foam swabs to help remove plaque

C. Rinse the mouth and immediately suction the oral cavity. Oral suction should always be available for unconscious patient

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? A. The respiratory rate is 28. B. The patient has a history of lung cancer. C. The patient is short of breath. D. He or she requests an order for a breathing treatment.

C. The patient is short of breath.

A patient is at risk for aspiration. What nursing action is most appropriate? A. Hold the patient's cup so he/she can concentrate on taking pills B. Thin out liquids so they are easier to swallow C. Give the patient a straw to control the flow of liquids D. Have the patient self-administer the medication

D. Have the patient self-administer the meds The patient should try to be independent and this can allow them to see how much of meds they can take/tolerate. They know what is right for them/ and how they feel.

Which of these interventation, to be included in the plan of care, is appropriate. for the patient outcome that states, "the patient will verbalize a plain level a 3 or below on a 0 to 10 scale throughout this shift?" A. Medicate the patient immediately after all procedures B. Discuss only nonpharmacological methods for pain management C. Teach the patient about the side effects of pain medication D. Medicate the patient based on patient assessment findings

D. Medicate the patient based on patient assessment findings.

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A. The professional nurse consults the health care provider for direction in establishing goals for patients. B. The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C. The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

Bactericidal

Deactivates bacteria

4 stages of Infectious Process

Incubation Process Prodromal Stage Illness Stage Convalencence

Considerations Post Medication Adminstrations:

Nursing Assesment: Adverse Effects: Side effect, toxic effects, idiosyncratic reactions, allergic reactions. Patient Education: Efiicacy of medication Adverse effects and side effects

Information found after check vitals signs such as observations/measurements is:

Objective

Nurse-Pateint Relationship

Pre-interaction: looking at charts before meeting patient. Orientation Phase: meeting patient for the first time/ getting to know the patient Working Phase: day to day communication with patient. Termination Phase: patient being discharge/farewell time/or going home for the day.

Interpreting nonverbal communication is problematic

Sociocultural background is a major influence on the meaning of nonverbal behavior. In the United States, with its diverse cultural communities, nonverbal messages between people of different cultures are easily misinterpreted. Because the meaning attached to nonverbal behavior is so subjective, it is imperative that you verify it (Stuart, 2009).

Patient explaining there injury/pain/the way they feel is/verbal self-report of symptoms is:

Subjective

SOLER

S—Sit facing the patient. O—Observe an open posture (i.e., keep arms and legs uncrossed). L—Lean toward the patient. This posture conveys that you are involved and interested in the interaction. E—Establish and maintain intermittent eye contact. R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient.

Medication Patient' Rights:

To be informed about a medication To refuse a med To have a med history To be properly advised about experimental nature of medication To receive labeled meds safely To recieve appropriate supportive therapy To not recieve unnecessary meds.

Communicable disease

Transferable Disease

Nurse

Who checks the medication at the final checkpoint before administration? This person also edcautes the patient and family about the meds and goes over accuracy for dose calculation.

Patient

Who experiences the adverse effects of a medication?

Pharmacist

Who prepares and distributes medications?

Key Points for Crushing Tablets:

You can mix it with food/beverages. Use the smallest amount possible. Avoid patient's favorite foods/beverages to mix it with. Do not crush: Sublingual Enteric Coated Sustained Released

Metacommunication Scenario

a nurse observes a young patient holding his body rigidly, and his voice is sharp as he says, "Going to surgery is no big deal." The nurse replies, "You say having surgery doesn't bother you, but you look and sound tense. I'd like to help." Awareness of the tone of the verbal response and the nonverbal behavior results in further exploration of the patient's feelings and concerns