Adult Health-Exam 2
1. An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload
1,,2,4
Environment
The setting for sender-receiver interactions
You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is: A. public. B. intrapersonal. C. transpersonal. D. small group.
d small group
3. When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume
2
5. The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr
2
6. An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.
2
9. A nurse sees an assistive personnel (AP) perform the following intervention for a patient receiving continuous enteral feedings. Which action would require immediate attention by the nurse? 1. Fastening tube to the gown with new tape 2. Placing client supine while giving a bath 3. Monitoring the client's weight as ordered 4. Ambulating patient with enteral feedings still infusing
2
What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.
2
2. Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. To improve the nurse's status with the health team members 2. To reduce the risk of errors to the patient 3. To provide an optimum level of patient care 4. To improve patient outcomes 5. To prevent issues that need to be reported to outside agencies
2, 3, 4
4. The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.) 1. Matching the rate of speech to be the same as that of the patient 2. Providing good eye contact 3. Demonstrating a calm presence 4. Spending time attentively with the patient 5. Assuring the patient that all will be well
2, 3, 4
10. The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse's silence? (Select all that apply.) 1. Allows the nurse time to focus and avoid saying the wrong thing 2. Prompts the patient to talk when he or she is ready 3. Allows the patient time to think and gain insight 4. Allows time for the patient to drift off to sleep 5. Determines whether the patient would prefer to talk with another staff member
2, 3.
8. A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. 1. The nurse states, "Let's work on learning injection techniques." 2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency. 3. The nurse summarizes progress made during the nursing relationship. 4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.
2, 4, 1, 3
1. The nurse is caring for a client with pneumonia, who has severe malnutrition. The nurse should assess the patient for which of the following assessment findings? (Select all that apply.) 1. Heart disease 2. Sepsis 3. Hemorrhage 4. Skin breakdown 5. Diarrhea
2,3,4
Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.
2,5
9. A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and image , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis
3
5. A patient is receiving both parenteral (PN) and enteral nutrition (EN). When would the nurse collaborate with the health care provider and request a discontinuation of parenteral nutrition? 1. When 25% of the patient's nutritional needs are met by the tube feedings 2. When bowel sounds return 3. When the central line has been in for 10 days 4. When 75% of the patient's nutritional needs are met by the tube feedings
4
A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
3
8. Which statement made by the parents of a 2-month-old infant requires further education by the nurse? 1. "I'll continue to use formula for the baby until he is at least a year old." 2. "I'll make sure that I purchase iron-fortified formula." 3. "I'll start feeding the baby cereal at 4 months." 4. "I'm going to alternate formula with whole milk, starting next month."
4
9. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
4
5. A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 PM yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days." 2. "The patient reported feeling very nauseated after her dose of levofloxacin an hour ago." 340 3. "Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started to complain of nausea yesterday evening and has vomited several times during the night."
5. 4S, 1B, 2A, 3R;
The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE improves patient safety by reducing transcription errors.
4;
5. Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
5, 8, 7, 2, 6, 3, 4, 1;
. Information regarding a patient's health status may not be released to non-health care team members because: A. legal and ethical obligations require health care providers to keep information strictly confidential. B. regulations require health care institutions to document evidence of physical and emotional well-being. C. reimbursement issues related to patient care and procedures may be of concern. D. fragmentation of nursing and medical care procedures may be identified.
A. legal and ethical obligations require health care providers to keep information strictly confidential.
5. While admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." The communication form used by the family member is: A. focusing. B. clarifying. C. summarizing. D. paraphrasing.
B. clarifying.
The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism? A. "The pituitary secretes aldosterone." B. "The kidneys secrete antidiuretic hormone." C. "The adrenal cortex secretes antidiuretic hormone." D. "The pituitary gland secretes antidiuretic hormone."
D. "The pituitary gland secretes antidiuretic hormone."
. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: A. exchange information among health care members. B. provide information about patients from one unit to another unit. C. ensure proper care for the patient. D. aid in the hospital's quality improvement program.
D. aid in the hospital's quality improvement program.
A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of: A. ADH deficit. B. extracellular fluid loss. C. insensible water loss. D. sensible water loss.
D. sensible water loss.
public
interaction with an audience
transpersonal
interaction within a person's spiritual domain
small group
interactions with a small number of people
2. To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.
mass colonic peristalsis occurs at this time.
referent
motivates one to communicate with another
intrapersonal
occurs within an individual
interpersonal
one-to-one interaction between two people
Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the: A. orientation stage. B. working stage. C. termination stage. D. preinteraction stage.
orientation stage.
Channels
Means of conveying and receiving messages
To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.) a.Allows fasting on Yom Kippur for a Jewish patient. b.Allows caffeine drinks for a Mormon patient. c.Serves no ham products to a Muslim patient. d.Serves kosher foods to a Christian patient. e. Serves no meat or fish to a Hindu patient.
a, c, e
Hand-off communication that occurs between the post anesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply) a.Vital signs, type of anesthesia provided, blood loss, and level of consciousness b.Uninterrupted time to review the recent pertinent events and ask questions c.Verification of the patient using one identifier and the type of surgery performed d.Review of pertinent events occurring in the operating room (OR) while at the nurses station e.Location of the patient's family members
a,b,e
The nurse is assessing a patient for nutritional status. Which action will the nurse take? a.Combine multiple objective measures with subjective measures. b.Forego the assessment in the presence of chronic disease c.Use the Mini Nutritional Assessment for pediatric patients. d.Choose a single objective tool that fits the patient's condition.
a. Combine multiple objective measures with subjective measure
The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a. obese b. normal weight c. underweight d. overweight
a. obese
The patient has just started on enteral feedings, and is now reporting abdominal cramping. Which action will the nurse take next? a.Slow the rate of tube feeding. b.Instill cold formula to "numb" the stomach. c.Change the tube feeding to a high-fat formula. d.Consult with the health care provider about prokinetic medication.
a. slow the rate of tube feeding
A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement? a.X-ray b. pH testing c.Auscultation d.Aspiration of contents
a. x ray
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a.Assessment b. Diagnosis c.Implementation d.Evaluation
a.Assessment
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide? a.Drink more water to prevent further dehydration. b. Drink more calorie-dense fluids to increase caloric intake. c.Drink more milk and dairy products to decrease the risk of osteoporosis. d.Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
a.Drink more water to prevent further dehydration.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a.Increased respiratory rate from 18 to 44/min. b.Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). c.Increased blood pressure from 112/68 to 120/72 mm Hg. d. Increased heart rate from 68 to 72/min.
a.Increased respiratory rate from 18 to 44/min.
The nurse is planning care for a group of stable patients. Which task will the nurse assign to the nursing assistive personnel? a.Measuring capillary blood glucose level b.Measuring nasoenteric tube for insertion c.Measuring pH in gastrointestinal aspirate d.Measuring the patient's risk for aspiration
a.Measuring capillary blood glucose level
Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a.The nursing assistive personnel is calling the older-adult patient "honey." b.The nursing assistive personnel is facing the older-adult patient when talking. c.The nursing assistive personnel cleans the older-adult patient's glasses gently. d.The nursing assistive personnel allows time for the older-adult patient to respond.
a.The nursing assistive personnel is calling the older-adult patient "honey."
A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment and Recommendation). a. " The patient started complaining of nausea yesterday evening and has vomited several times during the night." b." She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5pm yesterday. She complains of a poor appetite. c." The patient reported feeling very nauseated after her dose of Levaquin an hour ago." d. "Would you like to make a change in the antibiotics , or could we give her a nutritional supplement before her medications?"
b, c, d, a
Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a.Sore throat b.Acute pain c.Sleep apnea d.Heart failure
b. acute pain
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient? a.Position in semi-Fowler's. b.Flex head with chin down. c.Place food on left side d.Offer fruit juice.
b. flex head with chin down
A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a. "I think you've had a hard day." b."I feel uncomfortable hearing that statement." c."I don't think you should say things like that. It is not right." d."I have been checking on you regularly. How can you say that?"
b."I feel uncomfortable hearing that statement."
A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? a."The client should be seen by a neurologist." b."The client was found unconscious on the floor in her home." c."There are no provider's prescriptions available." d. "The client is disoriented. Pupils are slow to respond to light."
b."The client was found unconscious on the floor in her home."
The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? a.Nasogastric tube b.Jejunostomy tube c.Nasointestinal tube d.Percutaneous endoscopic gastrostomy (PEG) tube
b.Jejunostomy tube
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a.To form a language that can be encoded only by nurses b.To distinguish the nurse's role from the physician's role c.To develop clinical judgment based on other's intuition d.To help nurses focus on the scope of medical practice
b.To distinguish the nurse's role from the physician's role
A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? a.Improperly home-canned food b.Undercooked ground beef c.Soft cheese d.Custard
b.Undercooked ground beef
The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority? a.Observe the color of gastric contents. b.Verify tube placement before feeding. c.Add blue food coloring to the enteral formula d.Run the formula over 12 hours to decrease overload.
b.Verify tube placement before feeding.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing? a.Assigning clinical cues b.Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling
c. Diagnostic reasoning
A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a.Decreased gastrointestinal motility b.Pain medication c.Abdominal distention d. Constipation
c. abdominal distention
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? a. Antibiotic therapy b.Clostridium difficile c.Formula intolerance d.Bacterial contamination
c. formula intolerance
A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one?1. Elevate head of bed to at least 30 degrees.2. Check for gastric residual volume.3. Flush tubing with 30 mL of water.4. Verify tube placement.5. Initiate feeding. a. 4, 2, 1, 5, 3 b. 2, 4, 1, 3, 5 c.1, 4, 2, 3, 5 d.2, 1, 4, 5, 3
c.1, 4, 2, 3, 5
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a.Glasgow results b.Intracranial pressure readings c.Code status d.Plan of care changes for upcoming shift
c.Code status
The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially? a.Avoidance of wheat and oats. b.Milkshakes as a nutritious snack. c.Completion of antibiotic therapy. d.Nonsteroidal antiinflammatory drugs.
c.Completion of antibiotic therapy
Before giving the patient an intermittent gastric tube feeding, what should the nurse do? a.Make sure that the tube is secured to the gown with a safety pin. b.Inject air into the stomach via the tube and auscultate. cHave the tube feeding at room temperature. d.Check to make sure pH is at least 5.
c.Have the tube feeding at room temperature.
A patient was admitted 2 days ago with a diagnosis of pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR? a.Having chest pain b.Pulse rate of 108 c.History of angina d. Oxygen is needed
c.History of angina
A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the assistive personnel (AP)? a.Obtain initial vital signs. b.Determine if the client is in need of pain medication. c.Record the amount of urine in the catheter drainage bag. d.Instruct the client on the use of the incentive spirometer.
c.Record the amount of urine in the catheter drainage bag.
Which assessment finding is consistent with the diagnosis of malnutrition? a.Moist lips b.Pink conjunctivae c.Spoon-shaped nails d.Not easily plucked hair
c.Spoon-shaped nails
The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? a.Instill nonliquid medications without diluting. b.Irrigate the tube with 60 mL of water after all medications are given. c.Mix all medications together to decrease the number of administrations. d. Check with the pharmacy for availability of the liquid forms of medications.
d. Check with the pharmacy for availability of the liquid forms of medications.
. A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: A. abnormal defecation. B. constipation. C. fecal impaction. D. fecal incontinence.
. constipation.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record: A. an interpretation of patient behavior. B. objective data that are observed. C. lengthy entry using lay terminology. D. abbreviations familiar to the nurse.
. objective data that are observed.
2. During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.
1
4. A client who is receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What should be the nurse's priority action? 1. Have the patient turn on the left side and perform a Valsalva maneuver. 2. Clamp the intravenous (IV) tubing to prevent more air from entering the line. 3. Have the patient take a deep breath and hold it. 4. Notify the health care provider immediately.
1
7. Which action can a nurse delegate to assistive personnel (AP)? 1. Performing glucose monitoring every 6 hours on a patient 2. Teaching the client about the need for enteral feeding 3. Administering enteral feeding bolus after tube placement has been verified 4. Evaluating the client's tolerance of the enteral feeding
1
4. Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
1, 2, 3, 5
5. The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding.
1, 2, 5;
6. Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain
1, 2, 6, 8.
2. The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication
1, 3, 4
When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip-read. 3. Give the patient time to respond to questions. 4. Keep communication short and to the point. 5. Communicate only through written information.
1, 3, 4
3. Motivational interviewing (MI) is a technique that applies understanding a patient's values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply.) 1. Gaining an understanding of the patient's motivations 2. Directing the patient to avoid poor health choices 3. Recognizing the patient's strengths and supporting his or her efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors
1, 3, 5;
6. The patient states, "I don't have confidence in my doctor. She looks so young." The nurse therapeutically responds: (Select all that apply.) 1. Tell me more about your concern. 2. You have nothing to worry about. Your doctor is perfectly competent. 3. You are worried about your care? 4. You can go online and see how others have rated your doctor. I do that. 5. You should ask your doctor to tell you her background.
1, 3;
9. Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility
1, 3;
3. Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.
1, 5, 6;
10. A patient is receiving total parenteral nutrition (TPN). What are the primary interventions the nurse should follow to prevent a central line infection? (Select all that apply.) 1. Change the dressing using sterile technique. 2. Change TPN containers every 48 hours. 3. Change the TPN tubing every 24 hours. 4. Monitor glucose levels to watch and assess for glucose intolerance. 5. Elevate head of the bed 45 degrees to prevent aspiration.
1,3
4. What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness
1,4
8. A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights
1,4
2. The nurse is evaluating the recent lab results for a patient. Which labs are the best indicators for malnutrition? (Select all that apply.) 1. Serum total protein 2. Potassium 3. Lipids 4. Albumin 5 Serum BUN
1,5
1. The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours.
2.
The nurse works at an agency where military time is used for documentation, and needs to document that a patient was transported to the operating room for an emergency procedure at 8 in the evening. Point to the area on the clockface below that indicates 8 in the evening in military time:
2000
10. Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright
3
3. When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation
3
6. A client is receiving an enteral feeding at 65 mL/hr. The gastric residual volume in 4 hours was 125 mL. What is the priority nursing intervention? 1. Assess bowel sounds. 2. Raise the head of the bed to at least 45 degrees. 3. Continue the feedings; this is normal gastric residual for this feeding. 4. Hold the feeding until you talk to the primary care provider.
3
6. The nurse is administering a dose of metoprolol to a patient, and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert that states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)
3
10. A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?
4
2. The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.
4
3. The nurse is caring for a client with dysphagia and is feeding her a pureed chicken diet when she begins to choke. What is the priority nursing intervention? 1. Suction her mouth and throat. 2. Turn her on her side. 3. Put on oxygen at 2 L nasal cannula. 4. Stop feeding her.
4
The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN
4
The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-to-moist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast
4
7. The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.) 1. Validate health care needs through verbal discussion with the patient. 2. Compare actual and expected patient care outcomes with the patient. 3. Provide support through therapeutic communication techniques. 4. Complete a nursing history using verbal communication techniques.
4, 1, 3, 2
7. Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure.
6, 4, 2, 1, 5, 3, 7
A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states, A. "I will record the amount of all voided urine." B. "I will not count liquid stools as output." C. "I will not record a café mocha as intake." D. "I will notate perspiration and record it as a small or large amount."
A. "I will record the amount of all voided urine."
. A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception.
C. narrative charting.
Message
Content of the message
Interpersonal variables
Factors that influence communication
Feedback
Message the receiver returns
The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage 7. Rates pain 7/10 at location of surgical incision.
O: 1, 2, 3, 5, 6, 7. S: 4;
Sender and receiver
One who encodes and one who decodes the message
Which patient diagnosis increases the risk for developing neurogenic dysphagia? a.Benign peptic stricture b.Muscular dystrophy c.Myasthenia gravis d. Stroke
d. stroke
The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube? a.From the tip of the nose to the earlobe b.From the tip of the earlobe to the xiphoid process c.From the tip of the earlobe to the nose to the xiphoid process d.From the tip of the nose to the earlobe to the xiphoid process
d.From the tip of the nose to the earlobe to the xiphoid process
A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? a. To promote autonomy b.To use common courtesy c.To establish trustworthiness d.To standardize communication
d.To standardize communication
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? a.Run lipids for no longer than 24 hours. b.Take down a running bag of TPN after 36 hours. c.Clean injection port with alcohol 5 seconds before and after use. d.Wear a sterile mask when changing the central venous catheter dressing.
d.Wear a sterile mask when changing the central venous catheter dressing.
