Combo with 37 review questions for activity and exercise and 1 other

Disadvantages of Oral, Buccal and Sublingual Routes

--GI irritation

Disadvantages for Skin

--absorption occurs too rapid over abrasions --medications overall absorb slowly through this route

Advantages of Parenteral Routes

--can be used when oral drugs are contraindicated --more rapid absorption --epidural provides excellent pain control

Disadvantages for MM

--highly sensitive --awkward(vaginal and rectal)

Heat or Cold? Decreased Blood Viscosity

Heat

_________________ is the high-pitched, drumlike sound heard over a gastric air bubble

Tympany

What is an anti-pyretic?

a medicine that counteracts fever

What portion of the hand should be used when assessing for thorax excursion?

palmar surface

What are petechiae?

pin-point red or purple spots caused by small hemorrhages

dihiscence

rupture separion of one or more layers of a wound.

What does the abbreviation F/U stand for?

follow up

Define pyrexia

heat/fever

Disadvantages of Parenteral Routes

--introducing infection --tissue damage --more expensive --quicker absorption=quicker adverse reactions --more painful

A complete health assessment includes which of the following: A. Health History B. Doctor's Orders C. Behavioral Exam D. Physical Exam E. Nursing Diagnoses

A, C, D

The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?"

B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

If a patient is hypothermic, which action should be taken 1st, 2nd and 3rd? A. cover with warm blanket B. give warm IV fluids C. remove wet clothing

C, A, B

Place the following activities of planning in the correct order of their use. A: Establish goals/outcomes B: Write the care plan C: Set priorities D: Choose interventions

C: Set priorities A: Establish goals/outcomes D: Choose interventions B: Write the care plan

An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic

D) Temperature = 39° C (102° F), tympanic

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

On the chart, the health assessment is found under ____________________.

H&P

Position of ear for adult

Up and Back

What is malignant hyperthermia?

a hereditary condition of uncontrolled heat production, occurring when susceptible persons receive certain anesthetic drugs.

Which of the following terms is defined as the sense of identification with a collective cultural group? a. ethnicity b. race c. cultural acquisition d. culture shock

a. Ethnicity is the sense of identification with a collective cultural group, largely based on the group's common heritage.

Which of the following levels of basic human needs is most basic? a. Physiologic b. Safety & Security c. Love & belonging d. Self-actualization

a. Physiologic

Which nursing organization was the first international organization of professional women? a. ICN b. ANA c. NLN d. NSNA

a. The ICN, founded in 1899, was the first international organization of professional women.

A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? a. Two to three pillow orthopnea b. Dyspnea on excursion c. Resting apnea d. Dyspnea at rest

a. Two to three pillow orthopnea

You tell your instructor that your patient is fine and has "no complaints." You are likely to hear: a. You made an inference that she is fine because she has no complaints.How did you validate this? b. She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship. c. Sometimes everyone gets lucky. Why don't you try to help another patient? d. Maybe you should reassess the patient. He has to have a problem. Why else would he be here?

a. You made an inference that she is fine because she has no complaints.How did you validate this?

16. The nurse is caring for a client diagnosed with bilateral middle ear infections. Which of the following statements made by the nurse best reflects an understanding of the effects of this condition on the client's ability to move appropriately? 1. "He hasn't reported any nausea or vomiting." 2. "His ability to hear doesn't seem to be affected." 3. "I'll identify the client as a high falls' risk by noting it on his Kardex." 4. "I believe he is capable of using his call bell when he needs assistance."

"I'll identify the client as a high falls' risk by noting it on his Kardex."

17. An obese quadriplegic client has requested being transferred to a chair so he can be fed lunch sitting upright. Which of the following statements made by the ancillary personnel assigned the task reflects the best understanding of the implementation of this transfer? 1. "I'll reserve the mechanical lift for right before lunch." 2. "I'll certainly need someone to help me with this transfer." 3. "Eating in an upright position will certainly make lunch more enjoyable for him." 4. "Maybe he would enjoy being transferred into the dayroom to eat with the others."

"I'll reserve the mechanical lift for right before lunch."

20. Which of the following statements made by a woman recently diagnosed with osteoporosis indicates the greatest degree of readiness to begin a daily walking routine? 1. "The tests showed that I have osteoporosis and need to walk." 2. "I've walked around the local park three times, and that measures 1.75 miles." 3. "My sister has this problem, and she walks one mile a day around her neighborhood." 4. "I can join the spa and use the treadmill when the weather gets too cold to walk outside."

"I've walked around the local park three times, and that measures 1.75 miles."

A patient with cancer is experiencing increased pain issues. A plan is developed for adding ibuprofen 600mg BID to the medication regimen of narcotics. The patient asks the nurse why he is now expected to take ibuprofen because he does not have arthritis. What is the most appropriate reply by the nurse?

"Ibuprofen increases the effects of your narcotic, providing better pain relief" Nonsteroidal anti-inflammatory drugs potentiate the effects of opiates and, when in combination, are of particular use in cancer patients because of major contributing factor of pain is cell destruction. Narcotic doses may still need to be increased as the disease is progressive. NSAIDS have an anti-inflammatory effect, but the ability to block prostaglandin synthesis promotes their pain-relieving properties. There is no information to support that they act more slowly or extend pain relief.

14. A postmenopausal client is experiencing mild osteopenia and has been encouraged to walk 1 mile daily. Which of the following statements made by the client shows the best understanding of the positive effects of exercise on her condition? 1. "It makes me stronger and healthier." 2. "It helps make all my bones stronger." 3. "Walking increases the muscle mass in my legs." 4. "Regular walking improves my stamina and endurance."

"It helps make all my bones stronger."

21. Which of the following statements made by an older adult reflects the best understanding of the need to exercise no matter one's age? 1. "You are never too old to start exercising." 2. "My grandson and I walk together around the park 3 times a week." 3. "I got my granddaughter a subscription to a runner's magazine for her birthday." 4. "Kids today just don't seem to get the exercise we did when I was growing up."

"My grandson and I walk together around the park 3 times a week."

Three days after undergoing exploratory laparotomy and lysis of adhesions, a patient tells the nurse that his pain is no better than on the first day postop and he fears that he will be unable to return to his work withing the allotted time frame. Which response by the nurse is the most appropriate for the situation?

"You have undergone a major surgery, which is a major stressor to your body. As your body heals, your pain should resolve" Acute pain occurs after surgury and is usually limited and of predictable duration. Increased activity is needed to maintain function, promote healing, and prevent complications of surgery.

27. The nurse has delegated the task of ambulating a client who is experiencing activity intolerance. Which of the following statements made by the nurse best reflects an understanding of the nurse's role to properly instruct the ancillary personnel regarding this task? 1. "Stop the walking if the client complains of pain or weakness." 2. "Please be sure she has proper footwear on before starting out." 3. "Be sure to document the time spent and the distance she walked." 4. "Take her blood pressure and pulse both before and after walking."

"Stop the walking if the client complains of pain or weakness."

30. The nurse is discussing the benefits of regular walking with a group of senior citizens. Which of the following statements shows the best understanding of the positive impact of exercise on the older adult? 1. "Remember to warm up and cool down with stretching exercises." 2. "Find a walking partner that will accompany you on a regular basis." 3. "Be sure to hydrate yourself well before, during, and after your walk." 4. "Talk with your health care provider before starting a regular walking program."

"Talk with your health care provider before starting a regular walking program."

22. Which of the following nursing assessment questions will best determine the nature of an exercise-related injury? 1. "Do you experience the pain during or after your workout?" 2. "Tell me what is included in your typical workout routine." 3. "How long does it hurt after you have stopped exercising?" 4. "On a scale of 1 to 10, please rate your postexercise pain for me."

"Tell me what is included in your typical workout routine."

When assessing chronic pain in the older adult, which question will be most helpful in determining appropriate interventions?

"What treatments have you used and which have been most helful?" Chronic pain may begin insidiously and many remedies may have been tried before seeking treatment.

Identify initial assessment findings for a patient with EARLY STAGE LEFT sided heart failure

- fatigue - breathlessness - dizziness - confusion as a result of tissue hypoxia from the diminished CO

full thickness wound repair

- inflammatory (up to 3 days) - proliferative (3-24 days) - remodeling (up to 1 yr.)

partial thickness wound repair

- inflammatory response (24hrs.) - epithelial proliferation/migration - reestablishment of epidermal layers

Advantages of Oral, Buccal and Sublingual Routes

--Conveinent and comfortable --Economical --Sometimes produce local or systemic effects --rarely cause anxiety

Advantages for MM

--local application provides therapeutic effects --aqueous solutions readily absorbed and capable of causing systemic effects --potential ROA when oral drugs are contraindicated

Advantages for Skin

--local effect --painless --limited side effects

Advantages for Inhalation

--rapid relief

Disadvantages for Inhalation

--serious systemic effects

THE NURSE IS PREPARING TO ADMINISTER A MEDICATION VIA NG TUBE. WHAT GUIDELINE IS APPROPRIATE FOR THE NURSE TO FOLLOW WHEN ADMINISTERING A DRUG VIA THIS ROUTE? FLUSH THE TUBE WITH WATER BETWEEN EACH MED

...

Which of the following are examples of well-stated nursing interventions? 1. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. 2. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. 3. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. 4. Manage patient's pain.

1, 2, 3

To prevent recurrence of cystitis, the nurse should plan to encourage the female client to include which of the following measures in her daily routine? 1. Wearing cotton underpants. 2. Increasing citrus juice intake. 3. Douching regularly with 0.25% acetic acid. 4. Using vaginal sprays.

1. A woman can adopt several health-promotion measures to prevent the recurrence of cystitis, including avoiding too-tight pants, noncotton underpants, and irritating substances, such as bubble baths and vaginal soaps and sprays. Increasing citrus juice intake can be a bladder irritant. Regular douching is not recommended; it can alter the pH of the vagina, increasing the risk of infection.

A client had a left- sided cerebral vascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enternal feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? 1. Hematuria 2. Unilateral neglect 3. Limited ROM in the right hip 4. Coughing up moderate amount clear, thin sputum

1. Hematuria

A client has nephropathy. The physician orders that a 24-hour urine collection be done for creatinine clearance. Which of the following actions is necessary to ensure proper collection of the specimen? 1. Collect the urine in a preservative-free container and keep it on ice. 2. Inform the client to discard the last voided specimen at the conclusion of urine collection. 3. Ask the client what his weight is before beginning the collection of urine. 4. Request an order for insertion of an indwelling urinary catheter.

1. All urine for creatinine clearance determination must be saved in a container with no preservatives and refrigerated or kept on ice. The first urine voided at the beginning of the collection is discarded, not the last. A self-report of weight may not be accurate. It is not necessary to have an indwelling urinary catheter inserted for urine collection.

Which of the following statements by the client would indicate that she is at high risk for a recurrence of cystitis? 1. "I can usually go 8 to 10 hours without needing to empty my bladder." 2. "I take a tub bath every evening." 3. "I wipe from front to back after voiding." 4. "I drink a lot of water during the day."

1. Stasis of urine in the bladder is one of the chief causes of bladder infection, and a client who voids infrequently is at greater risk for reinfection. A tub bath does not promote urinary tract infections as long as the client avoids harsh soaps and bubble baths. Scrupulous hygiene and liberal fluid intake (unless contraindicated) are excellent preventive measures, but the client also should be taught to void every 2 to 3 hours during the day.

When teaching the client with a urinary tract infection about taking phenazopyridine hydrochloride (Pyridium), the nurse should tell the client to expect: 1. Bright orange-red urine. 2. Incontinence. 3. Constipation. 4. Slight drowsiness.

1. The client should be told that phenazopyridine hydrochloride (Pyridium) turns the urine a bright orange-red, which may stain underwear. It can be frightening for a client to see orange-red urine without having been forewarned. Other common adverse effects associated with phenazopyridine include headaches, gastrointestinal disturbances, and rash. Phenazopyridine does not cause incontinence, constipation, or drowsiness.

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results pH 6.8, RBC 3 per high power field, color-yellow, specific gravity-1.030 . The nurse should: 1. Encourage the client to increase fluid intake. 2. Withhold the next dose of antihypertensive medication. 3. Restrict the client's sodium intake. 4. Encourage the client to eat at least half of a banana per day.

1. The client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.

What are the three functions of the colon?

1. Absorption 2. Secretion 3. Elimination

Which of the following laboratory values would you expect in a client experiencing prolonged immobility? 1. Elevated calcium 2. Decreased sodium 3. Elevated hemoglobin 4. Elevated potassium

1. Elevated calcium

Unmet and partially met goals require the nurse to do which of the following? (Choose all that apply.) 1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the client's response with that of another client

1. Redefine priorities 2. Continue intervention

1. When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.) 1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 5. Increased cognitive function 6. Increased musculoskeletal flexibility

1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 6. Increased musculoskeletal flexibility

Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? (choose all that apply) 1. The client's weight 2. How cooperative the client is 3. The client's nutritional status 4. The presence of intravenous (IV) tubes

1. The client's weight 2. How cooperative the client is 4. The presence of intravenous (IV) tubes

Which is the most effective nursing action for controlling the spread of infection? 1.Thorough hand hygiene. 2.Wearing gloves and masks when providing direct client care. 3.Implementing appropriate isolation precautions. 4.Administering broad-spectrum prophylactic antibiotics.

1. Thorough hand hygiene. Rationale: Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand hygiene is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring standard precautions (option 2). Isolation precautions are used for clients with known communicable diseases (option 3). Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms (option 4).

AT WHAT POINT SHOULD THE NURSE DO THE 3 CHECKS OF MEDICATION ADMINISTRATION? A AS THE NURSE REACHES FOR THE DRUG PACKAGE B WHEN REVIEWING THE PATIENT;S MAR C AT THE BEGINNING OF SHIFT D AFTER RETRIEVING THE DRUG

A

Isotonic exercises such as walking are intended to achieve which of the following? Select all that apply. 1.Increase muscle tone and improve circulation. 2.Increase blood pressure. 3.Increase muscle mass and strength. 4.Decrease heart rate and cardiac output. 5.Maintain joint range of motion.

1.Increase muscle tone and improve circulation. 3.Increase muscle mass and strength. 5.Maintain joint range of motion. Rationale: Isotonic exercise increases muscle tone, mass, and strength, maintains joint flexibility, and improves circulation. During isotonic exercise, both heart rate and cardiac output quicken to increase blood flow to all parts of the body (option 4). Little or no change in blood pressure occurs (option 2).

Five minutes after the client's first postoperative exercise, the client's vital signs have not yet returned to baseline. Which is an appropriate nursing diagnosis? 1.Activity Intolerance. 2.Risk for Activity Intolerance. 3.Impaired Physical Mobility. 4.Risk for Disuse Syndrome.

1.Activity Intolerance. Rationale: Vital signs that do not return to baseline 5 minutes after exercising indicate intolerance of exercise at that time. This is a real problem, not "at risk for," as in option 2. There is no evidence that the client requires assistance (impaired mobility, option 3), or is immobile (disuse syndrome, option 4).

During an assessment, the nurse learns that the client has a history of liver disease. Which diagnostic tests might be indicated for this client? Select all that apply. 1.Alanine aminotransferase (ALT) 2.Myoglobin 3.Cholesterol 4.Ammonia 5. Brain natriuretic peptide or B-Type natriuretic peptide (BNP)

1.Alanine aminotransferase (ALT) 4.Ammonia Rationale: ALT is an enzyme that contributes to protein and carbohydrate metabolism. An increase in the enzyme indicates damage to the liver. The liver contributes to the metabolism of protein, which results in the production of ammonia. If the liver is damaged, the ammonia level is increased. Options 2, 3, and 5 (myoglobin, cholesterol, and BNP) are relevant for heart disease.

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority? 1. Automobile crashes 2. Drowning and firearms 3. Falls 4. Suicide and homicide

1.Automobile crashes Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply. 1. Document the behavior(s) that require continued use of the restraints. 2. Ensure that the restraints are tied to the side rails. 3. Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints.

1.Document the behavior(s) that require continued use of the restraints. 3.Provide range-of-motion exercises when the restraints are removed. 4. Orient the client. 5. Assess the tightness of the restraints. Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint

Performance of activities of daily living (ADLs) and active range of motion (ROM) exercises can be accomplished simultaneously as illustrated by which of the following? Select all that apply. 1.Elbow flexion with eating and bathing. 2.Elbow extension with shaving and eating. 3.Wrist hyperextension with writing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking.

1.Elbow flexion with eating and bathing. 4.Thumb ROM with eating and writing. 5.Hip flexion with walking. Rationale: Eating and bathing will flex the elbow joint, and grasping and manipulating utensils to eat and write will take the thumb through its normal ROM. Walking flexes the hip. Shaving and eating require elbow flexion, not extension (option 2). Writing brings the fingers toward the inner aspect of the forearm, thus flexing the wrist joint (option 3).

The client with cystitis is given a prescription for phenazopyridine hydrochloride (Pyridium). The nurse should teach the client that this drug is used to treat urinary tract infections by: 1. Releasing formaldehyde and providing bacteriostatic action. 2. Potentiating the action of the antibiotic. 3. Providing an analgesic effect on the bladder mucosa. 4. Preventing the crystallization that can occur with sulfa drugs.

3. Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic that works directly on the bladder mucosa to relieve the distressing symptoms of dysuria. Phenazopyridine does not have a bacteriostatic effect. It does not potentiate antibiotics or prevent crystallization.

When assessing a client's gait, which does the nurse look for and encourage? 1.The spine rotates, initiating locomotion. 2.Gaze is slightly downward. 3.Toes strike the ground before the heel. 4.Arm on the same side as the swing-through foot moves forward at the same time.

1.The spine rotates, initiating locomotion. Rationale: Normal gait involves a level gaze, an initial rotation beginning in the spine, heel strike with follow-through to the toes, and opposite arm and leg swinging forward.

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment? 1.Goggles 2.Gown 3.Surgical mask 4. Clean gloves

1.goggles Rationale: Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused.

NREM stage 2

10-20 min, can be awakened w/effort, deeper relaxation

What is the acceptable range for respiration?

12 - 20 RR/min

What is the average acceptable rate for blood pressure?

120/80

A client who weighs 207 lb is to receive 1.5 mg/ kg of gentamicin sulfate (Garamycin) I.V. three times each day. How many milligrams of medication should the nurse administer for each dose? Round to the nearest whole number. __________________ mg.

141 mg

Nitrofurantoin (Macrodantin), 75 mg four times per day, has been prescribed for a client with a lower urinary tract infection. The medication comes in an oral suspension of 25 mg/ 5 mL. How many milliliters should the nurse administer for each dose? ________________________ mL.

15 mL

NREM stage 3

15-30 min, early phase of deep sleep, snoring, relaxed muscle tone, little/no physical movement, difficult to arouse

NREM stage 4

15-30 min, shortens toward morning, deep sleep, sleep-walking, sleep-talking, bed-wetting may occur

Type of Syringe and Needle for ID

1ml 25-27 g 3/8-5/8"

Which of he following outcomes are correctly written? 1. Offer Mr Myer 60 mL fluid every 2 hours while awake. 2. During the next 24-hr period, the patient's fluid intake will total at least 2,000 mL. 3. By discharge Mrs Gaston will know how to bathe her newborn. 4. At the next visit, 12/23/12, the patient will correctly demonstrate relaxation exercises.

2 & 4

During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to do which of the following? 1) Formulate and validate prioritized nursing diagnoses 2) Identify expected patient outcomes 3) Select evidence-based nursing interventions 4) Communicate the plan of nursing care

2, 3 & 4

A client has been prescribed nitrofurantoin (Macrodantin) for treatment of a lower urinary tract infection. Which of the following instructions should the nurse include when teaching the client how to take this medication? Select all that apply. 1. "Take the medication on an empty stomach." 2. "Your urine may become brown in color." 3. "Increase your fluid intake." 4. "Take the medication until your symptoms subside." 5. "Take the medication with an antacid to decrease gastrointestinal distress."

2, 3. Clients who are taking nitrofurantoin (Macrodantin) should be instructed to take the medication with meals and to increase their fluid intake to minimize gastrointestinal distress. The urine may become brown in color. Although this change is harmless, clients need to be prepared for this color change. The client should be instructed to take the full prescription and not to stop taking the drug because symptoms have subsided. The medication should not be taken with antacids as this may interfere with the drug's absorption.

Use Maslow's hierarchy of human needs to prioritize the following patient problems from highest priority (#1) to lowest priority (#4): 1) Disturbed Body Image 2) Ineffective Airway Clearance 3) Spiritual Distress 4) Impaired Social Interaction

2, 4, 1, 3

The client at greatest risk for developing adverse effects of immobility is a: 1. 3-year-old child with a fractured femur 2. 78-year-old man in traction for a broken hip 3. 48-year-old woman following a thyroidectomy 4. 38-year-old woman undergoing a hysterectomy

2. 78-year-old man in traction for a broken hip

To auscultate the client's lung fields, the nurse uses a systematic pattern comparing: A) Side to side B) Top to bottom C) Anterior to posterior D) Interspace to interspace

A Side to side

What historic event in the 20th century led to an increased emphasis on nursing and broadened the role of nurses? a. religious reform b. crimean war c. world war II d. Vietnam War

c. World War II

The nurse teaches a female client who has cystitis methods to relieve her discomfort until the antibiotic takes effect. Which of the following responses by the client would indicate that she understands the nurse's instructions? 1. "I will place ice packs on my perineum." 2. "I will take hot tub baths." 3. "I will drink a cup of warm tea every hour." 4. "I will void every 5 to 6 hours."

2. Hot tub baths promote relaxation and help relieve urgency, discomfort, and spasm. Applying heat to the perineum is more helpful than cold because heat reduces inflammation. Although liberal fluid intake should be encouraged, caffeinated beverages, such as tea, coffee, and cola, can be irritating to the bladder and should be avoided. Voiding at least every 2 to 3 hours should be encouraged because it reduces urinary stasis.

A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. When obtaining the client's history, the nurse should ask the client if she has had: 1. Fever and chills. 2. Frequency and burning on urination. 3. Flank pain and nausea. 4. Hematuria.

2. The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination. Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis than cystitis. Hematuria may occur, but it is not as common as frequency and burning.

A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. A trapeze bar 2. A small transfer board 3. A powered standing-assist device 4. An ankle foot orthotic (AFO) for the affected foot

2. A small transfer board

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 1.Eliminate the reservoir. 2. Block the portal of exit from the reservoir. 3. Block the portal of entry into the host. 4.Decrease the susceptibility of the host.

2. Block the portal of exit from the reservoir. Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Since the carrier person is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir (option 1). Blocking the entry into a host (option 3) or decreasing the susceptibility of the host (option 4) will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir.

An operating room nurse has just finished setting up a sterile field for a kidney transplant surgery. She gets word that the donor organ will not be available for another thirty minutes. Which of the following is the best course of action? A) Personally watch the sterile field to ensure that it is not broken. B) Place cones or barriers in front of the main OR doors. C) Place sterile drapes over all surfaces. D) Thirty minutes is too long. The sterile field will need to be broken and reestablished later

A

A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an appropriate evaluative criterion used by the nurse? (Choose all that apply.) 1. Client drinks contents of water glass. 2. Client's lungs are clear to auscultation in bases. 3. Client reports abdominal pain on scale of 0 to 10. 4. Client's rate and depth of breathing are normal with head of bed elevated.

2. Client's lungs are clear to auscultation in bases. 4. Client's rate and depth of breathing are normal with head of bed elevated.

THE NURSE SHOULD USE EXTREME CAUTION WHEN APPLYING HEAT THERAPY TO WHICH OF THE FOLLOWING PATIENTS: A UNCONSCIOUS B HIGH PAIN SENSITIVITY C VENOUS ULCER D RECEIVING STEROIDS

A

Which nurse in history is credited with establishing nursing education? a. clara barton b. lilian wald c. lavinia dock d. florence nightingale

d. Florence Nightingale established nursing education

A primary care provider is going to perform a thoracentesis. The nurse's role will include which action? 1.Place the client supine in the Trendelenburg position. 2.Position the client in a seated position with elbows on the overbed table. 3.Instruct the UAP to measure vital signs. 4.Administer an opioid analgesic.

2. Position the client in a seated position with elbows on the overbed table. Rationale: The puncture site is usually on the posterior chest. The client should be positioned leaning forward. This will allow the ribs to separate for exposure of the site. Option 1 is incorrect. The client should not be placed in the Trendelenburg position because the site would not be exposed. Option 3 is incorrect since changes in vital signs do not routinely occur with this procedure. Option 4 is incorrect. The client does not need to be medicated for pain with this procedure.

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred? 1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day." 2. "We must wash or peel all raw fruits and vegetables before eating." 3. "A wound or sore is not infected unless we see it draining pus." 4. "We should not share toothbrushes but it is OK to share towels and washcloths."

2."We must wash or peel all raw fruits and vegetables before eating." Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels (option 4).

The client is supposed to have a fecal occult blood test done on a stool sample. The nurse is going to use the Hemoccult test. Which of the following indicates that the nurse is using the correct procedure? Select all that apply. 1.Mixes the reagent with the stool sample before applying to the card. 2.Collects a sample from two different areas of the stool specimen. 3.Assesses for a blue color change. 4.Asks a colleague to verify the pink color results. 5.Asks the client if he has taken vitamin C in the past few days.

2.Collects a sample from two different areas of the stool specimen. 3.Assesses for a blue color change. 5.Asks the client if he has taken vitamin C in the past few days. Rationale: The nurse should obtain the stool specimen from two different areas of the stool. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse should assess for the ingestion of vitamin C by the client because it is contraindicated for 3 days prior to taking the specimen. Option 1 is incorrect since the reagent is placed on the specimen after it is applied to the testing card. Option 4 is incorrect because a pink color would be considered negative and does not require verification.

The nurse would call the primary care provider immediately for which laboratory result? 1.Hgb = 16 g/dL for a male client. 2.Hct = 22% for a female client. 3.WBC = 9 x 10³/mL³ 4.Platelets = 300 x 10³/mL³

2.Hct = 22% for a female client. Rationale: Option 2 is very low and can lead to death. The client's red blood cells participate in oxygenation. Options 1, 3, and 4 are within normal range and should not be reported to the primary care provider.

The client has a urinary health problem. Which procedure is performed using indirect visualization? 1.Intravenous pyelography (IVP) 2.Kidneys, ureter, bladder (KUB) 3.Retrograde pyelography 4.Cystoscopy

2.Kidneys, ureter, bladder (KUB) Rationale: A KUB is an x-ray of the kidneys, ureters, and bladder. This does not require direct visualization. Option 1 is an IVP, an intravenous pyelogram, which requires the injection of a contrast media. Option 3 is a retrograde pyelography, which requires the injection of a contrast media. Option 4 is a cytoscopy, which uses a lighted instrument (cystoscope) inserted through the urethra, resulting in direct visualization.

So that breast tissue will be spread evenly over the chest wall during an examination, the nurse asks the client to lie supine with: A) The ipsilateral arm behind the head B) Hands clasped just above the umbilicus C) Both arms overhead with palms upward D) The dominant arm straight alongside the body

A The ipsilateral arm behind the head

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at this time of admission? Select all that apply. 1.Place a padded tongue depressor at the head of the bed. 2.Pad the bed with blankets. 3. Inform the client about the importance of wearing a medical identification tag. 4. Teach the client about epilepsy. 5. Test oral suction equipment

2.Pad the bed with blankets. 5.Test oral suction equipment. Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client's mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy.

The nurse evaluates the chart of a 65-year-old client and concludes that which immunizations are current? (Select all that apply.) 1.Last tetanus booster was at age 50. 2.Receives a flu shot every year. 3.Has not received the hepatitis B vaccine. 4.Has not received the hepatitis A vaccine. 5.Has not received the herpes zoster vaccine.

2.Receives a flu shot every year. 3.Has not received the hepatitis B vaccine. 4.Has not received the hepatitis A vaccine. Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note, this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination.

The nurse is performing an assessment of an immobilized client. Which assessment causes the nurse to take action? 1.Heart rate 86 2.Reddened area on sacrum 3.Nonproductive cough 4.Urine output of 50 mL/hour

2.Reddened area on sacrum Rationale: The reddened area of the skin can lead to skin breakdown. The other options are within normal limits.

What is white coat syndrome?

A fear of going to the doctor or having a medical procedure done

The nurse needs to collect a sputum specimen to identify the presence of tuberculosis (TB). Which nursing action(s) is/are indicated for this type of specimen? Select all that apply. 1.Collect the specimen in the evening. 2.Send the specimen immediately to the laboratory. 3.Ask the client to spit into the sputum container. 4.Offer mouth care before and after collection of the sputum specimen. 5.Collect a specimen for 3 consecutive days.

2.Send the specimen immediately to the laboratory. 4.Offer mouth care before and after collection of the sputum specimen. 5.Collect a specimen for 3 consecutive days. Rationale: The sputum specimen should be sent immediately to the laboratory. The client should be provided mouth care before and after the specimen is collected. The sputum specimen should be collected for three consecutive days. Option 1 is incorrect because the sputum specimen is collected in the morning not in the evening. Option 3 is incorrect because the term spit indicates that saliva is being examined. The client needs to cough up or expectorate mucus or sputum.

To increase stability during client transfer, the nurse increases the base of support by performing which action? 1.Leaning slightly backward. 2.Spacing the feet farther apart. 3.Tensing the abdominal muscles. 4.Bending the knees.

2.Spacing the feet farther apart. Rationale: A key word in the question is base, and the feet provide this foundation. Leaning backward actually decreases balance (option 1), and tensing abdominal muscles alone (option 3) or bending the knees (option 4) does not affect the base of support.

32. A client who will be going home will need to use crutches for ambulation. Following teaching, the nurse notes that the client complains of pain under his arms. How much room should be between the crutch pad and client's axilla? 1. Axilla should lightly touch the crutch pad 2. 1 to 2 finger widths from the axilla 3. 3 to 4 finger widths from the axilla 4. 4 to 5 finger widths from the axilla

3 to 4 finger widths from the axilla

NREM stage 1

A few minutes, light sleep, easily aroused, gradual reduction in vital signs

What is affect?

A person's outward expression of their inner mood. Example: smiling

The nurse has delegated administration of 10am medications to an LPN/LVN. At 10:15am, the nurse notes none of the medications have been administer yet. Which is the best action for the nurse to take? a) ask another LPN/LVN assigned to the unit to help administer medications b) begin administering the medications c) report he situation to the head nurse d) ask the LPN/LVN to give the nurse a status report

A

hematoma

the collection of blood under the skin as the result of blood escaping into the tissue from damaged blood vessels. bruise

What does a pulse oximeter measure?

the oxygenation of a patient's hemoglobin

A client with a urinary tract infection is to take nitrofurantoin (Macrodantin) four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client? 1. "You can wait and take the next dose when it is due." 2. "Double the amount prescribed with your next dose." 3. "Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." 4. "Take a lot of water with a double amount of your prescribed dose."

3. Antibiotics have the maximum effect when a blood level of the medication is maintained. However, because nitrofurantoin (Macrodantin) is readily absorbed from the gastrointestinal tract and is primarily excreted in urine, toxicity may develop by doubling the dose. The client should not skip a dose if she realizes that she has missed one. Additional fluids, especially water, should be encouraged, but not forced to promote elimination of the antibiotic from the body. Adequate fluid intake aids in the prevention of urinary tract infections, in addition to an acidic urine.

How can you determine a patient's history of allergies? (Select all that apply.) A) By looking at the patient's allergy bracelet B) By looking at the MAR C) By asking the patient D) By looking at the front of the chart E) By administering a dose and monitoring the patient's response

ABCD

All of the following are examples of increased risk for pressure ulcers (select all that apply) A Wheelchair Bound B Peripheral Vascular Disease C Diabetes D Malnourishment E Incontinence

ABCDE

When performing a tugor test, if the skin stays up after 3 seconds, what might you conclude?

the patient is dehydrated

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply. 1.Hire only competent nurses. 2.Improve the nurse's ability to multitask. 3.Establish a reporting system for "near misses." 4.Communicate effectively. 5.Create a culture of trust

3. Establish a reporting system for "near misses." 4.Communicate effectively. 5.Create a culture of trust. Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions.

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform? 1.Wear a mask during dressing changes. 2. Provide disposable meal trays and silverware. 3. Follow standard precautions in all interactions with the client. 4. Use surgical aseptic technique for all direct contact with the client.

3. Follow standard precautions in all interactions with the client. Rationale: Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room. A mask is indicated when working over a sterile wound rather than an infected one (option 1). Disposable food trays are not necessary for clients with infected wounds unlikely to contaminate the client's hands (option 2). Sterile technique (surgical asepsis) is not indicated for all contact with the client (option 4). The nurse would utilize clean technique when dressing the wound to prevent introduction of additional microbes.

The nurse practitioner requests a laboratory blood test to determine how well a client has controlled her diabetes during the past 3 months. Which blood test will provide this information? 1.Fasting blood glucose 2.Capillary blood specimen 3.Glycosylated hemoglobin 4.GGT (gamma-glutamyl transferase)

3. Glycosylated hemoglobin Rationale: A glycosylated hemoglobin will indicate the glucose levels for a period of time, which is indicated by the nurse practitioner. Options 1 and 2 will provide information about the current blood glucose not the past history. Option 4 is used to assess for liver disease

A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record? 1. Rebound hypotension 2. Positional hypotension 3. Orthostatic hypotension 4. Central venous hypotension

3. Orthostatic hypotension

Which of the following patients have risk factors for developing a wound infection? (Select all that apply.) A) An 80-year-old man who has a burn B) A 17-year-old patient who has a metal fragment lodged in his thigh C) A 30-year-old female who had an episiotomy after childbirth D) A patient receiving chemotherapy who has a surgical incision E) A patient with peripheral vascular disease and an ulcer on the heel

ABDE

Which statement from a client with one weak leg regarding use of crutches when using stairs indicates a need for increased teaching? 1."Going up, the strong leg goes first, then the weaker leg with both crutches." 2."Going down, the weaker leg goes first with both crutches, then the strong leg." 3."The weaker leg always goes first with both crutches." 4."A cane or single crutch may be used instead of both crutches if held on the weaker side."

3."The weaker leg always goes first with both crutches." Rationale: Although the crutches (or cane) are always used along with the weaker leg, the weaker leg should go down the stairs first. The stronger leg can support the body as the weaker leg moves forward. All of the other statements are correct.

A client weighs 250 pounds and needs to be transferred from the bed to a chair. Which instruction by the nurse to the unlicensed assistive personnel (UAP) is most appropriate? 1."Using proper body mechanics will prevent you from injuring yourself." 2."You are physically fit and at lesser risk for injury when transferring the client." 3."Use the mechanical lift and another person to transfer the client from the bed to the chair." 4."Use the back belt to avoid hurting your back."

3."Use the mechanical lift and another person to transfer the client from the bed to the chair." Rationale: It is prudent for nurses to understand and use proper body mechanics at all times to decrease risk, while keeping in mind the importance of assistive devices and help from other staff. While it is generally accepted that proper body mechanics alone will not prevent injury, many work settings do not yet have "no manual lift" and "no solo lift" policies and resources in place.

A 78-year-old male client needs to complete a 24-hour urine specimen. In planning his care, the nurse realizes that which measure is most important? 1.Instruct the client to empty his bladder and save this voiding to start the collection. 2.Instruct the client to use sterile individual containers to collect the urine. 3.Post a sign stating "Save All Urine" in the bathroom. 4.Keep the urine specimen in the refrigerator.

3.Post a sign stating "Save All Urine" in the bathroom. Rationale: Option 3 is the most important nursing measure. This will inform the staff that the client is on a 24-hour urine collection. Option 1 is not appropriate since the first voided specimen is to be discarded. Option 2 is not an appropriate nursing measure since the specimen container is clean not sterile, and one container is needed—not individual containers. Option 4 is inappropriate because some 24-hour urine collections do not require refrigeration.

When assisting with a bone marrow biopsy, the nurse should take which action? 1.Assist the client to a right side-lying position after the procedure. 2.Observe for signs of dyspnea, pallor, and coughing. 3.Assess for bleeding and hematoma formation for several days after the procedure. 4.Stand in front of the client and support the back of the neck and knees.

3.Assess for bleeding and hematoma formation for several days after the procedure. Rationale: Bone marrow aspiration includes deep penetration into soft tissue and large bones such as the sternum and iliac crest. This penetration can result in bleeding. The client should be observed for bleeding in the days following the procedure. Option 1 is a nursing action during a liver biopsy. Option 2 is a nursing action for a thoracentesis, and Option 4 is a nursing action for a lumbar puncture.

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority? 1.Sports contribute to an adolescent's self-esteem. 2.Sunbathing and tanning beds can be dangerous. 3.Guns are the most frequently used weapon for adolescent suicide. 4. A driver's education course is mandatory for safety.

3.Guns are the most frequently used weapon for adolescent suicide. Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver's education course does not ensure safe practice.

Adduction is movement __________ the body.

toward

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? 1.Leave the bathroom light on. 2. Withhold the client's diuretic medication. 3 Provide a bedside commode. 4. Keep the side rails up.

3.Provide a bedside commode. Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client's medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child? 1.Risk for Suffocation 2. Risk for Injury 3. Risk for Poisoning 4. Risk for Disuse Syndrome

3.Risk for Poisoning Rationale: A home that was built prior to 1978 has lead-based paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint.

The nurse determines that a field remains sterile if which of the following conditions exist? 1. Tips of wet forceps are held upward when held in ungloved hands. 2. The field was set up 1 hour before the procedure. 3. Sterile items are 2 inches from the edge of the field. 4. The nurse reaches over the field rather than around the edges.

3.Sterile items are 2 inches from the edge of the field. Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4).

The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding in regard to wound dehiscence? A) The nurse should be alert for an increase in serosanguineous drainage from the wound. B) Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery. C) The nurse should administer cough suppressant to prevent wound dehiscence. D) The condition is an emergency that requires surgical repair.

A

What is the average acceptable range for pulse pressure?

30 - 50 mm Hg

What is the average acceptable temperature taken axillary?

36.5 C or 97.7 F

What is the average acceptable temperature taken rectally?

37.5 or 99.5 F

What is the average acceptable temperature if taken orally or in the ear?

37.5C or 98.6 F

Type of Syringe and Needle for IM

3ml 20-25g 1-1.5"

Type of Syringe and Needle for SQ

3ml 25-29 g 1/2-5/8"

UPON RESPONDING TO A PATIENTS CALL BELL, THE NURSE DISCOVERS THAT THE PATIENT'S WOUND HAS DEHISCED. INITIAL NURSING MANAGEMENT INCLUDES WHICH OF THE FOLLOWING A COVERING THE WOUND AREA WITH STERILE TOWELS MOISTENED WITH STERILE 0.9% SALINE B CLOSING WOUND WITH STERI STRIPS C HOLDING WOULD TOGETHER AND COVER WITH BLANKET D POURING H202 INTO ABDOMINAL CAVITY AND PACKING WITH GAUZE

A

When teaching a patient about wound healing, the nurse should tell the patient: A) Inadequate nutrition delays wound healing and increases risk of infection. B) Chronic wounds heal more efficiently in a dry, open environment, so leave them open to air when possible. C) Long-term steroid therapy diminishes the inflammatory response and speeds wound healing. D) Fat tissue heals more readily because there is less vascularization.

A

When caring for a patient with a suspected viral infection, which medication order would the nurse question?

Aspirin ASA may pose a risk for people of any age when administered to those with viral infections. Adults have experienced Reye's syndrome-like manifestations.

The ___________________ nerve is a sensory and motor nerve enervating the side of the face and jaw.

trigeminal

Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. True False

true

The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, cystitis is caused by: 1. Congenital strictures in the urethra. 2. An infection elsewhere in the body. 3. Urinary stasis in the urinary bladder. 4. An ascending infection from the urethra.

4. Although various conditions may result in cystitis, the most common cause is an ascending infection from the urethra. Strictures and urine retention can lead to infections, but these are not the most common cause. Systemic infections are rarely causes of cystitis.

The client, who is a newlywed, is afraid to discuss her diagnosis of cystitis with her husband. Which would be the nurse's best approach? 1. Arrange a meeting with the client, her husband, the physician, and the nurse. 2. Insist that the client talk with her husband because good communication is necessary for a successful marriage. 3. Talk first with the husband alone and then with both of them together to share the husband's reactions. 4. Spend time with the client addressing her concerns and then stay with her while she talks with her husband.

4. As newlyweds, the client and her husband need to develop a strong communication base. The nurse can facilitate communication by preparing and supporting the client. Given the situation, an interdisciplinary conference is inappropriate and would not promote intimacy for the client and her husband. Insisting that the client talk with her husband is not addressing her fears. Being present allows the nurse to facilitate the discussion of a difficult topic. Having the nurse speak first with the husband alone shifts responsibility away from the couple.

The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink: 1. Twice as much fluid as usual. 2. At least 1 quart more than usual. 3. A lot of water, juice, and other fluids throughout the day. 4. At least 3,000 mL of fluids daily.

4. Instructions should be as specific as possible, and the nurse should avoid general statements such as "a lot." A specific goal is most useful. A mix of fluids will increase the likelihood of client compliance. It may not be sufficient to tell the client to drink twice as much as or 1 quart more than she usually drinks if her intake was inadequate to begin with.

The nurse is teaching an 80-year-old client with a urinary tract infection about the importance of increasing fluids in the diet. Which of the following puts this client at a risk for not obtaining sufficient fluids? 1. Diminished liver function. 2. Increased production of antidiuretic hormone. 3. Decreased production of aldosterone. 4. Decreased ability to detect thirst.

4. The sensation of thirst diminishes in those greater than 60 years of age; hence, fluid intake is decreased and dissolved particles in the extracellular fluid compartment become more concentrated. There is no change in liver function in older adults, nor is there a reduction of ADH and aldosterone as a normal part of aging.

You are caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following client statements reflects a need for further education? 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if i need to have a bone mineral density check this year." 3. "If i don't drink milk at dinner, i will eat broccoli or cabbage to get the calcium that i need in my diet." 4. "The more frequently i walk the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."

4. "The more frequently i walk, the more likely i will be to fall and break my leg. I think i will get a wheelchair so i don't have to walk any more."

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.

A Check the client's temperature history.

The nurse conducts a general survey of an adult client, which includes: A) Checking appearance and behavior B) Measuring vital signs C) Observing specific body systems D) Conducting a detailed health history

A Checking appearance and behavior

The nurse is caring for a client who has right-sided weak-ness. The nurse needs to help the client walk. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. Hold the client's left hand while walking 2. Hold the client's right hand while walking 3. Put a gait belt on the client and provide support on the left side 4. Put a gait belt on the client and provide support on the right side

4. Put a gait belt on the client and provide support on the right side

A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be: 1. Pain 2. Impaired skin integrity 3. Altered tissue perfusion 4. Risk for activity intolerance

4. Risk for activity intolerance

The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: 1. prevent varicose veins 2. prevent muscular atrophy 3. ensure joint mobility and prevent contractures 4. facilitate the return of venous blood to the heart

4. facilitate the return of venous blood to the heart

The client is ambulating for the first time after surgery. The client tells the nurse, "I feel faint." Which is the best action by the nurse? 1.Find another nurse for help. 2.Return the client to her room as quickly as possible. 3.Tell the client to take rapid, shallow breaths. 4.Assist the client to a nearby chair.

4.Assist the client to a nearby chair. Rationale: Placing the client in a safe position is the best maneuver. Leaving the client creates unsafe conditions because the client may faint before being able to return to her room (options 1 and 2). Rapid, shallow breathing (hyperventilation) may increase the dizziness (option 3).

A GRADUATE NURSE IS ADMINISTERING SEVERAL MEDICATIONS TO A NEWLY ADMITTED PATIENT. WHO IS LEGALLY RESPONSIBLE FOR THE DRUGS ADMINISTERED BY THIS NURSE? A THE NURSE ADMINISTERING THE DRUG B PHARMACIST WHO DISPENSED C NURSE MANAGER D PHYSICIAN WHO WROTE THE ORDER

A

Describe the clinical signs of RIGHT sided heart failure.

weight gain distended neck veins hepatomegaly and splenomegaly dependent peripheral edema

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inch. What is the best action for the nurse to take? 1. Remove the glove and start over with a new pair. 2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand. 3. Ask a colleague to assist by unrolling the cuff. 4. Leave the cuff rolled under.

4.Leave the cuff rolled under. Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the glove (option 3).

A nurse on a pediatric unit is preparing the assignment for the evening shift. The unit employs unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? a) setting up Bryant's traction b) completing the FACES pain scale for a child with sickle cell crisis c) obtaining post-operative vital signs on a client status post-tonsillectomy d) setting up an intravenous therapy pump

A

evisceration

wound separation with protrusion of organs

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting? 1.Keep all of the side rails up. 2.Review prescribed medications. 3.Complete the "get up and go" test. 4.Place the bed in the lowest position.

4.Place the bed in the lowest position. Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option 3 would help the nurse to assess a client's risk for falling but would not prevent injury.

Which noninvasive procedure provides information about the physiology or function of an organ? 1. Angiography 2.Computerized tomography (CT) 3.Magnetic resonance imaging (MRI) 4.Positron emission tomography (PET)

4.Positron emission tomography (PET) Rationale: This type of nuclear scan demonstrates the ability of tissues to absorb the chemical to indicate the physiology and function of an organ. Option 1 is an invasive procedure that focuses on blood flow through an organ. Options 2 and 3 provide information about density of tissue to help distinguish between normal and abnormal tissue of an organ.

A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure? 1.Restrain the client in bed. 2.. Ask a family member to stay with the client. 3..Check the client every 15 minutes. 4.Use a bed exit safety monitoring device.

4.Use a bed exit safety monitoring device. Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client's independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.

A nurse is teaching a client about active range-of-motion (ROM) exercises. The nurse then watches the client demonstrate these principles. The nurse would evaluate that teaching was successful when the client does which of the following? 1.Exercises past the point of resistance. 2.Performs each exercise one time. 3.Performs each series of exercises once a day. 4.Uses the same sequence during each exercise session.

4.Uses the same sequence during each exercise session. Rationale: When the client performs the movements systematically, using the same sequence during each session, the nurse can evaluate that the teaching was understood and is successful. When performing active ROM the client should exercise to the point of slight resistance, but never past that point of resistance in order to prevent further injury (option 1). The client should perform each exercise at least three times, not just once (option 2). The client should perform each series of exercises twice daily, not just once per day (option 3).

What is considered a normal difference in systolic-diastolic pressure?

40 mm Hg

The following are all classic elements of evaluation. What is the correct sequence? 1. Interpreting and summarizing findings 2. Collecting data to determine whether evaluative criteria and standards are met. 3. Documenting your judgment 4. Terminating, continuing, or modifying the plan 5. Identifying evaluative criteria and standards (what you are looking for when you evaluate, eg, expected pt outcomes)

5,2,1,3,4

C

52 year old woman admitted with dyspnea and discomfort in her left chest with deep breaths. SHe smoked for 35 years and recently lost over 10 pounds. What vital sign should not be delegated to a nursing assistant: a) temperature b) radial pulse c) respiratory rate d) oxygen saturation

What is the acceptable range for pulse?

60 - 100 bpm

1, 2, 4, 7

82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. HR 2. Skin turgor 3. Smoking history 4. Allergies to antibiotics 5. Recent BM's 6. BP in right arm 7. Client's normal temperature 8. BP in distal extremity

Low blood pressure is characterized by a systolic reading that is less than __________.

90

closed wound

wound that involves underlying tissue without break in the skin

18. During a musculoskeletal assessment of a 20-month-old toddler, the nurse expects to observe: 1. A swayback and outwardly turned feet 2. A spine that is flexed and lacking anteroposterior curves 3. Widened hips and fat deposits on the thighs and buttocks 4. A stance with moderately spaced foot placement and a slightly rounded abdomen

A swayback and outwardly turned feet

The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

A. Client and Family B. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work

A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.

The use of percutaneous electrical stimulation as an effective means to control pain is based on which of the following? a. Gate-control theory b. Concept of therapeutic touch c. idea of using distraction d. theory of using heat application

A. Gate-control theory

The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit

A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience

A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented.

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation

A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview.

Which part of the small intestine absorbs carbohydrates and protein? A. Jejunum B. Ileum C. Duodenum

A. Jejunum

After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration B. Explanation C. Achievement of 90 on written test D. Have client explain produce to the family

A. Return demonstration Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are "hands-on" skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests.

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

A pulse of 104 bpm could indicate which of the following: A. anxiety B. heart problem C. increased blood pressure D. shock

A. anxiety B. heart problem

The nurse is planning care for a pediatric client with a fractured and casted left tibia. The nurse anticipates an appropriate goal for this client is to ultimately reach what level of mobility after removal of the cast and rehabilition? A: 5 (Not compromised) B: 3 (Moderately Compromised) C: 2 (Substantially Compromised) D: 1 (Severely Compromised)

A: 5 (Not compromised)

Which of the following principles does the nurse use in selecting interventions for the care plan? A: Actions should address the etiology of the nursing diagnosis B: Always select independent interventions when possible C: There is one best intervention for each goal/outcome D: Interventions should be "doing," not just "monitoring"

A: Actions should address the etiology of the nursing diagnosis

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? A: Hospital policies B: Standardized care plans C: Orthopedic protocols D: Standards of care

A: Hospital policies

The nurse ranks the following client diagnoses in what priority (from highest to lowest)? A: Ineffective Airway Clearance related to poor cough effort B: Pain related to surgical incision C: Risk for Constipation related to pain medications and decreased activity D: Risk for infection related to surgical incision

A: Ineffective Airway Clearance related to poor cough effort B: Pain related to surgical incision D: Risk for infection related to surgical incision C: Risk for Constipation related to pain medications and decreased activity

The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse updates the care plan on the computer to reflect the current client assessment. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan

A: Ongoing individualized care planning

The nurse has identified the nursing diagnosis of Impaired Physical Mobility related to inflammation of knee joint. A short-term goal could be: A: The client will ambulate will crutches by the end of the week B: The client will ambulate C: The client will verbalize his frustration D: The client will stand without assistance by the end of the month

A: The client will ambulate will crutches by the end of the week

Which of the following is likely to occur if the goal statement is poorly written? A: There is no standard against which to compare outcomes B: The nursing diagnoses cannot be prioritized C: Only dependent nursing interventions can be used D: It is difficult to determine which nursing interventions can be delegated

A: There is no standard against which to compare outcomes

Consider the following nursing diagnosis for a client who is on bed rest. Risk for Impaired Skin Integrity related to bed rest. The nursing interventions are derived from the etiologic portion of the nursing diagnosis, which includes: A: Turn and reposition every 2 hours B: Select high-protein foods at each meal C: Proide a daily bath D: Offer a back rub from time to time

A: Turn and reposition every 2 hours

primary intention

wounds that heal under conditions of minimal tissue loss(partial thickness)

6. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client: 1. Uses a banister or wall for support when descending 2. Uses one crutch for support while going up and down 3. Advances the crutches first to ascend the stairs 4. Advances the affected leg after moving the crutches to descend the stairs

Advances the affected leg after moving the crutches to descend the stairs

Which of the following guidelines for outcome writing are correct? 1. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis. 2. The patient (and family) values the outcomes. 3. The outcomes are supportive of the total treatment plan. 4. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.

All of the above

D

An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic

puncture wound

An open wound that tears through the skin and destroys underlaying tissues. A penetrating puncture wound can be shallow or deep. A perforating puncture wound has both an entrance and an exit wound.

A terminally ill patient is experiencing chronic pain due to spinal cord tumor and has been admitted on several occasions for pain crises. Which intervention can produce positive outcome for the individual with uncontrolled pain and a short life expectancy?

Analgesic Nerve Blocks Analgesic blocks using neurolytic agents block nerve conductivity and destroys the nerves. Topical anesthesia, local anesthetic agents, and nonnarcotics are not effective for a patient experiencing pain due to cord compression.

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory

Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain

2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.

Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.

Of the following characteristics, which one is not a part of chronic illness? a. Permanent change in body structure or function b. Self-treatment that relieves symptoms c. Long period of treatment and care d. Often has remission and exacerbation

b. Self-treatment that relieves symptoms

An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis

Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome

Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed

Answer A. The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler.

A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis

Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min

Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction

4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site.

Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.

A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increase oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray

Answer B. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, - hypercapnia, - dyspnea on exertion and at rest - oxygen desaturation with exercise - and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min

Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.

A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss

Answer B. The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever

An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury

Answer B. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the clients take three deep breaths c. Asking the client to split into the collection container d. Asking the client to obtain the specimen after eating

Answer B. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning

A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum

Answer C. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds.

Answer C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly b. Inhale through the nose c. Hold the breath after inhalation d. Take two inhalations during one breath

Answer C. Instructions for using a metered-dose inhaler include - shaking the canister, - holding it right side up, - inhaling slowly and evenly through the mouth, - delivering one spray per breath, - and holding the breath after inhalation.

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds

Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids

Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after.

A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum

Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination.

Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.

A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration

Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and Sx include - pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation - shallow respirations - splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. T his is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

Presence of overdistended and non-functional alveoli is a condition called: a. Bronchitis b. Emphysema c. Empyema d. Atelectasis

Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.

The S2 (dub) sound is the second heart sound and indicates closure of the _______________ and ________________ valves.

Aortic; pulmonic

Identify what is included during the assessment phase of the nursing process for a cardiopulmonary focus.

Assessment • In-depth history of the client's normal and present cardiopulmonary function • Past impairments in circulatory or respiratory functioning • Patient history including a review of drug, food, and other allergies • Physical examination of the client's cardiopulmonary status reveals the extent of existing signs and symptoms. • Use PQRST for pain / HPI for other symptoms • Review of laboratory and diagnostic test results

A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an evaluative measure used by the nurse? 1. Suctioning the airway 2. Sitting client up in bed 3. Auscultating lung sounds 4. Asking client to describe type of discomfort

Auscultating lung sounds

DURING A SKIN ASSESSMENT, THE NURSE RECOGNIZES THE 1ST INDICATION THAT A PRESSURE ULCER MAY BE DEVELOPING WHEN SHE NOTICES THE SKIN IS WHICH COLOR? A BLUE B WHITE C YELLOW D RED

B

PATIENT TELLS NURSE "I CANT GET ANY SLEEP AROUND HERE" NURSES FIRST RESPONSE: A ADD MORE CARBS TO DINNER B ASSESS FACTORS THAT PATIENT BELIEVES TO BE PROBLEM C TEACH PATIENT RELAXATION TECHNIQUES AND REDUCE NOISE ON THE UNIT D OBTAIN PRN ODER FOR SEDATIVE

B

THE NURSE WOULD RECOGNIZE WHICH OF THE FOLLOWING PATIENTS TO HAVE IMPAIRED WOUND HEALING A NPO FOLLOWING SURGERY B OBESE WOMAN WITH TYPE 1 DIABETES C MAN WITH SEDENTARY LIFESTYLE AND LIFELONG SMOKER D A WOMAN WHO'S BREAST RECONSTRUCTION SURGERY REQUIRED NUMEROUS INCISION

B

Mr. Xenobia's chronic cancer pain has recently increased and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? a. "if you take more morphine, it will not change your pain effect" b. "I'll call the physician and ask for an increased dose" c. "the amount you are taking now is all I can give you" d. "I'm worried if we increase your dose that you will stop breathing"

B "I'll call the physician and ask for an increased dose" Rationale: there is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

WHEN ADMINISTERING ORAL MEDICATIONS, WHICH OF THE FOLLOWING PRACTICES SHOULD THE NURSE FOLLOW(SELECT ALL THAT APPLYS) A DISPENSE MULTIPLE LIQUID MEDICATIONS INTO A SINGLE CUP TO REDUCE THE NUMBER OF CONTAINERS THE PATIENT MUST HANDLE B PERFORM HAND HYGIENE BEFORE AND AFTER MEDICATION ADMINISTRATION C STAY AT THE BEDSIDE UNTIL THE PATIENT HAS FINISHED ALL MEDICATIONS D KEEP THE PATIENTS MAR AT THE BEDSTIME AT ALL TIMES E VERIFY THE PATIENTS RESPONSE TO THE MEDICATION 30 MINUTES AFTER ADMINISTRATION, OR AS APPROPRIATE FOR THE DRUG

B C E

The nurse is teaching a client how to perform a testicular self-examination. The nurse tells the client which of the following? A) "The testes are normally round, moveable, and have a lumpy consistency." B) "Contact your health care provider if you feel a painless pea-sized nodule." C) "The best time to do a testicular self-examination is before your bath or shower." D) "Perform a testicular self-examination weekly to detect signs of testicular cancer."

B Contact your health care provider if you feel a painless pea-sized nodule."

The nurse should assist the client to a sitting position to provide the best position to examine which of the following? A) Heart B) Lungs C) Abdomen D) Pulse sites

B Lungs

The client's respiratory assessment reveals loud, low-pitched, rumbling, coarse sounds heard during inspiration and expiration. The nurse interprets these sounds as: A) Normal B) Rhonchi C) Crackles D) Wheezes

B Rhonchi

The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.

B The client has an arrhythmia.

Besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch

B headache, flushing of the face, and nosebleed

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Can head trauma affect temperature?

yes

The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next

B. Client has a wellness diagnosis E. Specific questions about the diet should be asked next Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.

The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician

B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C. Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility

B. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility.

The nurse is assessing the confused client, in trying to determine the client's level of pain, the nurse should: a. be aware that confused clients don't feel as much pain due to their confusion b. observe the client carefully for changes in behavior or vital signs c. ask the client's family how much pain the client normally has d. use only pain scales that feature numbers or "faces" the client can point to.

B. Observe the client carefully for changes in behavior or vital signs Rationale: the nurse should observe the confused client for nonverbal cues to pain

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

34. In teaching a newly diagnosed 17-year-old client with type 1 diabetes, the nurse knows that the exercise is an important component in care. Which of the following activities would be most appropriate for the previously sedentary client? 1. Kick-boxing class 2. Football 3. Bicycling 4. Soccer

Bicycling

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

The home health care nurse is visiting a client with a nursing diagnosis of Activity Intolerance related to the effects of inflammation secondary to rheumatoid arthritis. While planning care with the client, the nurse will: (select all that apply) A: Perform procedures required by the client B: Identify resources to help the client accomplish tasks that require a great deal of energy C: Prioritize care needs D: Set a desired outcome to demonstrate energy conservation E: Assess the client's ability to take care of herself

B: Identify resources to help the client accomplish tasks that require a great deal of energy C: Prioritize care needs D: Set a desired outcome to demonstrate energy conservation

The nurse lists the different types of planning that nurses perform, and includes: A: The care plan, interventions, and outcomes B: Initial planning, ongoing planning, and discharge planning C: Interventions, outcomes, and evaluation D: Collaboration with health officials, management of care, and implementation

B: Initial planning, ongoing planning, and discharge planning

The nurse reviews which level of the Nursing Interventions Classification (NIC) taxonomy for interventions? A: Classes B: Level 3 C: Level 1 D: Level 2

B: Level 3

"The client will ambulate 20 yards without assistance in 8 weeks." The nurse recognizes this is an example of a: A: Nursing intervention B: Long-term goal C: Short-term goal D: Rationale

B: Long-term goal

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea, and reports no bowel movements in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? A: Pain B: Nausea C: Constipation D: Potential for wound infection

B: Nausea

A taxonomy of nursing outcome statements was developed to describe measureable states, behaviors, or perceptions to respond to which part of the nursing process? A: Nursing outcomes B: Nursing interventions C: Nuring assessments D: Nursing goals

B: Nursing interventions

Outcomes and goals should not only be compatible with the nurse and client, but also with: A: The family B: Other health care workers assigned to the client's care C: The classification system used D: Facility policy

B: Other health care workers assigned to the client's care

In the long-term care setting, it is important for the nurse to: A: Revise care plans to reflect standardized protocols B: Revise care plans to reflect goal achievement C: Carry out dependent nursing actions D: Have an informal care plan

B: Revise care plans to reflect goal achievement

The nurse is planning the client's care. One of the activities performed by the nurse during this phase is: A: Analyzing data B: Selecting nursing interventions C: Determining the nurse's need for assistance D: Reassessing the client

B: Selecting nursing interventions

The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse utilizes the agency's "Brain Tumor" care plan. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan

B: Standardized care plan

When setting priorities for delivering care, the nurse considers which of the following processes first? A: The client's home setting B: The most important disease process that the client is experiencing C: The client's ability to pay D: The client's ethnic background

B: The most important disease process that the client is experiencing

The nurse recognizes which of the following as a benefit of using a standardized care plan? A: No individualization is needed B: The nurse chooses from a list of interventions C: They are much shorter than the nurse-authored care plans D: They have been approved by accrediting agencies

B: The nurse chooses from a list of interventions

The best reason for the development of the nursing outcomes classification (NOC) is that: A: Measuring outcomes makes it easier for clients to reach their goals B: The use of NOC will enable nursing data to be analyzed to help improve nursing practice C: NOC outcomes identify the specific behavior to be measured D: A classification system is helpful in writing care plans

B: The use of NOC will enable nursing data to be analyzed to help improve nursing practice

33. When planning care for a client with newly diagnosed hypertension, the nurse knows that which form of exercise would be most beneficial in lowering both systolic and diastolic blood pressure? 1. Lifting weights 2. Running 3. Bicycling 4. Competitive swimming

Bicycling

A nurse is performing wound care. Which of the following practices violates surgical asepsis? a. Holding sterile objects above the waist b. Considering a 1″ edge around the sterile field as being contaminated c. Pouring solution onto a sterile field cloth d. Opening the outermost flap of a sterile package away from the body

C

Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first? a. Assess the drainage in the dressing. b. Slowly remove the soiled dressing c. Wash hands thoroughly. d. Put on latex gloves.

C

THE NURSE WOULD RECOGNIZE THAT AN OBESE MALE PATIENT WHO HAS BEEN DIAGNOSED WITH OBSTRUCTIVE SLEEP APNEA FACES AN INCREASED RISK OF WHICH OF THE FOLLOWING? A DEPRESSION B RESPIRATORY ACIDOSIS C HEART DISEASE D SEIZURES

C

THE PHYSICIANS ADMITTING ORDERS INDICATE THAT THE PATIENT IS TO BE PLACED IN A FOWLERS POSITION, UPON POSITIONING THIS PATIENT, HOW MUCH WILL THE NURSE ELEVATE THE HEAD? A 15 B 90 C 45-60 D 30

C

WHICH MEDICATION WILL DELAY HEALING OF A POST-OP WOUND A LAXATIVE B ANTIHYPERTENSIVE C CORTICOSTEROID D K+ SUPPLEMENT

C

Which of the following clients would least likely be at risk of developing skin breakdown? a. A client incontinent of urine feces b. A client with chronic nutritional deficiencies c. A client with decreased sensory perception d. A client who is unable to move about and is confined to bed

C

While auscultating heart sounds, the nurse documents that S2 is best heard at the base. This sound (S2) correlates with closure of which of the following? A) Aortic and mitral valves B) Mitral and tricuspid valves C) Aortic and pulmonic valves D) Tricuspid and pulmonic valves

C Aortic and pulmonic valves

A common abnormality encountered during inspection of the skin is pallor. Pallor is easily seen in the face, mucosa of the mouth, and nail beds. How would pallor appear in a brown-skinned client? A) As shiny skin B) As bluish skin C) As yellowish skin D) As ashen gray skin

C As yellowish skin

The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference

C Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference

To correctly palpate the client's skin for temperature, the nurse uses which of the following? A) Base of the hands B) Fingertips of the hands C) Dorsal surface of the hands D) Palmar surface of the hands

C Dorsal surface of the hands

The nurse teaches the client to inspect all skin surfaces and to report pigmented skin lesions that: A) Are symmetrical B) Are uniform in color C) Have irregular borders D) Are smaller than 6 mm in diameter

C Have irregular borders

While the nurse was palpating the calf muscles of the client's right leg, the client complained of tenderness. Further assessment by the nurse should include which of the following? A) Observation for reduced hair growth and ulceration B) Observation for venous distention while the client is standing C) Observation of the area for swelling, warmth, redness, and a positive Homans' sign D) Observation for cyanosis, pallor, and change in pigmentation around the ankles

C Observation of the area for swelling, warmth, redness, and a positive Homans' sign

The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.

C Obtain orthostatic blood pressure measurements.

In assessing the client's lungs, the nurse notes that the lungs are normal upon percussion. This means that the nurse detected: A) Dullness B) Tympany C) Resonance D) Hyperresonance

C Resonance

In assessing the client's lungs the nurse hears adventitious breath sounds that are high-pitched, continuous musical sounds, such as a squeak heard continuously during inspiration or expiration, usually louder on expiration. These adventitious breath sounds are known as: A) Crackles B) Rhonchi C) Wheezes D) Pleural friction rub

C Wheezes

When writing a nursing goal and desired outcome, the nurse is aware that goals should: A: Be prioritized B: Be taken from a standardized list C: Have physician input D: Be realistic for the client

D: Be realistic for the client

A 73 year old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? a. phantom b. visceral c. deep somatic d. referred

C. Deep somatic Rationale: Deep somatic pain originates in ligaments, tendons, nerves, blood vessels, and bones. Therefore, a hip fracture causes deep somatic pain. Phantom pain is a pain that is perceived to originate from a part that was removed during surgery. Visceral pain is caused by deep internal pain receptions and commonly occurs in the abdominal cavity, cranium, and thorax. Referred pain occurs in an area that is distant to the original site.

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate. Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship.

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation

C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.

An increased respiratory rate could indicate a possible: A. Liver problem B. Lung problem C. Heart problem D. Infection

C. Heart problem

When establishing a plan for pain control, what question would the nurse first ask the patient? a. "How long have you been having this pain?" b. "What measures relieve your pain?" c. "How does the presence of this pain affect your life?" d. "Aren't you tired of being in pain?"

C. How does the presence of this pain affect your life? Rationale: Before developing a plan for controlling a patient's pain, the nurse must elicit information about the patient's perception of his pain.

Which part of the small intestine absorbs water, fat, and bile salts? A. Jejunum B. Ileum C. Duodenum

C. Ileum

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question B. Open-ended question C. Leading question D. Neutral question

C. Leading question Rationale: A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings. Neutral questions do not influence the client's answer.

If a blood pressure is high or low, what should you do first: A. Chart the blood pressure and retake B. Chart the blood pressure and move on C. Retake the blood pressure D. Check other vitals to see if a pattern can be determined.

C. Retake the blood pressure

The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday.

C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement.

Which of the following would be recommended for a patient with a fever greater than 101.1? A. cool off quickly B. cover with blankets C. give IV fluids D. give cold bath

C. give IV fluids

It is most important for the nurse to understand the various ways in which pain is classified. a. so that he can document the client's pain using accurate terms. b. so that he can be clear in his communication with the physician. c. so that he can develop an effective pain management plan. d. So that he can educate the client thoroughly

C. so that he can develop an effective pain management plan Rationale: different modalities are used in the treatment/management of pain and are often based on how the pain is classified.

The nurse understands that, in order to individualize client care, decisions are made during the planning phase to: A: Set goals for multiple clients B: Address all of the client's disease processes C: Address problems that need individualized approaches D: Address interventions that can be delegated

C: Address problems that need individualized approaches

The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse integrates dependent and independent nursing function. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan

C: Complete individualized plan of care

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will: A: Turn in bed q2h B: Report the importance of applying lotion to skin daily C: Have intact skin during hospitalization D: Use a pressure-reducing mattress

C: Have intact skin during hospitalization

The nurse, when developing a care plan, uses the nursing outcome classification to: A: Put interventions into action B: Set priorities C: Measure desired outcomes and evaluate client progress D: Diagnose a client's problem

C: Measure desired outcomes and evaluate client progress

Which of the following are appropriate nursing guidelines when prioritizing a client's care? A: The items from client identifies as a priority should always be addressed first B: Resolve all high-priority items before addressing lower-priority items C: Priorities change as the client responds to therapies D: Rank nursing diagnoses by degree of importance E: Priorities may need to be shifted based on available resources

C: Priorities change as the client responds to therapies D: Rank nursing diagnoses by degree of importance

The student nurse is developing a nursing care plan and performs which of the following during the planning phase? A: Reassesses the client B: Determines the need for assistance C: Selects nursing interventions D: Analyze data

C: Selects nursing interventions

Consider the following nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inability to feed self. What is an example of a short-term goal for this client? A: The client will acquire competence in managing cookware designed for handicapped clients B: The client will choose one correct menu C: The client will eat 50% of his meals by Friday with the use of modified eating utensils to feed self with minimal assistance D: The client will demonstrate safe preparation techniques

C: The client will eat 50% of his meals by Friday with the use of modified eating utensils to feed self with minimal assistance

The care plan includes a nursing intervention "4/2/11 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? A: Action verb B: Content C: Time D: None

C: Time

Where do food that small intestine cannot digest go to?

Cecum

At 7 months after back injury and lumbar laminectomy, a patient complains of tenderness at the operative site and appearss depressed and unwell. Other symptoms include depression, fatigue, and sleep disturbances. Which nursing diagnosis is a priority for this patient?

Chronic Pain Chronic pain has vague symptoms and few other physical findings and occurs beyond

A client is recovering from surgery for removal of an ovarian tumor. It is one day after her surgery. Because she has an abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? 1. Client will remain afebrile to discharge. 2. Client's wound will remain free of infection by discharge. 3. Client will receive ordered antibiotic on time over next 3 days. 4. Client's abdominal incision will remain covered with a sterile dressing for 2 days.

Client's wound will remain free of infection by discharge.

Heat or Cold? Decreased blood flow to injured site

Cold

Heat or Cold? Helps prevent edema from forming

Cold

Heat or Cold? Increased Blood Viscosity

Cold

Heat or Cold? Local Anesthesia

Cold

Heat or Cold? Promotes blood coagulation at injury site

Cold

Heat or Cold? Reduced cell metabolism

Cold

Heat or Cold? Reduces Inflammation

Cold

Heat or Cold? Reduces O2 needs of tissues

Cold

Heat or Cold? Relieves Pain

Cold

Heat or Cold? Vasoconstriction

Cold

Why is the colon so important?

Colon excretes potassium and serious alteration of the colon can cause severe electrolyte imbalance

Heat or Cold? Promotes movement of wastes and nutrients

Heat

36. A client with coronary heart disease has been meeting with a cardiac rehabilitation nurse for the past 5 weeks. The nurse has provided the client with interventions to increase the client's activity level. The client states that they don't know if the exercise program is helping. The nurse can assess the effectiveness of the interventions by: 1. Comparing baseline vital signs with current vital signs 2. Weighing the client 3. Asking the client if he feels that he has met his goals 4. Telling the client that the exercise will only help if the client has a positive attitude

Comparing baseline vital signs with current vital signs

When admitting a postop patient to the surgical unit, which nursing action is a priority?

Conduct Pain Assessment Assessment is a constant ongoing task for the postop patient

PRIOR TO STARTING A TUBE FEEDING, THE NURSE ASSESSES THE PH AND COLOR OF THE PATIENT'S GASTRIC CONTENTS AND RECEIVES A PH READING OF 6.2 AND THE ASPIRATE IS OFF-WHITE COLOR. A STOMACH B SMALL INTESTINE C COLON D RESPIRATORY TRACT

D

THE DRESSING CHANGE ON A DEEP UPPER-ARM WOUND IS PAINFUL FOR THE PATIENT. WHEN PREPARING A CARE PLAN FOR THE PATIENT, THE NURSE WILL INCORPORATE WHICH OF THE FOLLOWING MEASURES: A ADMINISTER ANALGESIC IMMEDIATELY BEFORE DRESSING CHANGE B PERFORM DRESSING CHANGE WHEN PATIENT IS FATIGUED FROM PT C PERFORM DRESSING CHANGE DURING MEALTIME SO PATIENT IS DISTRACTED D ADMINISTER ANALGESIC 30-45 MIN BEFORE DRESSING CHANGE

D

The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

D

The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse is noticing? A) These are expected findings for this postoperative time period. B) The patient may becoming dependent upon pain medication. C) The nurse should observe the patient more closely for wound dehiscence. D) The patient is demonstrating signs of a postoperative wound infection.

D

Using an otoscope, the nurse can inspect the tympanic membrane. A normal tympanic membrane appears: A) Round and white B) Pink and bulging C) Dark yellow and sticky D) Translucent, shiny, and pearly gray

D

WHICH ONE OF THE NUTRITIONAL GUIDELINES SHOULD THE NURSE GIVE A WOMAN IN HER 2ND TRIMESTER OF PREGNANCY A EAT NORMAL NUMBER OF CALORIES BUT INCREASE FRUITS AND VEGETABLES B MAINTAIN REG CALORIE INTAKE, BUT TAKE SUPPLEMENTS C EAT AS MUCH AS YOU CAN D MORE CALORIES AND HIGH IN NUTRIENTS

D

Heat or Cold? Reduced muscle tension

Heat

Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension

D A client who is being admitted for elective surgery who has a history of stable hypertension

The nurse asks the client to interpret the saying, "Don't count your chickens before they're hatched." The client's response provides information about the client's: A) Judgment B) Knowledge C) Association D) Abstract reasoning

D Abstract reasoning

The nurse asks the client to shrug the shoulders and turn the head side to side against the resistance of the examiner's hand. These actions allow the nurse to evaluate which cranial nerve? A) VII—Facial B) V—Trigeminal C) XII—Hypoglossal D) Abstract reasoning

D Abstract reasoning

The nurse should use which anatomical sites for the auscultatory assessment of cardiac function? A) Inner costal, outer costal, and sternal B) Aortic, carotid, coronary, and jugular C) Apical, lateral, anterior, and posterior D) Aortic, pulmonic, tricuspid, and mitral

D Aortic, pulmonic, tricuspid, and mitral

The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respirations. C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.

D Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.

During general inspection of the musculoskeletal system of an older client, the nurse notes kyphosis. Kyphosis is: A) Lateral spinal curvature B) Loss of or decrease in muscle tone C) Increased lumbar curvature D) Exaggeration of the posterior curvature of the thoracic spine

D Exaggeration of the posterior curvature of the thoracic spine

To assess a client's superficial lymph nodes, the nurse: A) Deeply palpates using the entire hand B) Deeply palpates using a bimanual technique C) Lightly palpates using a bimanual technique D) Gently palpates using the pads of the index and middle fingers

D Gently palpates using the pads of the index and middle fingers

The techniques of physical assessment are inspection, palpation, percussion, and auscultation. The order in which these techniques are used is slightly different during abdominal examination than during examination of other body areas. The nurse should perform which two of the following first? A) Palpation and inspection B) Inspection and percussion C) Palpation and auscultation D) Inspection and auscultation

D Inspection and auscultation

To assess the client's dorsalis pedis pulse, the nurse palpates: A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe

D Lateral to the extensor tendon of the great toe

Turgor is the skin's elasticity, which can be diminished by edema or dehydration. Which is the best place for the nurse to assess skin turgor in the older adult? A) Side of the neck B) Back of the hand C) Palm of the hand D) Over the sternal area

D Over the sternal area

The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.

D Recheck the blood pressure, make sure the client is safe, and report the findings.

The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

D Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

D Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering

D Vasoconstriction, reduction of blood flow to extremities, and shivering

Which of the following values for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic

D oxygen saturation by pulse oximetry = 89%

Heat or Cold? Vasodilation

Heat

Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated

D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all."

D. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month

D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members.

For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse? A. Discomfort B. Deficit C. Feeding D. Fractured wrists

D. Fractured Wrists Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem.

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

Mr. Mitchell and Mr. Farrell have both had their gallbladders removed laparascopically. Mr. Mitchell is rating his pain at a 5 on a 10-pain scale and states he does not require pain medication. Mr. Farrell is rating his pain a 5 on a 10-pain scale and is demanding something stronger for his pain. This is an example of a difference in which of the following? a. Surgeon's skill b Patient's pain thresholds c. Patient's personalities d. Patient's pain tolerance

D. Patient's pain tolerance Rationale: Both patients would perceive the surgical incision to be painful at about the same point. Mr. Mitchell is able to tolerate his pain when it is rated at a 5, whereas Mr. Farrell is not. The patient's personality is a factor that affects pain tolerance.

Nurses use a standardized care plan as: A: A means to address all of the client's disease processes B: A guide in determining if the client is able to assist with the care planning C: A guide for developing nursing diagnoses D: A guide for developing goals and interventions

D: A guide for developing goals and interventions

Assessment of a client who is 2 days after surgery reveals a dressing that is dry and intact, temperature 100.2 degrees F, pulse 90, and respiratory rate of 36. The client requests additional juice or water due to a very dry mouth, and says he is feeling weak and having pain with ambulation. The nurse's highest priority finding that indicates that the plan of care should be changed is: A: Elevated temperature B: Dry mouth C: Pain D: Elevated respiratory rate

D: Elevated respiratory rate

The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse includes family and client preoperative teaching in the client's care plan. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan

D: Individualized care plan

Which of the following accurately explain how the nurse chooses a nursing intervention? A: Interventions are nurse-initiated activities only B: Most interventions are part of the nurse's dependent role C: Interventions are chosen to alleviate or reduce the impact of the client's medical diagnosis D: Interventions focus on the etiology of the nursing diagnosis

D: Interventions focus on the etiology of the nursing diagnosis

When writing a care plan, a nurse may use what model or theory to assist in prioritizing? A: Orem's model B: Roy's model C: The most important disease process that the client is experiencing D: Maslow's hierarchy of needs

D: Maslow's hierarchy of needs

The nurse chooses nursing interventions from the nursing intervention classification based on: A: The nursing process B: Nursing assessments C: Nursing outcomes classification D: Nursing diagnosis

D: Nursing diagnosis

The nurse finds the nursing interventions of touch in the Nursing Interventions Classification (NIC) by looking up the: A: Problem list B: Client's specific need C: Medical diagnosis D: Nursing diagnosis

D: Nursing diagnosis

The nurse, who is caring for a client with a nursing diagnosis of Ineffective Airway Clearance, instructs the postoperative client on turning, coughing, and deep breathing every 2 hours. What is the relationship of nursing interventions to problem status? A: Observation interventions B: Health promotion interventions C: Treatment interventions D: Prevention interventions

D: Prevention interventions

When written properly, NOC outcomes and indicators: A: Do not require customization B: Address several nursing diagnoses C: Are broad statements of desired end points D: Reflect both the nurse's and the client's values

D: Reflect both the nurse's and the client's values

When developing client care plans, the first process the nurse engages in is: A: Establishing client goals B: Selecting nursing interventions C: Writing individualized nursing interventions to be performed D: Setting priorities

D: Setting priorities

"Client will walk to the end of hallway without assistance by Friday" is an example of: A: Nursing intervention B: Rationale C: Long-term goal D: Short-term goal

D: Short-term goal

The nursing intervention classification (NIC): A: Improves cost effectiveness in planning care B: Isolates community input C: Conflicts with nursing management and therapies D: Standardizes and defines the knowledge base for nursing curricula and practice

D: Standardizes and defines the knowledge base for nursing curricula and practice

After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? A: Initial B: Ongoing C: Discharge D: Strategic

D: Strategic

Is light or deep palpitation needed to assess for masses, lumps and bumps?

Light

Which order would the nurse question when caring for a postop patient receiving epidural morphine infusion?

Lovenox 40mg SC BID Molecular weight heparins have been linked to spinal hematoma in clients with epidurals.

The client is being assessed for range of joint movement. The nurse asks the client to move the arm toward the body to evaluate: A) Flexion B) Extension C) Abduction D) Adduction

DAdduction

D

Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension

A 72 year old patient is hospitalized after a fall at home, is restless, has elevated blood pressure, and moans with turns. When the nurse asks, the patient denies being in pain. What initial interventions should the nurse employ?

Discuss the symptoms and explain how medication will increase comfort and increase healing Older adults are hesitant to express pain becasue they may fear being labeled as a complainer

While reviewing the medication list for an older client with a history of heart failure, diabetes, and hypertension, which medication might cause concern?

Dolobid 250mg Salicylate salts containing mg or na should be avoided in clients whom excessive amounts of these electrolytes might be harmful

Position of Ear for child

Down and Back

13. Which of the following nursing interventions is likely to have the most impact on reducing friction when positioning an immobile client? 1. Involving at least two personnel in the actual transfer 2. Lubricating all body parts that are in contact with the bed 3. Dressing the bed with a lift sheet to be use during the transfer 4. Thoroughly explaining the process to the client before the move

Dressing the bed with a lift sheet to be use during the transfer

25. The nurse has determined that a client reporting general fatigue is experiencing activity intolerance. Which of the following assessment findings, observed after the client ambulates to the bathroom, best confirms this nursing diagnosis? 1. Dyspnea 2. Diaphoresis 3. Hypotension 4. Mental confusion

Dyspnea

7. While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: 1. Support the client and walk quickly back to the room 2. Lean the client against the wall until the episode passes 3. Lower the client gently to the floor 4. Go for help

Lower the client gently to the floor

40. A client with cancer expresses interest in increasing his activity level. The nurse begins by assessing baseline data regarding the client's current activity patterns. The nurse uses professional standards to develop a plan of care for this client. Professional standards are important because they: 1. Are developed by government agencies 2. Establish scientifically proven guidelines 3. Shift responsibility for the plan of care from the nurse 4. Are required by all healthcare organizations

Establish scientifically proven guidelines

11. Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be: 1. Resting heart rate will be 90 to 100 beats/minute 2. Blood pressure will be maintained between 140/80 and 160/90 mm Hg 3. Exercise will be performed 3 to 4 times over the next 2 weeks 4. Achievement of a rating of 3 for activity endurance

Exercise will be performed 3 to 4 times over the next 2 weeks

10. The nurse is presenting a teaching session on exercise for a group of corporate executives. An appropriate recommendation is that 1. Continuous activity is required in order for the exercise to be worthwhile 2. 3000 to 4000 calories may be easily expended each week 3. Lower-intensity activities need to be done more often for value 4. Only formal exercise activities are counted in a regular plan

Lower-intensity activities need to be done more often for value

8. A client is admitted to the medical unit following a CVA (stroke). There is evidence of left-sided hemiparesis and the nurse will be following up on range-of-motion and other exercises performed in physical therapy. The nurse correctly teaches the client and family members which one of the following principles of range-of-motion exercises? 1. Flex the joint to the point of discomfort. 2. Work from proximal to distal joints. 3. Move the joints quickly. 4. Provide support for distal joints.

Flex the joint to the point of discomfort.

9. Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1. Flex the knees and keep the feet wide apart. 2. Assume a position far enough away from the client. 3. Twist the body in the direction of movement. 4. Use the strong back muscles for lifting or moving.

Flex the knees and keep the feet wide apart.

What does FIO2 stand for?

Fraction of Inspired oxygen concentration

Stage III pressure Ulcer

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV pressure Ulcer

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with this type of pressure ulcer.

The nurse is called to a patients room who complains of pain 9/10 and requests pain medication. He is laughing, watching football, and is in conversation with a visitor. Based on the assessment, what intervention should the nurse employ?

Give the total dose of pain medication Pain is a multidimensional phenomenon that is difficult to define. It is personal and subjective and is whatever the patient says it is.

Heat or Cold? Decreases Spasmodic Pain

Heat

Heat or Cold? Improves delivery of antibiotics to wound

Heat

Heat or Cold? Improves delivery of leukocytes to wound

Heat

Heat or Cold? Increased Capillary Permeability

Heat

Heat or Cold? Increased Tissue metabolism

Heat

Heat or Cold? Increases Blood flow

Heat

Heat or Cold? Promotes Muscle Relaxation

Heat

15. A client who is confined to a wheelchair is encouraged to engage in resistive isometric exercises to increase muscle strength and decrease the development of pressure ulcers. Which of the following is the most appropriate example of such an exercise for this client? 1. Hip lifting 2. Gluteal contraction 3. Foot pressure off-loading 4. Bicep-tricep compression

Hip lifting

What does central cyanosis indicate?

Hypoexmia

_______________ muscle has little tone and feels flabby, usually because of atrophy of muscle mass.

Hypotonic

The difference in systolic-diastolic pressure is used as an indicator for what?

ICP (intracranial pressure), HTN (hypertension), shock

A non-english speaking hispanic client is moaning and appears to be in pain. How does the nurse intervene to faciliatate adequate pain management?

If an interpreter is available, explain that pain is related to illness and by treating the pain healing will promote wellness Moaning and crying are used to alleviate the pain rather than communicate a need for intervention. If the patient understands that pain is related to illness there is a higher likelihood that the patient will accept treatment.

19. The nurse recognizes that the older adult's tendency to take smaller steps with feet kept closer together will most likely: 1. Increase the client's risk of injury resulting from falls 2. Result in less stress on the client's knees, hips, and ankles 3. Decrease the amount of energy the client expends on movement 4. Allow for mobility in spite of the effects of aging on the client's joints

Increase the client's risk of injury resulting from falls

31. A client who is immobilized in bed due to skeletal traction tells the nurse that they miss their exercise regimen that they had started prior to the accident that resulted in their hospitalization. The nurse knows that which of the following is a good form of exercise that this client can still perform while immobilized? 1. Isotonic exercise 2. Isometric contraction 3. Resistive isometric exercise 4. Aerobic exercise

Isometric contraction

Which parts of the small intestines absorb most of the nutrients?

Jejunum and Duodenum

The evaluation process, which determines the effectiveness of nursing care, includes five elements, one being interpreting findings. Which of the following is an example of interpretation? 1. Evaluating the client's response to selected nursing interventions 2. Selecting an observable or measurable state or behavior that will reflect goal achievement 3. Reviewing the client's nursing diagnoses and establishing goals and outcome statements 4. Matching the results of evaluative measures with expected outcomes to determine client's status

Matching the results of evaluative measures with expected outcomes to determine client's status

What are the 10 Rights of Medication Administration

Medication Assessment Dose Documentation Route Patient Education Timing Evaluation Refusal (MADDRPETER)

An 80 year old patient who is recovering from a hip fracture with surgical nailing is becoming increasingly confused and unable to participate in care, and has experienced several periods of urinary incontinence. Which orders might the nurse suspect of contributing to the patient's sypmptoms?

Meperidine 25mg Meperidine causes confusion and delerium in the older adult and should be used caustiously in patients with altered renal function.

Two days after undergoing surgery, a patient refuses to get out of bed. What information can the nurse provide that may increase compliance with the treatment plan?

Movement can cause breakthrough pain. We can give you medication to control the pain and help you to increase your activity

A 28 year old quadriplegic complains of burning pain in his lower legs. What type of pain should the nurse suspect?

Neuropathic Pain Nociceptive/neuropathic pain is due to damage to nerve cells or changes in the processing of pain

Stage I pressure Ulcer

Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators

39. The nurse is working with a nursing assistive personnel to provide care for a group of clients. The nurse can delegate which of the following activities to the nursing assistive personnel? 1. Assess for medical limitations before beginning the exercise activity. 2. Teach the clients breathing skills to help reduce their anxiety. 3. Obtain preexercise and postexercise vital signs. 4. Document the client's progress.

Obtain preexercise and postexercise vital signs.

Stage II pressure Ulcer

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

What information about pain must the nurse understand when designing a plan of care to manage pain?

Past experience with pain effects the way current pain is perceived Past experience affects the way current pain is perceived, the impact of pain experiences is not predictable, anxiety influences an individuals response to pain, and no matter what the experience is, one never becomes accustomed to pain.

To determine the significance of a blood-pressure reading of 148/100, it is first necessary to: a. Compare this reading to standards b. Check the taxonomy of nursing diagnoses for a pertinent label. c. Check a medical text for the signs and symptoms of high blood pressure d. Consult with collleagues.

a. Compare this reading to standards

1, 5, 2, 4, 3

Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37.3 (99.4) 4) HR= 72 BPM 5) RR= 28 BrPM

26. A client with a nursing diagnosis of activity intolerance has developed reddened areas on both heels and his coccyx. Which of the following nursing interventions will most likely have the greatest impact on this diagnosis? 1. Ambulating him to the bathroom before returning to bed 2. Encouraging him to change position every 2 hours while in bed 3. Including active range-of-motion exercises in both AM and PM care 4. Planning a rest period after AM care but before walking to the dining room for lunch

Planning a rest period after AM care but before walking to the dining room for lunch

brown green or yellow

Purulent

1. A client has been prescribed bed rest for a prolonged time. To specifically promote the use of resistive isometric exercise for the client, the nurse will initiate: 1. Quadriceps setting 2. Gluteal muscle contraction 3. Moving the arms and legs in circles 4. Pushing against a footboard

Pushing against a footboard

2. The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to: 1. Observe gait 2. Put the client at ease 3. Determine activity tolerance 4. Determine range of joint motion

Put the client at ease

12. The primary purpose for placing an immobile client's arms across his or her chest when preparing to transfer the client up in the bed is to: 1. Increase the stability of the client's body 2. Protect the client's arms from being hurt during the transfer 3. Produce a more compact form that facilitates the transfer 4. Reduce the amount of body surface area that is in contact with the bed.

Reduce the amount of body surface area that is in contact with the bed.

Abduction is movement __________ from the body.

away

38. One of the most debilitating health hazards among nurses is musculoskeletal injuries. In order to eliminate these injuries, the American Nurses Association is advocating which of the following? 1. Mandate that physical therapists do all patient transfers. 2. Require minimum staffing levels in health care organizations. 3. Request the use of assistive equipment and devices. 4. Require a minimum number of staff to be involved in all patient transfers.

Request the use of assistive equipment and devices.

A goal specifies the expected behavior or response that indicates: 1. The specific nursing action was completed 2. The validation of the nurse's physical assessment 3. The nurse has made the correct nursing diagnoses 4. Resolution of a nursing diagnosis or maintenance of a healthy state

Resolution of a nursing diagnosis or maintenance of a healthy state

Functions of Sleep

Restoration, reducing fatigue,stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the immune system,promoting cellular growth and repair, improving the capacity for learning and memory storage

___________________ are loud, low-pitched, rumbling, coarse sounds heard most often during inspiration or expiration.

Rhonchi

blood

Sanguinous

_________________ is lateral spinal curvature.

Scoliosis

abrasion

Scraping or wearing away of the skin by friction; irritation

blood+water

Serosanguinous

3. An average-size male client has right-sided hemiparesis. The nurse helps this client to walk by: 1. Standing at his left side and holding his arm 2. Standing at his left side and holding one arm around his waist 3. Standing at his right side and holding his arm 4. Standing at his right side and holding one arm around his waist

Standing at his right side and holding one arm around his waist

28. A client is discussing an exercise program that includes running 1.5 miles 3 times a week. Which of the following suggestions made by the nurse is most likely to result in minimizing the client's risk for injury? 1. Stretching before and after running 2. Alternating running paths every week 3. Hydrating well with sports drinks during and after running 4. Wearing running shoes that have been professionally fitted

Stretching before and after running

D

The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered.

C

The client, who has been on bed rest for 2 days, asks to get out of bed to go to the bathroom. He has new orders for "up ad lib." What action should the nurse take? A) Give him some slippers and tell him where the bathroom is located. B) Ask the nursing assistant to assist him to the bathroom. C) Obtain orthostatic blood pressure measurements. D) Tell him it is not a good idea and provide a urinal.

D

The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering

B

The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.

D

The nurse finds that the systolic blood pressure of an adult client is 88 mm Hg. What are the appropriate nursing interventions? A) Check other vital signs. B) Recheck the blood pressure and give the client orange juice. C) Recheck the blood pressure after ambulating the client safely. D) Recheck the blood pressure, make sure the client is safe, and report the findings.

D

The nurse is to measure vital signs as part of the preparation for a test. The client is talking with a visiting pastor. How should the nurse handle measuring the rate of respiration? A) Count respirations during the time the client is not talking to the visitor. B) Wait at the client's bedside until the visit is over and then count respirations. C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress.

D

The nurse observes that a client's breathing pattern represents Cheyne-Stokes respiration. Which statement best describes the Cheyne-Stokes pattern? A) Respirations cease for several seconds. B) Respirations are abnormally shallow for two to three breaths followed by irregular periods of apnea. C) Respirations are labored, with an increase in depth and rate (more than 20 breaths per minute); the condition occurs normally during exercise. D) Respiration rate and depth are irregular, with alternating periods of apnea and hyperventilation; the cycle begins with slow breaths and climaxes in apnea.

How often should a nurse assess the skin and nares of the patient with a nasal cannula?

The nurse should assess the client's nares and ears for skin breakdown every 6 hours.

C

The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference

Which factor regarding older adults and medication is important for the nurse to understand?

The older adult is more likely to experience drug interactions than the general public

What is a realistic outcome for the patient who is terminally ill with bone cancer and is experiencing uncontrolled pain?

The patient experiences improved quality of life

You are caring for a 72 year old patient with advanced cancer who complains of increased pain and tactile sensitivity over the last several weeks. Which non pharmacological alternative could be added to her plan of care to enhance her comfort?

Therapeutic Touch Therapeutic touch is thought to realign aberrant energy fields through passing hands over the energy fields without actually touching the body and promoting comfort.

35. A newly diagnosed client with type 2 diabetes expresses concern that he will not be able to maintain his active lifestyle, which includes bicycling. The nurse instructs the client about risks and precautions regarding exercise including which of the following? 1. To avoid leisurely bicycling day trips 2. To avoid strenuous bicycling for long periods of time 3. It is better for them to exercise for 1 to 2 hours once a week than for 20 minutes 3 days per week 4. As long as he is not participating in strenuous exercise, there is no need to include warm-up or cool-down exercises

To avoid strenuous bicycling for long periods of time

Maslow's Hierarchy of basic human needs is useful when planning and implementing nursing care as it provides a structure for : a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care

b. Establishing priorities of care

True or False The character of the exudate, in amount, color and odor, can help to identify the exact nature of the infection

True

41. When moving a client who is unable to assist, what is the most important principle for the nurse to remember to avoid injury? 1. Face opposite of the direction of movement. 2. Keep your feet close together. 3. The higher the center of gravity, the greater the stability of the nurse. 4. Try to avoid lifting the patient if possible.

Try to avoid lifting the patient if possible.

4. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly? 1. The client keeps the cane on the left side. 2. Two points of support are kept on the floor at all times. 3. There is a slight lean to the right when the client is walking. 4. After advancing the cane, the client moves the right leg forward.

Two points of support are kept on the floor at all times.

5. A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use? 1. Two-point 2. Three-point 3. Four-point 4. Swing-through

Two-point

37. Passive range-of-motion exercises are most important for which of the following clients? 1. Pediatric client with a broken femur 2. Diabetic client with a total knee replacement 3. Unconscious client in ICU 4. Elderly client with a bowel obstruction

Unconscious client in ICU

Careful hand-washing and using sterile techniques are ways in which nurses meet which basic human need? a. Physiologic b. Safety & Security c. Self-esteem d. Love & belonging

b. Safety & Security (By carrying out careful hand-washing and using sterile technique, nurses provide safety from infection)

29. The first rule of safety when managing client transfers is: 1. Flex your knees and plant your feet far apart 2. Keep your back aligned with your neck, pelvis, and feet 3. Use lift teams or mechanical lifts when the transfer requires it 4. Always use the large muscles of the arms and legs, not the small muscles of the back

Use lift teams or mechanical lifts when the transfer requires it

23. The nurse encourages a non-insulin-dependent diabetic client to engage in a regular exercise program primarily because to do so will most likely improve the client's: 1. Gastric motility, thus affecting glucose digestion 2. Respiratory recovery time, thus decreasing breath load 3. Average cardiac output, thus decreasing resting heart rate 4. Use of glucose and fatty acids, thus decreasing blood glucose level

Use of glucose and fatty acids, thus decreasing blood glucose level

A

Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.

________________ are high-pitched continuous muscles sounds such as a squeak heard continuously during inspiration and expiration.

Wheezes

What is orthostatic hypotension?

When a person's blood pressure falls when moving from a seated or lying position to a standing position.

D

Which of the following vlues for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic

A patient with colon cancer is being managed with OxyContin 30mg PO BID and Oxycodone 5mg PO q4h PRN for breakthrough pain. The patiens wife voices her concern that the patient is becoming addicted to the medication and questions whether milder nonnarcotic medications could be used. What is the most appropriate response by the nurse?

With the diagnosis of cancer, there is a need to use regular and strong mediaction for pain control to provide a better quality of life Persistent pain can be managed using long acting medications and narcotics when the condition warrants their use. Addiction is not an issue for the patien with chronic cancer pain. Amount and types of meds are adjusted according to patient status

If a doctor's order only indicates a minimum, can more be done or given?

Yes.

reactive hyperemia

a bright red flush on the skin occurring after pressure is relieved

What temperature warrants an order for tylenol?

a fever greater than 101F

REM sleep

a recurring sleep state during which dreaming occurs

When a patient you are admitting to the unit asks you why you are doing a history and exam since the doctor just did one, your best reply is: a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick." c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care. This information will help me develop a plan of care individualized to your unique needs." d. "We want to make sure that your responses are consistent and that all our data are accurate."

a. "In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths."

As a nurse, you follow the guidelines for a healthy lifestyle. How can this promote health in others? a. By being a role model for healthy behaviors. b. By not requiring sick days from work. c. By never exposing others to any type of illness d. By not being overweight

a. By being a role model for healthy behaviors. (Good personal health enables the nurse to serve as a role model for patients and families.)

a 48-year-old client doesn't smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client? a. Do you smoke or inhale marijuana or other herbal products? b. Have you had allergy testing? c. Have you received a flu or pneumonia vaccination? d. Have you tried to stop smoking?

a. Do you smoke or inhale marijuana or other herbal products?

The position of a conscious client during suctioning is: a. Fowler's b. Supine position c. Side-lying d. Prone

a. Fowler's Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.

Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol) a. Hepatitis B b. Occasional alcohol use c. allergy to aspirin d. gastric limitation with bleeding

a. Hepatitis B

Where do individuals learn their health beliefs and values? a. In the family b. In school c. From school nurses d. from peers

a. In the family (Healthcare activities, heal beliefs, and health values are learned within one's family)

During a physical assessment, the nurse documents eupnea on the client's medical record. What does this finding suggest? a. Normal respirations b. Slow respirations c. Irregular respirations d. Rapid respirations

a. Normal respirations

After inspecting a client's thorax, the nurse writes "AP:T 1:2, bilateral symmetrical movements, sternum midline, respiratory rate 16 and regular." What do these findings suggest? a. Nothing. These findings are normal. b. The client has pneumonia. c. The client has a respiratory illness. d. The client has allergies.

a. Nothing. These findings are normal.

A school nurse notices that Jill is losing weight and wants to perform a focused assessment on Jill's nutritional status, fearing that she might have an eating disorder. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention d. Request an order from the nutritionist since this is a collaborative intervention

a. Perform the focused assessment. This is an independent nurse-initiated intervention

23. The accumulation of fluids in the pleural space is called: a. Pleural effusion b. Hemothorax c. Hydrothorax d. Pyothorax

a. Pleural effusion

Who are the largest group of healthcare providers in the United States? a. Registered Nurses b. Physicians c. Physical therapists d. Social Workers

a. Registered nurses are the largest group of healthcare providers in the United States

A patient complains about feeling nauseated after lunch. This is an example of what type of data? a. Subjective b. Objective c. Signs and symptoms d. Overt

a. Subjective

Mr Price tells the nurse he fears becoming "hooked on drugs" and consequently waits until his pain becomes unbearable before requesting his prn analgesic. The nurse plans to be more attentive to Mr Price and to assess his needs for pain management more closely. Which of the following consequences of informal planning ought to be the major concern for this nurse? a. The lack of a coordinated plan known by everyone will result in uneven pain management. b. Faulty prioritization of patient needs c. Inability to evaluate the patient's responses to nursing care d. Lack of a record for reimbursement purposes

a. The lack of a coordinated plan known by everyone will result in uneven pain management.

From which of the following are outcomes derived? a. The problem statement of the nursing diagnosis b. The etiology of the problem of the nursing diagnosis c. The defining characteristics of the problem d. The evaluative statement

a. The problem statement of the nursing diagnosis (Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis in the plan of care, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement)

A client with a strained trapezius muscle complains of having occasional shortness of breath. What might be the reason for this symptom? a. The strained muscle is an accessory muscle of respiration. b. The diaphragm muscle is also injured. c. There is an undiagnosed heart problem. d. There is a blood clot in his lung.

a. The strained muscle is an accessory muscle of respiration.

Prior to listening to a client's lung sounds, the nurse palpates the sternum and feels a horizontal bump on the bone. What does this finding suggest to the nurse? a. This is the angle of Louis. b. The manubrium is damaged. c. The costal angle is greater than normal. d. The xiphoid process is misshaped.

a. This is the angle of Louis.

An experienced nurse tells you not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underline your response? a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years. It's time to champion intuitive, creative thinking! d. It's simply a matter of preference. Some of us are logical, scientific thinkers, and some are intuitive, creative thinkers

a. When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem-solving forward quickly, but it might result in a lot of trial-and-error approaches.

Which pain management task can the nurse safely delegate to nursing assistive personnel? a. asking about pain during vital signs b. evaluating the effectiveness of pain medication c. developing a plan of care involving nonpharmacologic interventions d. administering over-the-counter pain medications

a. asking about pain during vital signs Rationale: The nurse can delegate the task of asking about pain when nursing assistive personnel obtain vital signs. The NAP must be instructed to report findings to the nurse without delay. The nurse should evaluate the effectiveness of pain medications and develop the plan of care. Administering over-the-counter and prescription medications is the responsibility of the RN or LPN

Where do individuals learn their health beliefs and values? a. in the family b. in school c. from school nurses d. from peers

a. healthcare activities, health beliefs, and values are learned within one's family.

What group is the largest subculture of the healthcare system? a. nurses b. physicians c. social workers d. physical therapists

a. nurses are the largest subculture of the healthcare system

Which of the following levels of basic human needs is most basic? a. physiologic b. safety and security c. love and belonging d. self-actualization

a. physiologic

The agent-host-environment model of health and illness is based on the concept of: a. risk factors b. infectious diseases c. behaviors to promote health d. stages of illness

a. risk factors (The interaction of the agent-host-environment creates risk factors that increase the probability of disease)

fistula

abnormal passageway between two organs or between an internal organ and the body surface

crushing injury

an injury caused by compression that involves both direct tissue injury caused by circulation disturbance resulting from pressure on blood vessels

open wound

an injury in which the skin is interrupted, exposing the tissue beneath

contusion

an injury to underlying tissues without breaking the skin and is characterized by discoloration and pain

Which of the numbered areas is considered sterile on a person in the operating room? You may assume that all articles were sterile when applied.

area 1 Rationale: Sterile objects are considered unsterile if placed lower than the waist. Only area 1 in this situation would be considered sterile. Above the neck, higher than 2 inches above the elbow, below the waist/table, and the back are all considered unsterile.

If listening for the S1 sound (mitral valve closing),adhere would you hear the sound the best with auscultated?

at the left fifth intercostal space along the mid-clavicular line.

Fearful of attempting your first nursing history, you ask your instructor how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear: a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different." d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment for you must use."

b. " You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."

Which of the following is one element of a healthy community? a. meets all the needs of its inhabitants b. offers access to healthcare services c. has mixed residential and industrial areas d. is little concerned with air and water quality

b. A healthy community offers access to healthcare services to treat illness and to promote health.

The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Left of the sternum, third intercostal space b. Above the clavicles c. Below the scapula d. Right of the sternum, sixth intercostal space

b. Above the clavicles The apex of each lung is slightly superior to the inner third of the clavicle.

Your neighbor, Alan, asks you to come over because he has a high temperature, feels "awful," and did not go to work. What stage of illness behavior is Alan exhibiting? a. Experiencing symptoms b. Assuming the sick role c. Assuming the dependent role d. Achieving recovery and rehabilitation

b. Assuming the sick role (When people assume the sick role, they define themselves as ill, seek validation of this experience from others, and give up normal activities)

Which of the following phrases best defines culture? a. A dominant group within a society b. A shared system of beliefs, values, and behaviors c. One's values are replaced by the values of the dominant culture d. Categories are based on specific physical characteristics

b. Culture may be defined as a shared system of beliefs, values, and behavioral expectations that provide social structure for daily living

Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. This characteristic of the nursing process is described as: a. Systematic b. Dynamic c. Interpersonal d. Outcome oriented

b. Dynamic

A school nurse is teaching a class of junior-high students about the effects of smoking. This educational program will meet which of the aims of nursing? a. promoting health b. preventing illness c. restoring health d. facilitating coping with disability or death

b. Educational programs can reduce the risk of illness by teaching good health habits

The nurse is assessing the client's lung bases posteriorly. At which area can the nurse assess this portion of the lung? a. Right anterior axillary line b. Scapular line c. Midsternal line d. Left midclavicular line

b. Scapular line

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.

b. Grasp the retention sutures to spread the opening.

Of the following statements, which is most true of health and illness? a. Health and illness are the same for all people b. Health and illness are individually defined by each person c. People with acute illness are actually healthy d. People with chronic illnesses have poor health beliefs

b. Health and illness are individually defined by each person

The nursing process ensures that nurses are patient centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristics of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situatins

b. Interpersonal (Each of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process)

A young hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What should the nurse do? a. Use short words and talk more loudly? b. Ask an interpreter for help c. Explain why care can't be provided d. Provide instructions in writing.

b. Many agencies have a qualified interpreter who understands the healthcare system and can reliably provide assistance.

A nurse is providing care based on Maslow's hierarch of basic human needs. For which of the following nursing activities is the approach useful? a. making accurate nursing diagnoses b. establishing priorities of care c. communicating concerns more concisely d. integrating science into nursing care

b. Maslow's hierarch of basic human needs is useful for establishing priorities of care.

Which was the first state to identify diagnosing as part of the legal domain of professional nursing? a. New Jersey b. New York c. North Carolina d. North Dakota

b. New York

Which of the following would you expect to find in the Nursing Interventions Classification Taxonomy? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions. b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings. c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention. d. A complete list of reimbursable charges for each nursing intervention.

b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

This text is based upon a notion of blended skills. .Simply described, this means: a. Nursing works best when nurses competently use the intellectual and technical skills that achieve patient outcomes. Nursing has been held back by outdated notions of care and compassion (interpersonal skills), which can be done by anyone. b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation. c. All of the blended skills are important, but not every nurse has to be skilled in each area. d. Every nursing situation demands the same blend of basic nursing skills, intellectual, technical, interpersonal, and ethical/legal skills.

b. Nursing works best when each nurse competently uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation.

One element of a healthy community is that it: a. Meets all the needs of its inhabitants b. Offers access to healthcare services c. Has mixed residential and industrial areas d. Is little concerned with air and water quality

b. Offers access to healthcare services

A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness e. Syndrome

b. Risk

In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area? a. Screening for environmental triggers b. Smoking cessation c. Develop action plans d. Identify those at risk

b. Smoking cessation

What is the purpose of the ANA's Scope and Standards of Practice? a. To describe the ethical responsibility of nurses b. To define the activities that are special and unique to nursing c. To establish nursing as an independent and free standing profession d. To regulate the practice of nursing

b. The ANA's Scope and Standards of Practice define the activities of nurses that are specific and unique to nursing.

The mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? a. I see what you mean. That seems odd. b. The chest of a child appears round and is normal. c. I wouldn't worry about that. d. Did you tell the doctor about this?

b. The chest of a child appears round and is normal.

A nurse wants to acquire knowledge of a specific culture. What could be done first? a. talk to coworkers b. review literature c. talk to family members of the patient d. ask others with more experience for help

b. reviewing literature about a specific culture can provide the nurse with a starting point for information about cultural values, dietary practices, family lines of authority, and helth and illness beliefs and practices.

Practicing careful hand hygiene and using sterile techniques are ways in which nurses meet which basic human need? a. physiologic b. safety and security c. self esteem d. love and belonging

b. safety and security

Which phrase best describes the science of nursing? a. The skilled application of knowledge b. The knowledge base for care c. Hands-on care, such as giving a bath d. Respect for each individual patient

b. the science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing.

B

besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch

While administering a medication to relieve a patient's pain, you wonder if there are some nonpharmacologic interventions that would enhance relief by complementing the pain medication. When you discuss this with your instructor you are most likely to hear: a. "You should wait until after you evaluate the effect of the medication you just administered before planning a different intervention" b. "One step at a time, dear. Don't start planning a new intervention until you evaluate the old." c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap." d. "Think about this patient. Nonpharmacologic interventions wouldn't be effective with her."

c. "Lets talk about this... we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap."

Identify all of the following that are purposes of diagnosing. The purpose of diagnosing is to identify: 1. How an individual, group, or community responds to actual or potential health and life processes. 2. Factors that contribute to or cause health problems (etiologies) 3. Strengths the patient can draw on to prevent or resolve problems. 4. Nursing interventions to resolve health problems a. 1 & 2 b. 3 & 4 c. 1, 2, & 3 d. All of the above

c. 1, 2, & 3

The patient is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond? a. Ask the son if he is willing to translate and be sure to thank him if he says yes. b. Determine if the son can translate medical information, and if so, begin. c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity. d. Explain to the son that hospital policy forbids using family members as translators and find a hospital approved translator.

c. After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity.

Although all of the following are important to culturally competent nursing care, which one is the most basic? a. learning another language b. having signifigant information c. treating each person as an individual d. recognizing the importance of family

c. In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care.

A nurse is interviewing a newly admitted patient. Which question would be considered culturally sensitive? a. do you think you will be able to eat the food we have here? b. Do you understand that we can't prepare special meals? c. What types of food do you eat for meals? d. Why cant you just eat our food while you are here?

c. Asking patients what types of foods they eat for meals is culturally sensitive

Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis a. ibuprofren b celecoxib c aspirin indomethacin

c. Aspirin Rationale: Aspirin is a unique NSAID that inhibits platelet aggregation. Low dose aspirin therapy is commonly administered to decrease the risk of thrombophlebitis, MI, and stroke. Ibuprofren, celecoxib, and indomethacin are NSAIDS, but they do not inhibit platelet aggregation

Which action should the nurse take before administering morphine 4.0 intravenously to a patient complaining of incisional pain? a. Assess the patient's incision b. Clarify the order with the prescriber c. assess the patient's respiratory status d. monitor the patient's heart rate

c. Assess the patient's respiratory status

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be: a. Nuclear family b. Extended family c. Blended family d. Cohabiting family

c. Blended family

A nurse states, I know I am cleaner than most of my patients. What does this statement indicate? a. cultural assimilation b. racism c. ethnocentrism d. sterotyping

c. Ethnocentrism occurs when one believes that one's own ideas and practices are superior to those of others.

The best description of critical thinking indicators (CTIs) is which of the following: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice. b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice. c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice. d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice.

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in clinical practice.

The client tells the nurse he sometimes coughs up "thick yellow mucous." What does this information suggest to the nurse? a. He might have an allergy. b. He might have a fungal infection. c. He might have episodic lung infections. d. He might have tuberculosis.

c. He might have episodic lung infections Rationale: The color and odor of any mucus is associated with specific diseases or problems. Green or yellow mucus often signals a lung infection.

Which group is responsible for the promotion and organization of activities to continue the development, classification, and scientific testing of nursing diagnoses? a. American Nurses Association b. National Nursing Diagnosis Association c. North American Nursing Diagnosis Association d. Clearinghouse for Nursing Diagnoses

c. North American Nursing Diagnosis Association

A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? a. She has a history of smoking. b. She is using accessory muscles to breathe. b. She is in pending respiratory failure. c. Nothing. This is normal.

c. Nothing. This is normal.

What type of authority regulates the practice of nursing? a. International standards and codes b. Federal guidelines and regulations c. State nurse practice acts d. Institutional policies

c. Nurse practice act are established in each state to regulate the practice of nursing

When helping Mr Price turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of: a. Initial Planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning

You are asked to teach a group of preschool parents about poison control in the home. This activity is an example of what level of preventive care? a. Lowest b. Tertiary c. Primary d. Secondary

c. Primary (teaching poison control in the home is an example of primary preventive care)

Of the following terms, which would be defined as a disease? a. Excess fluid volume b. Risk for infection c. Rheumatoid arthritis d. Altered body image

c. Rheumatoid arthritis

You are a brand new RN. When you orient to a new nursing unit that is currently understaffed, you are told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response? a. Allow the UAPs to do the admission assessment and report the findings to you. b. Do your own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration. d. Contact your labor representative and complain.

c. Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from administration.

While palpating the posterior thorax of a client, the nurse notes increased fremitus. What does this finding suggest to the nurse? a. The client needs to speak up. b. The client has a thick chest wall. c. The client could either have fluid in the lungs or have an infection. d. Nothing. This is a normal finding.

c. The client could either have fluid in the lungs or have an infection.

Of the following statements, which one is true of self-actualization? a. Humans are born with fully developed self-actualization b. Self-actualization needs are met by having confidence and independence c. The self-actualization process continues throughout life d. Loneliness and isolation occur when self-actualization needs are unmet

c. The self-actualization process continues throughout life. (Self-actualization, or reaching one's full potential, is a process that continues through life.)

Of the following clinic patients, which one is most likely to have annual breast examinations and mammograms based on the physical human dimension? a. Jane, because her best friend had a benign breast lump removed. b. Sarah, who lives in a low-income neighborhood. c. Tricia, who has a family history of breast cancer. d. Nancy, because her family encourages regular physical examinations

c. Tricia, who has a family history of breast cancer.

You are surprised to detect and elevated temperature (102 F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. The first thing you do is to: a. Inform the charge nurse b. Inform the surgeon c. Validate your finding d. Document your finding.

c. Validate your finding

Minority groups living within a dominant culture may lose the cultural characteristics that made them different. What is this process called? a. cultural diversity b. cultural imposition c. cultural assimilation d. ethnocentrism

c. When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be described as which of the following: a. nuclear family b. extended family c. blended family d. cohabitating family

c. a blended family is formed when parents bring unrelated children from previous relationships together to form a new family

Of the following statements, which one is true of self actualization? a. Humans are born with fully developed self-actualization b. self-actualization needs are met by having confidence and indepence c. The self-actualization process continues throughout life. d. loneliness and isolation occur when self-actualization needs are unmet

c. self actualization, or reaching one's full potential is a process that continues through life

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire? a.Report the fire. b. Extinguish the fire. c. Protect the clients. d. Contain the fire.

c.Protect the clients. Rationale: In the event of a fire, the nurse's priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire

Evaluation of pain therapy requires the consideration of the ________ character of pain, ____ to therapy, ___ to function, and patient's perception of a therapy's effectivness

changing response ability

What is atelectasis?

collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs

secondary intention

complex healing of a larger wound involving sealing of the wound through scab formation, granulation or filling of the wound, and constriction of the wound. (full thickness)

________________ are moist sounds heard during inspiration that are not cleared with coughing.

crackles

The movement of the head and shoulders is controlled by ______________, also known as the spinal accessory nerve.

cranial nerve XI

Which of the following nursing degrees prepares a nurse for advanced practice as a clinical specialist or nurse practitioner? a. LPN b. ADN c. BSN d. Master's

d. A Master's degree prepares advanced practice nurses.

One of the developmental tasks of the older adult family is to: a. Maintain a supportive home base b. Prepare for retirement c. Cope with loss of energy and privacy d. Adjust to loss of spouse

d. Adjust to loss of spouse (A developmental task of the older adult family is adjusting to the loss of a spouse)

Which one of the following is an example of an affective outcome? a. within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/12, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/12, the patient's ulcer will begin to show signs of healing (eg, size shrinks form 3" to 2.5"). d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. (Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes describe increases in patient knowledge of intellectual behaviors; psychomotor outcomes describe the patient's achievement of new skills. )

Which of the following is an optional element in a measurable outcome? a. Subject b. Verb c. Performance criteria d. Conditions e. target time

d. Conditions (Conditions specify the particular circumstances in or by which the outcome is to be achieved. Not every outcome specifies conditions.)

What do both the health-illness continuum and the high-level wellness models demonstrate? a. Illness as a fixed point in time b. The importance of family c. Wellness as a passive state d. Health as a constantly changing state

d. Health as a constantly changing state (both these models view health as a dynamic, constantly changing state)

The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine position b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen

d. Hyperventilating the client with 100% oxygen

Jeanne is a college student who wants to lost 20 pounds. She meets with the student health nurse and develops a plan to increase her activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate her weight loss monthly. When Jeanne arrives for her first "weigh-in", the nurse discovers that instead of the projected weight loss of 5 pounds, Jeanne has only lost 1 pound. Which is the best nursing response? a. Congratulate Jeanne and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving Jeanne more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for Jeanne's partial success

d. Modify the plan of care after discussing possible reasons for Jeanne's partial success.

Altered Health Maintenance is an example of: a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing problem (because it describes a problem that can be treated by nurses within their scope of independent nursing practice)

Of all the physiologic needs, which one is the most essential? a. Food b. Water c. Elimination d. Oxygen

d. Oxygen (Oxygen is the most essential of all needs because all body cells require oxygen for survival)

When you receive shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over body prominences. You should: a. Correct the initial assessment form. b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment on skin integrity

d. Perform and document a focused assessment on skin integrity

Following the birth of his first child and after reading about the long-term effects of nicotine, John decides to stop smoking. This behavior change is most likely based on John's perceptions of all but one of the following. Which one is not true? a. His susceptibility to lung cancer b. How serious lung cancer would be c. What benefits his stopping smoking will have d. Personal choice and economic factors

d. Personal choice and economic factors (the others are components of the health-belief model)

Which of the following phrases describes one of the purposes of the ANA's nursing's social policy statement? a. to describe the nurse as a dependent caregiver b. To provide standards for nursing educational programs c. to regulate nursing research d. to describe nursing's values and social responsiblity

d. The nursing's social policy statement describes the values and social responsibility of nursing

Which of the following statements about the nursing process is most accurate? a. The nursing process is a four-step procedure for identifying and resolving patient problems. b. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process c. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept

d. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept (a.The nursing process is a five-step process, b. The term nursing process was first used by Hall in 1955, c. Standards demand the use of the nursing process, so it is not optional.)

After examining a 75-year-old male client, the nurse writes down "barrel chest." What does this finding suggest? a. The client has a history of smoking. b. The client has osteoporosis. c. The client has long-standing respiratory disease. d. This is a change associated with aging.

d. This is a change associated with aging.

The nurse sees that the client will breathe deeply and then stop breathing for a short while. Which of the following does this observation suggest? a. This client is hyperventilating. b. This client is in a diabetic coma. c. This client has pneumonia. d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.

d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.

The terms diagnose and diagnosis have legal implications. they imply that there is a specific problem that requires management by a qualified expert. Which of the following statements is false? a. If you make a diagnosis, it means that you accept accountability for accurately naming and managing the problem b. If you treat a problem or allow a problem to persist without ensuring that the correct diagnosis has been made, you may cause harm and be accused of negligence. c. You are accountable for detecting, identifying, or recognizing signs and symptoms that may indicate problems beyond your expertise. d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

d. When nurses diagnose a medical problem, they are just as accountable as physicians for detecting, identifying, and managing the signs and symptoms of disease.

Which of the following is one of the developmental tasks of the older adult family? a. maintain a supportive home base b. prepare for retirement c. cope with loss of energy and privacy d. adjust to loss of a spouse

d. a developmental task of an older individual is to cope with the loss of a spouse.

What is the best broad definition of a family? a. A father, a mother, and children b. Members are biologically related c. Includes aunts, uncles, and cousins d. A group of people who live together

d. a group of people who live together (Although all the responses may be true, the best definition is a group of people who live together.)

What is the best broad definition of family? a. a father, a mother, and children b. a gruop whose members are biologically related c. a unit that includes aunts, uncles, and cousins d. a group of people who live together

d. although all of the responses may be true, the best definition is a group of people who live together

The nurse administers codeine sulfate 30mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? a. Immediately b. in 10 minutes c. in 15 minutes d. in 60 minutes

d. in 60 minutes Rationale: Codeine administered by the oral route reaches peak concentration in 60 minutes; therefore the nurse should reassess the patient's pain 60 min after administering. The nurse should reassess pain after 10 min when administering codeine by IM or SC routes. Drug administered by the IV routes are effective almost immediately; however codeine is NOT recommended for IV administration.

When you enter the patient's room to begin your nursing history, the patient's wife is there. You should: a. Introduce yourself to both and thank the wife for being present. b. Introduce yourself to both and ask the wife if she wants to remain. c. Introduce yourself and ask the wife to leave. d. Introduce yourself and ask the patient if the would like the wife to stay.

d. introduce yourself and ask the patient if he would like the wife to stay.

Of all physiologic needs, which one is the most essential? a. food b. water c. elimination d. oxygen

d. oxygen

A nurse states, that woman is 78 years old-too old to learn how to change a dressing. What is the nurse demonstrating? a. cultural imposition b. clustering c. cultural competency d. stereotyping

d. stereotyping is assuming that all members of a group are alike.

What portion of the hand should be used when assessing temperature?

dorsum of hand/fingers

If a doctor orders antibiotics and a CBC, what should you do first?

draw up the blood

What two populations are at the highest risk of experiencing hypothermia?

elderly and infants

What portion of the hand should be used when assessing for organ size?

entire palmar surface of hand or palmar surface of fingers

How often should a health assessment be performed?

every shift, unless in ICU (then every 2 hours)

What criteria should be measured in regard to the thorax during a health assessment?

excursion, tenderness and fremitus

A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. True False

false

What portion of the hand should be used when assessing for thorax tenderness?

finger pads/palmar surface of fingers

Define exudate.

fluid, cells, or other substances that have been slowly exuded, or discharged, from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus, and serum are sometimes identified as exudates.

Unstageable

full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar

pain modulation

hindering the transmission of pain by release of inhibitory neurotransmitters (endorphins&enkephalins) that produce an analgesic effect

What actions could affect oral temperature?

hot or cold drinks, smoking

_________________________ can be heard over emphysematous lungs as a booming sound

hyperresonance

What does the abbreviation HTN stand for?

hypertension

The ____________________ nerve innervates portions of the tongue.

hypoglossal

What does the abbreviation HOTN stand for?

hypotension

What part of the body is considered to be the temperature control center?

hypothalamus

During a physical assessment, what can a sweet, heavy, thick odor indicate?

infection

hypostatic pneumonia

inflammation of the lung from stasis or pooling of secretions from lack of movement and exercise

What is the purpose of a spacer?

it helps the medication reach the lungs used in children and elderly helps avoid mouth fungus,nervousness and other side effects

During a physical assessment, what can a sweet/fruity odor indicate?

ketones/diabetes

The S2 (dub) sound is the second heart sound and indicates closure of the _________________ and ____________________ valves.

mitral; tricuspid

transmission of pain

movement of pain impulses from the periphery to the spinal cord & then to the brain

What are some of the risk factors for decreased skin integrity?

neuro deficit patients (stroke, spinal chord injury) chronic illness (diabetes) orthopedic problems (broken bones) decreased mental capacity (dementia, Alzheimer's) poor tissue oxygenation low cardia output (low blood pressure) inadequate nutrition (malnourished)

What are the two most accurate routes for taking a temperature?

oral and rectal

What portion of the hand should be used when assessing for gland swelling?

pads of fingers

During a physical assessment always perform ____________ procedures last.

painful

What portion of the hand should be used when assessing for thorax fremitus?

palmar or ulnar surface of entire hand.

What portion of the hand should be used when assessing for skin moisture?

palmar surface

What portion of the hand should be used when assessing for blood vessel pulse amplitude?

palmar surface/pads of fingertips

Factors affecting sleep

physical illness drugs and substances emotional stress environment lifestyle exercise and fatigue food and caloric intake sound

Administration of intraocular disk

position convex side on fingertip place on conjuctival sac btw iris and lower lid gently pull eyelid over disk carefully pinch disk to remove from patient's eye

A patient's age, gender,anxiety, culture, and __________ influence the pain experience

previous experience&meaning of pain

transduction of pain

process that begins in the periphery when pain-producing stimulus send an impulse across a peripheral nerve fiber

NSAIDs inhibit the synthesis of

prostaglandins

perception of pain

protects the body from damage, and is stimulated by extremes of pressure and temperature, as well as chemicals released from damaged tissues(physical component)

What criteria should be measured in regard to blood vessels during a health assessment?

pulse amplitude, elasticity, rate and rhythm

nonblanchable hyperemia

redness of the skin due to dilation of the superficial capillaries. The redness persists when pressure is applied to the area, indicating tissue damage

blanchable hyperemia

redness of the skin due to dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color

Describe Tachypnea

respirations > 35 clinical significance/contributing factors: - respiratory failure - response to fever - anemia - pain - respiratory infection - anxiety (emergencies SNS system kicks in)

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _____________________.

risk for infection Rationale: Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk.

What criteria should be measured in regard to organs during a health assessment?

size, shape, tenderness, absence of masses

What medication can prevent a client who is ill from running a fever?

steriods

Aside from increased temperature, what are other signs of fever?

stomach cramps, dizziness, loopiness.

incision

surgical cut or wound produced by a sharp instrument

What criteria should be measured in regard to glands during a health assessment?

swelling, symmetry and mobility

What needs to be done with a doctor orders specify to take BP "x all 4 extremities"?

take BP to measure for hypotension when moving from one position to another.

What criteria should be measured in regard to skin during a health assessment?

temperature, moisture, texture, turgor and elasticity, tenderness, thickness

Define Cyanosis.

the appearance of a blue or purple coloration of the skin or mucous membranes

Circadian Rhythm

the biological clock; regular bodily rhythms that occur on a 24-hour cycle