FINAL EXAM

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The nurse is administering 250 mg of a medication elixir to the patient. The medication comes in a dose of 1000 mg/5 mL. How many milliliters should the nurse administer? Record your answer using two decimal places. __ mL

1.25

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? 30 to 60 10 to 15 22 to 28 16 to 20

30 to 60

A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? Developmental capabilities and physical capabilities Stage of grieving and overall physical health Psychosocial adaptation to illness and active participation Sociocultural background and motivation

A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? Effectively provides for multifaceted healthcare needs. Communicates effectively in a multicultural context. Visits a foreign country. Speaks a different language.

A nurse is providing different types of therapies to a patient with excessive fatigue. Which technique will cause the nurse manager to intervene? Active progressive relaxation Guided imagery Passive relaxation Meditation

A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? One who has excessive risks. One who uses nontraditional healing practices. One who has unlimited access to health care. One who is pregnant.

A nurse is standing beside the patient's bed and the following exchange occurs.Nurse: How are you doing?Patient: I don't feel good.Which element will be identified as feedback? I don't feel good. Patient How are you doing? Nurse

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care? A patient with neck surgery A patient with a stage IV pressure ulcer A patient with hypostatic pneumonia A patient with a total knee replacement

A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? Coronary artery Superior vena cava Carotid artery Pulmonary artery

A patient in the emergency department is reporting left lower abdominal pain. Which proper order will the nurse follow to perform the comprehensive abdominal examination? Inspection, auscultation, palpation Inspection, palpation, auscultation Percussion, auscultation, palpation Percussion, palpation, auscultation

An older-adult patient needs an intramuscular (IM) injection of antibiotic. Which site is best for the nurse to use? Ventrogluteal Vastus lateralis Dorsal gluteal Deltoid

During a school physical examination, the nurse reviews the patient's current medical history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies? Pale nasal mucosa Clubbing Puffiness of nasal mucosa Yellow nasal discharge

During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? A delay in or cancellation of surgery Instructions to determine what education was provided in the preoperative visit Additional questions about why the patient had coffee Questions regarding components of the coffee

Having misplaced a stethoscope, a nurse borrows a colleague's stethoscope. The nurse next enters the patient's room and identifies self, washes hands with soap, and states the purpose of the visit. The nurse performs proper identification of the patient before auscultating the patient's lungs. Which critical health assessment step should the nurse have performed? Cleaning stethoscope with alcohol Running warm water over stethoscope Rubbing stethoscope with betadine Draping stethoscope around the neck

The group leader is overheard saying to the gathering of patients, "Focus on your breathing once again .... Notice how it is regular .... Now focus on your left arm .... Notice how relaxed your left arm feels .... Notice the relaxation going down the left arm to the hand." A patient asks the nurse what the group is doing. What is the nurse's best response? Progressive relaxation training Group biofeedback Guided imagery Meditation

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? Carbon monoxide tightly binds to hemoglobin, causing hypoxia. Carbon monoxide detectors are required by law in the home. Carbon monoxide signals the cerebral cortex to cease ventilations. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

The nurse caring for a group of patients is monitoring for sensory deprivation. Which patient will the nurse monitor most closely? A patient on the unit with tuberculosis on airborne precautions A patient receiving hospice care for end-stage lung cancer A patient who recently had a stroke and has left-sided weakness A patient in the ICU under constant monitoring following a myocardial infarction

The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises? 1. Turning 2. Breathing 3. Coughing 4. Leg exercises 4, 1, 2, 3 1, 2, 3, 4 3, 1, 4, 2 2, 3, 4, 1

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? Responsibility Confidentiality Accountability Advocacy

The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? Autonomy Fidelity Justice Consequentialism

The patient presented to the ambulatory surgery center to have a colonoscopy is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? The procedure requires a depressed level of consciousness. The procedure results in loss of sensation in an area of the body. The procedure necessitates the patient to be immobile. The procedure will be performed on an outpatient basis.

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? Regurgitation of the mitral valve The opening of the aortic valve Presence of orthopnea The beginning of the systolic phase

A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? A patient who is diaphoretic A patient who is afebrile A patient with strong pedal pulses A patient with adequate skin turgor

A patient who is diaphoretic

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? Heart failure Sore throat Sleep apnea Acute pain

Acute pain

A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? Sequential compression devices Blood pressure cuff Elastic stockings Thermometer

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? Carotid Apical Brachial Radial

Carotid

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? It has no risk of injury to patient or nurse. It is not affected by skin moisture. It is accurate even when the forehead is covered with hair. It reflects rapid changes in radiant temperature.

It has no risk of injury to patient or nurse.

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? Clear the path to the bathroom of all obstacles before bedtime. Practice Kegel exercises to strengthen bladder muscles. Leave the bathroom light on to illuminate a pathway. Limit fluid and caffeine intake before bed.

Limit fluid and caffeine intake before bed.

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? Transport patients quickly and efficiently through the elevators. Manage all patients using standard precautions. Prepare for posttraumatic stress associated with this bioterrorism attack. Monitor for specific symptoms.

Manage all patients using standard precautions.

A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool? Bright red blood Mucoid Dark black blood Microscopic

Microscopic

The nurse is assessing the patient's respirations. Which action by the nurse is most appropriate? Do not touch the patient until completed. Inform the patient that she is counting respirations. Obtain without the patient knowing. Estimate respirations.

Obtain without the patient knowing.

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)? Inserting a straight catheter Obtaining a midstream urine specimen Irrigating a catheter Interpreting a bladder scan result

Obtaining a midstream urine specimen

In order to receive payment for care provided, nursing centers must comply with requirements outlined in what federal legislation? Omnibus Budget Reconciliation Act Medicare Act Medicaid Act Affordable Care Act

Omnibus Budget Reconciliation Act

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? Focusing on helping patients be disease free Directing focus only on the pathological state Assuring that care is strictly personal in nature Providing care that involves the whole person

Providing care that involves the whole person

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting? Experimental research Evaluation research Nonexperimental research Qualitative research

Qualitative research

A patient recovering from a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? Administering laxatives to the patient Preparing to administer a barium enema Raising the head of the bed Withholding narcotic pain medication

Raising the head of the bed

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) Reimbursement Nursing process Education Legal documentation Communication Research

Reimbursement Education Legal documentation Communication Research

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? "Teaching is most effective when it responds to the learner's needs." "Teaching and learning can be separated." "Learning is an interactive process that promotes teaching." "Learning consists of a conscious, deliberate set of actions designed to help the teacher."

A patient has been prescribed to receive 0.3 mL of U-500 insulin. Which syringe will the nurse use to administer the medication? Tuberculin syringe 3-mL syringe Needleless syringe U-100 syringe

A patient refuses medication. Which is the nurse's first action? Explore with the patient reasons for not wanting to take the medication. Agree with the patient's decision and document it in the chart. Educate the patient about the importance of the medication. Discreetly hide the medication in the patient's favorite gelatin.

A registered nurse interprets that a scribbled medication prescription reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? Nurse Health care provider Hospital Pharmacist

A teen patient is tearful and reports locating lumps in her breasts. Other history obtained is that she is currently menstruating. Physical examination reveals soft and movable cysts in both breasts that are painful to palpation. The nurse also notes that the patient's nipples are erect, but the areola is wrinkled. Which action will the nurse take after talking with the health care provider? Discuss the possibility of fibrocystic disease as the probable cause. Consult a breast surgeon because of the abnormal nipples and areola. Reassure patient that her symptoms are normal. Tell the patient that the symptoms may get worse when her period ends.

A nurse is working as a public health nurse. What will be the nurse's primary focus? Individuals and families Needs of a population The individual as one member of a group Health promotion

A patient diagnosed with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to address this topic? At bath time, when the nurse is cleaning the patient. At medication time, when the nurse is administering patient medication. At lunchtime, while the nurse is preparing the food tray. At bedtime, while the patient is relaxed.

The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record? Stage III pressure ulcer Healing Stage III pressure ulcer Healing Stage II pressure ulcer Stage I pressure ulcer

In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide? Give cow's milk during the first year of life. Supplement breast milk with corn syrup. Provide breast milk or formula for the first 4 to 6 months. Add honey to infant formulas for increased energy.

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan? A patient who is completely immobile A patient who is at risk for multisystem problems A patient who is not completely immobile A patient at risk for single-system involvement

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? Place a face mask delivering 100% oxygen over the nose and mouth. Manually occlude the tracheostomy with sterile gauze. Insert a spare tracheostomy with the obturator. Press the emergency response button.

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPICDISCHARGE SUMMARY Medication DietActivity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge SOAP notes Clinical decision support system Admission nursing history Mode of transportation

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? An acuity rating A referral An electronic record entry A verbal report

A nurse grimaces while changing a patient's colostomy bag. Which effect will the nurse's behavior most likely have on the patient? Develop a kind nickname for the colostomy bag. Assist recovery by using honest communication. Motivate the patient to increase physical activity. Promote development of a negative body image.

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent? Back Arm Ankle Hip

The nurse performing a moist-to-dry dressing has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the following steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin .4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze. 1, 3, 4, 5, 6, 2 1, 4, 3, 5, 6, 2 4, 1, 3, 5, 6, 2 4, 3, 1, 5, 6, 2

The nurse plans to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? Diminished respiratory muscle strength may cause poor chest expansion. Thinner heart valves cause lipid accumulation and fibrosis. Alterations in mental status prevent patients' awareness of ineffective breathing. An increased number of pacemaker cells make proper anesthesia induction more difficult.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? Bundle of His AV node SA node Purkinje fibers

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? Left atrium, left ventricle, right ventricle Right ventricle, left ventricle, left atrium Left atrium, right ventricle, left ventricle Right ventricle, left atrium, left ventricle

The nurse is assessing skin turgor. Which technique will the nurse use? Press lightly on the fingertips. Press lightly on the forearm. Grasp a fold of skin on the back of the hand. Grasp a fold of skin on the sternal area.

The nurse is intervening for a patient with a risk for a urinary infection. Which direct care nursing intervention is most appropriate? Transports urine specimen to the lab. Properly cleans the patient's toilet. Informs the oncoming nurse during hand-off. Teaches proper handwashing technique.

The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse? "It is required that you have a family member at this appointment." "Your family can come and wait with you in the waiting room." "There is no need for an additional person at the appointment." "We recommend including family members at this appointment."

Which coughing technique will the nurse use to help a patient clear central airways? Incentive spirometry Cascade Quad Huff

The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? Flossing removes plaque and tartar from the teeth Using waxed floss prevents bleeding Performing flossing at least 3 times a day is beneficial Applying toothpaste to the teeth before flossing is harmful

Flossing removes plaque and tartar from the teeth

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? Hypoactive bowel sounds Jaundice in sclera Soft tender abdomen Increased fluid intake

Hypoactive bowel sounds

The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse to emphasize washing hands before and after what form of contact? Shaking hands Performing treatments Opening the refrigerator Working on a computer

Performing treatments

After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? Temperatures vary depending on the route used. Axillary temperatures are higher than oral temperatures. Rectal temperatures are cooler than when taken orally. Temperatures are readings of core measurements.

Temperatures vary depending on the route used.

A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? Continuing care Restorative care Preventive care Tertiary care

Tertiary care

The nurse is caring for a patient diagnosed with diabetes who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient? The current self-treatment is likely impeding with circulation to the toes. Tighter shoes would help to compress the corns and make them smaller. The patient should avoid soaking the feet before using a pumice stone. Corn pads are an adequate treatment and should be continued.

The current self-treatment is likely impeding with circulation to the toes.

A nurse is emphasizing the use of touch to decrease "skin hunger" in caring for patients. Which age-group is the nurse primarily describing? Older adults Children Infants Middle age

A nurse is evaluating care of an immobilized patient. Which action will the nurse take? Compare the patient's actual outcomes with the outcomes in the care plan. Focus on whether the interdisciplinary team is satisfied with the care. Use objective data solely in determining whether interventions have been successful. Involve primarily the patient's family and health care team to determine goal achievement.

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action? Joint contractures Pressure ulcers Renal calculi Atelectasis

A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for? Loss of hope Loss of bone mass Loss of strength Loss of weight

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. 5, 3, 1, 2, 4, 6 4, 5, 1, 2, 3, 6 3, 1, 2, 5, 4, 6 1, 2, 3, 4, 5, 6

A patient has an order to receive 12.5 mg of hydrochlorothiazide. The nurse has on hand a 25 mg tablet of hydrochlorothiazide. How many tablet(s) will the nurse administer? 1/2 tablet 1 1/2 tablets 1 tablet 2 tablets

A patient has been diagnosed with heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? Stroke volume × heart rate Preload/afterload Ventricular filling time/diastolic filling time Myocardial contractility × myocardial blood flow

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? Patient takes antianxiety medications. Patient smokes 2 packs of cigarettes a day. Patient drinks 1 to 2 glasses of wine every night. Patient occasionally uses marijuana.

A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient? Increased appetite Increased diarrhea Increased pulse rate Increased metabolic rate

A nurse is charting. Which event is critical for the nurse to document? The family is demanding and argumentative. The patient had a good day with no complaints. The patient received a pain medication. The family is poor and had to go on welfare.

A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority to assist learning? Identify that teaching is the same as the nursing process. Assess laboratory results for high cholesterol and other data. Focus on a patient's learning needs and objectives. Perform nursing care therapies to address hypertension.

A nurse is using a critical thinking model to provide care. Which component is first implemented when helping a nurse make clinical decisions? Attitude Experience Specific knowledge base Nursing process

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? Establishes minimal passing standards for testing. Bypasses the patient's feelings to promote ethical standards. Uses critical thinking for the highest level of quality nursing care. Utilizes evidence-based practice based on nurses' needs.

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? Use the same password all the time. Share password with only one other staff member. Chart on the computer immediately after care is provided. Print out and review computer nursing notes at home.

A patient describes practicing a complementary and alternative therapy involving breathwork and yoga. The nurse also recommends using energy field therapies. Which techniques did the nurse suggest? Massage therapy and ayurveda The "zone" and acupressure Reiki therapy and therapeutic touch Prayer and tai chi

A patient develops a foodborne disease from Escherichia coli. When taking a health history, which food item will the nurse most likely find the patient ingested? Improperly home-canned food Custard Undercooked ground beef Soft cheese

A patient diagnosed with type 2 diabetes 26 years ago is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction? "The neurological gates open when wearing shoes, which protects your feet." "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot." "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet."

A patient is at risk for aspiration. Which nursing action is most appropriate? Give the patient a straw to control the flow of liquids. Turn the head toward the stronger side. Have the patient self-administer the medication. Thin out liquids so they are easier to swallow.

A verbally abusive partner has told a significant other many negative comments over the years. In the crisis center, the nurse would anticipate that the patient may have which self-concept deficits? Body image Yearning Rigidity Role confusion

When caring for an older-adult patient, which technique will the nurse use to enhance an older-adult patient's self-concept? Reviewing old photos with patients Allowing patients extra computer time Discussing current weather Encouraging patients to sing

A nurse is teaching a community group of school-aged parents about safety. The proper fitting of which safety item is most important for the nurse to include in the teaching session? Swimming goggles Baseball sliding shorts Soccer shin guards A bicycle helmet

A bicycle helmet

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP? Ulnar site Radial site Femoral site Brachial site

Brachial site

Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? Blood clots or sediment in the drainage bag Output that is smaller than the amount instilled Bladder distention with tenderness Bright red urine turns pink in the tubing

Bright red urine turns pink in the tubing

An older-adult patient is visiting the clinic after a fall during the night. The nurse obtains information on what medications the patient takes. Which medication most likely contributed to the patient's fall? Iron supplement Benzodiazepine L-tryptophan Melatonin

Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer? Sodium Vitamin E Prealbumin Potassium

The nurse is planning to administer a tuberculin test with a 27-gauge, ⅝-inch needle. At which angle will the nurse insert the needle? 45 degree 30 degree 90 degree 15 degree

While gathering an adolescent's health history, the nurse recognizes that the patient began to act out behaviorally and engaged in risky behavior when the patient's parents divorced. Which information will the nurse gather to help in determining situational low self-esteem? Why the patient is acting out of control? Why the parents are divorcing? How long the parents were married? How the patient views behaviors?

When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition? Nail polish remover Nail polish Friction Fungi

Fungi

A nurse is preparing a teaching session about contemporary influences on nursing. Which examples should the nurse include? (Select all that apply.) Human rights Affordable Care Act Demographic changes Medically underserved Decreasing health care costs

Human rights Affordable Care Act Demographic changes Medically underserved

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) Maturation Hemostasis Reestablishment of epidermal layers Inflammatory Reproduction Proliferative

Maturation Hemostasis Inflammatory Proliferative

An older-adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? Hospice Respite care Assisted living Skilled nursing

Skilled nursing

The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) Age Obesity Nutrition Race Ambulatory surgery Pregnancy

Age Obesity Nutrition Pregnancy

The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do? Dry the skin with a towel. Avoid using a bath towel. Rinse the skin thoroughly. Allow the skin to air-dry.

Allow the skin to air-dry.

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? Document the variance in the patient's record. Focus chart using the DAR format. Report a positive variance in the next interdisciplinary team meeting. Add this data to the problem list.

A nurse is assessing a patient for possible altered self-concept. Which assessment finding is consistent with altered self-concept? Hesitant to express opinions Appropriately dressed in clean clothes Independent attitude Holds eye contact

A nurse is assessing a patient's ethnic history. Which question should the nurse ask? How different is your life here from back home? How different is what we do from what your family does when you are sick? What language do you speak at home? Which caregivers do you seek when you are sick?

A nurse is attempting to administer an oral medication to a child, but the child refuses to take the medication. A parent is in the room. Which statement by the nurse to the parent is best? "I will prepare the medication for you and observe if you would like to try to administer the medication." "Let's turn the lights off and give your child a moment to fall asleep before administering the medication." "Since your child loves applesauce, let's add the medication to it, so your child doesn't resist." "Please hold your child's arms down, so I can give the full dose."

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment? Uses the diaphragm to listen for bowel sounds. Uses the bell to listen for lung sounds. Uses the bell to listen for high-pitched murmurs. Uses the diaphragm to listen for bruits.

A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? Assessing own biases and attitude Developing cultural skills Learning about the world view of others Understanding organizational forces

A nurse is caring for a group of patients. Which patient should the nurse see first? A patient with hypercapnia wearing an oxygen mask A patient with thick secretions being tracheal suctioned first and then orally A patient with a chest tube ambulating with the chest tube unclamped A patient with a new tracheostomy and tracheostomy obturator at bedside

A nurse is caring for a group of patients. Which patient will the nurse see first? An adult with an S4 heart sound A young adult with bronchovesicular breath sounds between the scapula posteriorly A young adult with an S3 heart sound An adult with vesicular lung sounds in the lung periphery

A nurse is caring for a patient prescribed continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? Ventricular tachycardia Sinus rhythm Atrial fibrillation Paroxysmal supraventricular tachycardia

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any physical distress. Which response by the nurse is most therapeutic? "What would you like to try to alleviate your pain?" "Your vitals do not show that you are having pain; can you describe your pain?" "OK, I will go get you some narcotic pain relievers immediately." "You do not look like you are in pain."

A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? There is an increased incidence of disease. There is a decreased frequency of morbidity. There is a decreased mortality rate. There is an increased level of health.

A nurse is completing a history on a patient with role conflict. Which finding is consistent with role conflict? A patient has to travel for work and misses children's birthdays. A patient feels less of a man after a leg amputation. A patient loses a job from the company's downsizing. A patient is unsure about job expectations in a fast-paced company.

A nurse is describing a patient's perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? Self-efficacy Active participation Motivation Attentional set

A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? A patient demonstrates how to inject insulin. A family member listens to a lecture on diabetes. A primary care provider hands a diabetes pamphlet to the patient. A nurse presents information about diabetes.

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? Provide the patient with a writing board each shift. Ask the family to provide a sitter to remain with the patient at all times. Assist the patient in performing swallowing exercises each shift. Obtain an interpreter for the patient as soon as possible.

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? Reduced errors of omission Varied clinical databases More time to read charts Increased hospital costs

A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? Let the patient touch and use the exercise equipment. Provide the patient with a case study about the exercise equipment. Provide the patient with pictures of the exercise equipment. Let the patient listen to a video about the exercise equipment.

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? Establish a rapport. Get an interpreter. Obtain pictures of food. Refer to a dietitian.

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? Promotion of health and illness prevention Restoration of health Coping with impaired functions Health analogies

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? If you still do not understand, ask again. Inappropriate medical tests are the most common mistakes. The nurse is the center of the health care team. Ask a nurse to be your advocate or supporter.

A nurse is teaching a patient relaxation techniques to decreases stress. Which finding will support the nurse's evaluation that the therapy is effective? Decreased heart rate Increased blood sugar Elevated blood pressure Dilated pupils

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What form of energy is the nurse discussing? Basal metabolic rate (BMR) Nutrient density Nutrients Resting energy expenditure (REE)

A nurse is teaching about the therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness. Which therapy is the nurse describing? Allopathic Mind-body Alternative Complementary

A nurse is teaching the staff about the sleep cycle. Which sequence will the nurse include in the teaching session? NREM Stage 1, 2, 3, 4, 3, 2, REM NREM Stage 1, 2, 3, 4, 3, 2, 1, REM NREM Stage 1, 2, 3, 4, REM NREM Stage 1, 2, 3, 4, REM, 4, 3, 2 REM

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? Review the effectiveness of nursing actions. Examine the meaning of data. Search for links between the data and the nurse's assumptions. Support findings and conclusions.

A nurse is working at a health fair screening people for colorectal cancer. Which population group should the nurse monitor most closely for this form of cancer? Non-Hispanic Blacks Asian Americans Hispanic Non-Hispanic Caucasians

A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? Feminist ethics Utilitarianism Deontology Teleology

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? The patient stating that eating yogurt is better than eating cake The patient The nurse The nurse teaching about healthy food choices

A nurse's goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? Teaching a teenager with a broken leg how to use crutches Teaching a family member to provide passive range of motion for a stroke patient Teaching a woman who recently had a hysterectomy about possible adoption Teaching expectant parents about changes in childbearing women

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? Assist patient into and out of bed every 4 hours or as tolerated. Keep all side rails down at all times. Encourage patient to remain in bed most of the shift. Place patient in room away from the nurses' station if possible.

A patient injured in a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA? The patient rates pain at a level of 2 on a 0 to 10 scale. The patient has sufficient medication left in the PCA syringe. The patient presses the control button to deliver pain medication. The patient is sleeping and is difficult to arouse.

A patient is in need of immediate pain relief for a severe headache. Which medication will the nurse administer to be absorbed the quickest? Hydromorphone 4 mg IV Ketorolac 8 mg IM Acetaminophen 650 mg PO Morphine 6 mg SQ

A patient is on a full liquid diet. Which food item choice by the patient will cause the nurse to intervene? Mashed potatoes and gravy Frozen yogurt Custard Pureed vegetables

Before a patient with beginning stage of Alzheimer's disease is discharged, the community-based nurse is making a visit to the patient's home. The patient's daughter and family live in the home with the patient. What is the major focus of this visit? Demonstrate techniques for providing care. Stress to the family how difficult it will be to provide care at home. Teach the family how to monitor blood pressure. Encourage the family to send the patient to an extended care facility.

During a routine pediatric history and physical, the parents report that their child was a very small, premature infant that had to stay in the neonatal intensive care unit longer than usual. They state that the infant was "yellow" when born and developed an infection that required "every antibiotic under the sun" to reach a cure. Which exam is a priority for the nurse to conduct on the child? Hearing acuity Respiratory Cardiac Ophthalmic

In general, when a patient's energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe? Weight does not change. Weight increases. Weight decreases. Weight fluctuates daily.

The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question? Irrigate with Dakin's solution. Use a low-air-loss therapy unit. Apply a hydrogel dressing. Consult a dietitian.

The nurse caring for a preoperative patient teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? Assess for the presence of anxiety, pain, or fatigue. Encourage the patient to practice at a later date. Ask the patient why exercises are not being done. Evaluate the educational methods used to educate the patient.

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? Notify the operating suite that the patient has a latex allergy. Ask the nursing assistive personnel to obtain vital signs. Administer the ordered preoperative intravenous antibiotic. Document that the patient had a bath at home this morning.

The nurse is administering medications to several patients. Which action should the nurse take? Advise a patient to wait 2 minutes after a corticosteroid inhaler treatment to rinse mouth with water. Administer an intravenous medication through tubing that is infusing blood. Aspirate before administering a subcutaneous injection in the abdomen. Pinch up the deltoid muscle of an adult patient receiving a vaccination.

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? The patient who is experiencing 8/10 pain and has an immediate order for pain medication. The patient who needs to be premedicated before walking. The patient who needs to take a scheduled dose of maintenance pain medication. The patient who has a PCA running that needs the syringe replaced.

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system? Auscultate the entire lung region to assess lung sounds. Assess the patient at least every 4 hours. Inspect chest wall movements primarily during the expiratory cycle. Focus auscultation on the upper lung fields.

The nurse is caring for a Chinese patient using the teach-back technique. Which action by the nurse indicates successful implementation of this technique? Asks, "What will you tell your spouse about changing the dressing?" Asks, "Do you think you can do this at home?" Asks, "Does this make sense?" Asks, "Would you tell me if you don't understand something, so we can go over it?"

The nurse is caring for a patient experiencing fluid volume overload. Which physiological effect does the nurse most likely expect? Increased preload Decreased afterload Decreased tissue perfusion Increased heart rate

The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.) "Can you explain the risk for infection in your home?" "Have you traveled outside of the United States?" "Will you demonstrate how to wash your hands?" "What are the signs and symptoms of infection?" "Are you able to walk to the mailbox?" "Who runs errands for you?"

"Can you explain the risk for infection in your home?" "Have you traveled outside of the United States?" "Will you demonstrate how to wash your hands?" "What are the signs and symptoms of infection?"

Which assessment question should the nurse ask if stress incontinence is suspected? "Do you experience urine leakage when you cough or sneeze?" "Do you empty your bladder completely when you void?" "Do your symptoms increase with consumption of alcohol or caffeine?" "Do you think your bladder feels distended?"

"Do you experience urine leakage when you cough or sneeze?"

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? "You should schedule a colonoscopy as soon as possible." "Do you take iron supplements?" "Are you under a lot of stress?" "This is probably a false negative; we should rerun the test."

"Do you take iron supplements?"

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? "Set your alarm clock to wake you every 2 hours, so you can get up to void." "Drink your nightly glass of milk earlier in the evening." "Empty your bladder completely before going to bed." "Line your bedding with plastic sheets to protect your mattress."

"Drink your nightly glass of milk earlier in the evening."

The patient and the nurse discuss the need for sleep. After the discussion, the patient is able to state factors that hinder sleep. Which statements indicate the patient has a good understanding of the teaching? (Select all that apply.) "Drinking coffee at 7 PM could interrupt my sleep." "Taking an antacid can decrease sleep." "Staying up late for a party can interrupt sleep patterns." "Worrying about work can disrupt my sleep." "Exercising 2 hours before bedtime can decrease relaxation." "Changing the time of day that I eat dinner can disrupt sleep."

"Drinking coffee at 7 PM could interrupt my sleep." "Staying up late for a party can interrupt sleep patterns." "Worrying about work can disrupt my sleep." "Changing the time of day that I eat dinner can disrupt sleep."

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure? Emergency Major Elective Urgent

The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area? 1. Neck, shoulders, and chest 2. Abdomen and groin/perineum 3. Legs, feet, and web spaces 4. Back of neck, back, and then buttocks 5. Both arms, both hands, web spaces, and axilla 5, 1, 2, 3, 4 5, 1, 2, 4, 3 1, 5, 2, 4, 3 1, 5, 2, 3, 4

1, 5, 2, 3, 4

The patient is to receive amoxicillin 500 mg q8h; the medication is dispensed at 250 mg/5 mL. How many milliliters will the nurse administer for one dose? Record your answer using a whole number. __ mL

10 The drug is dispensed at 250 mg/5 mL. The nurse is to give 500 mg, which is 10 mL. OR Dose ordered over dose on hand (500/250) × volume or amount on hand (5). 500/250 × 5 = 10 mL.

A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? 120/80 in a middle-aged adult 115/70 in an infant 98/50 in a 7-year-old child 146/90 in an older adult

120/80 in a middle-aged adult

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. 2, 1, 4, 3 1, 2, 4, 3 2, 1, 3, 4 1, 2, 3, 4

2, 1, 4, 3

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication .4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. 2, 1, 5, 4, 3 4, 3, 1, 5, 2 1, 5, 2, 4, 3 5, 4, 5, 1, 2

2, 1, 5, 4, 3

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? Stimulation of chemical receptors in the aorta Requirement of elastic recoil lung properties Enhancement of accessory muscle usage Reduction of arterial oxygen saturation levels

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? Making a clinical decision based on previous shift assessments Making an informed clinical decision Making an ethical clinical decision Making a clinical decision in the patient's best interest

A head and neck physical examination is completed on a 50-year-old female patient. All physical findings are normal except for fine brittle hair. Which laboratory test will the nurse expect to be ordered, based upon the physical findings? Thyroid-stimulating hormone test Carbon monoxide Liver function test Oxygen saturation

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? Reports to third-party payers Nursing process form Step-by-step skills manual A list of possible procedures

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? Critical pathway design Nursing process design Computerized provider order entry system Clinical decision support system

A male student comes to the college health clinic. He hesitantly describes that he found something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer? Hard, pea-sized testicular lump Painful enlarged testis Prolonged diuretic use Rubbery texture of testes

A novice nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." "Evaluative measures are objective views for completion of nursing interventions." "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." "Evaluative measures are multiple-page documents used to evaluate nurse performance."

A nurse has instructed the patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? Demonstrated use of crutches Patient went up and down stairs Deficient knowledge related to never using crutches Used crutches with no difficulties

A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion of the medication. What should the nurse do? Have another nurse witness the wasted medication. Return the wasted medication to the medication dispenser. Place the wasted portion of the medication in the sharps container. Exit the medication room to call the health care provider to request an order that matches the dosages.

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? A minimum data set A focused assessment/specific body system An admission assessment and acuity level An intake assessment form and auditing phase

A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use? An article that uses randomized controlled trials (RCT). An article that is an opinion of expert committees. An article that uses qualitative research. An article that is peer-reviewed.

An article that uses randomized controlled trials (RCT).

An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? Apply a skin protective ointment after perineal care. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. Massage the skin with light kneading pressure. Tape an occlusive moisture barrier pad to the patient's skin.

Apply a skin protective ointment after perineal care.

A nurse is administering oral medications to patients. Which action will the nurse take? Crush enteric-coated medication and place it in a medication cup with water. Place all of the patient's medications in the same cup, except medications with assessments. Remove the medication from the wrapper and place it in a cup labeled with the patient's information. Measure liquid medication by bringing liquid medication cup to eye level.

A nurse is assessing a patient's self-concept. Which area should the nurse assess first? Anxiety Role performance Morals Vital signs

A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe? Chin, elbow, hips Ileum, clavicle, humerus Shoulder, anterior iliac spine, ankles Occipital region of the head, coccyx, heels

A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? On the way a patient reacts to family/social interactions On the way a patient reacts to disease On the malfunctioning of biological processes On the malfunctioning of psychological processes

A nurse is assessing the social system of a community. Which area should the nurse assess? Housing Volunteer programs Economic status Predominant ethnic groups

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? Decreased drive to breathe Increased metabolic demands Infection destroying lung tissues Anxiety over illness

A nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? Non-rebreather mask Nasal cannula Partial non-rebreather mask Simple face mask

A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use? Educator Epidemiologist Caregiver Case manager

A nurse performs cardiopulmonary resuscitation (CPR) on a 92 year old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse? The patient was resuscitated according to the policy. The CPR procedure was done incorrectly. The patient would have died if nothing was done. The older patient with brittle bones might sustain fractures when chest compressions are done.

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? Documenting medication administered to the patient Sharing patient information with another student Reading the patient's plan of care Reviewing the patient's medical record

A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? Pressure ulcers Renal stones Hypostatic pneumonia Thrombus formation

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? "Hyperventilation will open up my alveoli, preventing atelectasis." "It is important to do breathing exercises every hour to prevent atelectasis." "If I develop atelectasis, I will need a chest tube to drain excess fluid." "Atelectasis affects only those with chronic conditions such as emphysema."

A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful? "I will place the medication in the same location." "I should let the medication dissolve completely." "I better chew my medication first for faster distribution." "I can only drink water, not juice, with this medication."

A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult? Progress notes Graphic record and flow sheet Patient care summary Database

A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? Fairness Institutional practice guidelines Independent reasoning Intellectual standards

A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? Document staff satisfaction. Reduce disparities. Focus on the family. Implement change on a grand scale.

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? Frequently reassesses the patient's pain scores. Softly plays music that the patient finds relaxing. Reassures the patient that the provider will come to the emergency department soon. Teaches the patient how to do yoga.

A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. Which term would best describe this type of clinic? Naturopathic medical Integrative medical Ayurvedic Homeopathic

A patient asks the nurse for a nonmedical approach for excessive worry and work stress. Which therapy should the nurse recommend? Ayurvedic herbs Meditation Chiropractic care Acupuncture

A patient at risk for skin impairment is able to sit up in a chair. How long should the nurse schedule the patient to sit in the chair? Until the patient expresses being uncomfortable Less than 2 hours at any one time No longer than 30 minutes out of every hour For a total of least than 3 hours daily

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. Breathing without difficulty. Sitting up in bed watching TV. Had a good day.

A patient has been taught how to change a colostomy bag but is having difficulty manipulating the equipment and has many questions. To which resource should the nurse institute a referral to? A dietitian An ostomy specialist A wound care specialist A mental health specialist

A patient has sued a post-surgical unit nurse who provided care after abdominal surgery with nursing malpractice. Which resource would be used to determine whether the nurse has acted in a prudent manner? The testimony of the patient's primary health care provider Scope and Standards of Nursing Care Comparison of documentation of the care provided by the nurse to similar patients The typical level of care provided by other unit nurses

A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? High-carbohydrate Moderate-carbohydrate High-caffeine Low-caffeine

A patient is having difficulty reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? Humility Creativity Confidence Risk taking

A patient is proficient at meditation from long-time use of the technique. Which finding in the medication history will cause the nurse to follow up? Anticoagulant medication Thyroid-regulating medication Loop diuretic medication Corticosteroid medication

A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? "I believe you can overcome this because I've seen how strong you are." "This must be hard news to hear." "What's your biggest fear about this diagnosis?" "Tomorrow will be better."

A patient prefers not to take the daily allergy pill this morning because it causes drowsiness throughout the day. Which response by the nurse is best? "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon." "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping." "You can skip this medication on days when you need to be awake and alert." "The physician ordered it; therefore, you must take your medication every morning at the same time whether you're drowsy or not."

A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use? Cloze test Return demonstration Verbalization of steps Computer instruction

A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement? pH testing X-ray Aspiration of contents Auscultation

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? Develop a problem-solving scenario. Wrap a bandage around a stuffed animal's ear. Use discussion throughout the teaching session. Encourage independent learning.

An older-adult patient is taking aminoglycoside for a severe infection. Which assessment is the priority? Eyes Ears Skin Reflexes

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions 1, 2, 4, 5, 3 2, 4, 3, 5, 1 4, 3, 2, 1, 5 5, 1, 2, 3, 4

The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning? Replaces all lace-up shoes with Velcro straps for ease. Places colored stickers on faucet handles to indicate temperature. Uses a heating pad on a low setting to keep warm. Asks the nurse to test the temperature of the water before entering the bath.

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? Limit visitors while the patient is upset. Ask the patient what triggered the crying. Provide privacy and check on the patient 30 minutes later. Set a box of tissues at the patient's bedside before leaving the room.

The nurse in an addictions clinic is working with a patient on priority setting before the patient's discharge from residential treatment. Which goal is a priority at this time? Staying away from all triggers that cause substance abuse Identifying local self-help groups before being discharged from the program Recognizing personal areas of weakness to grow stronger Stating a plan to never be tempted by illicit substances after discharge

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? "Have you considered working with a physical therapist?" "What activities, if any, has your pain prevented you from doing?" "Would you please rate your pain on a scale from 0 to 10 for me?" "When does your pain medication typically take effect on your pain?"

The nurse is assessing the tympanic membranes of an infant. Which action by the nurse demonstrates proper technique? Holds handle of the otoscope between the thumb and little finger. Uses an inverted otoscope grip while pulling the auricle downward and back. Pulls the auricle upward and backward. Places the handle of the otoscope between the thumb and index finger while pulling the auricle upward.

The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk? Pad the bed with absorbent pads. After cleansing thoroughly dry the skin. Request a therapeutic bed and mattress. Use products that retain moisture.

The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? The patient will be free of infection. The patient will be free of burns at the grounding pad. The patient will be free of pain. The patient will be free of nausea and vomiting.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? Gather supplies. Provide analgesic medications as ordered. Don sterile gloves. Avoid accidentally removing the drain.

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? Low-air-loss Air-fluidized Lateral rotation Standard mattress

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take initially? Remove the drain; a drain is no longer needed. Call the health care provider; a blockage is present in the tubing. Chart the results on the intake and output flow sheet. Do nothing, as long as the evacuator is compressed.

The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy? After the acute phase of the disease has passed. As soon as the ability to move is lost. When the patient requests it. Once the patient enters the rehab unit.

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion? Assess the patient's level of consciousness and document every 4 hours. Keep a day-by-day calendar at the patient's bedside. Prepare to discharge once the patient is awake, alert, and oriented. Place a patient observer in the patient's room for safety.

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? "I been thinking I will be ready to go home early next week." "I really need a bath and linen change right; I feel so awful." "I am hoping there will be something good to eat for my dinner tonight." "I am so weak and tired. I just want to feel better."

The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply? "You will need to cough only a few times during this shift." "Deep breathing and coughing will clear your lungs of the anesthesia." "If you don't deep breathe and cough, you will get pneumonia." "Let's try clearing the throat because that will work just as well."

The nurse is evaluating outcomes for the patient diagnosed with insomnia. Which key principle will the nurse consider during this process? The nurse is the best evaluator of sleep. The patient is the best evaluator of sleep. Effective interventions are the best evaluators of sleep. Observations of the patient are the best evaluators of sleep.

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding? The arms hang comfortably at the sides. Both feet are supported on the floor with ankles flexed. The body weight is directly on the buttocks only. The edge of the seat is in contact with the popliteal space.

Which patient is demonstrating a refractive error sensory problem? A patient who is having difficulty remembering how to perform familiar tasks. A patient who frequently reports the incorrect time from the clock across the room. A patient who has trouble saying words. A patient who turns the television up as loud as possible

Which patient using an inhaler would benefit most from using a spacer? A 50 year old with hearing impairment who uses a hearing aid A 25 year old with limited coordination of the extremities A 15 year old with a repaired cleft palate who is alert A 72 year old with left-sided hemiparesis using a dry powder inhaler

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? Postpone catheter insertion until the next shift. Adapt the positioning technique to the situation. Notify the health care provider for a urologist consult. Follow textbook procedure with contraindicated position.

While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment? Population Structure Social system Welfare system

he nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take? Position legs flat against bed. Place pillow under the patient's lower legs. Turn head toward one side with large, soft pillow. Raise head of bed to 45 degrees.

he paramedics transport an adult involved in a motor vehicle accident to the emergency department. On physical examination, the patient's level of consciousness is reported as opening eyes to pain and responding with inappropriate words and flexion withdrawal to painful stimuli. Which value will the nurse report for the patient's Glasgow Coma Scale score? 7 9 11 5

B According to the guidelines of the Glasgow Coma Scale, the patient has a score of 9. Opening eyes to pain is 2 points; inappropriate word use is 3 points; and flexion withdrawal is 4 points. The total for this patient is 2 + 3 + 4 = 9.

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? Backs wheelchair into elevator, leading with large rear wheels first. Unlocks wheelchair for easy maneuverability when patient is transferring. Places locked wheelchair on same side of bed as patient's weaker side. Positions patient's buttocks close to the front of wheelchair seat.

Backs wheelchair into elevator, leading with large rear wheels first.

A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection? Casts Crystals Protein Bacteria

Bacteria

A nurse is caring for a patient being treated for sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) Synchronized intermittent mandatory ventilation (SIMV) Pressure support ventilation (PSV) Assist-control (AC) Bilevel positive airway pressure (BiPAP) Continuous positive airway pressure (CPAP)

Bilevel positive airway pressure (BiPAP) Continuous positive airway pressure (CPAP)

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? Immediate, strong desire to void Awakes from sleep due to urge to void Burning upon urination Blood in the urine

Burning upon urination

A nurse has compassion fatigue. What is the nurse experiencing? Lateral violence and intrapersonal conflict Burnout and secondary traumatic stress Short-term grief and single stressor Physical and mental exhaustion

Burnout and secondary traumatic stress

A nurse caring for a patient prescribed warfarin discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? Angina Increased cholesterol level Bleeding Distended jugular vein

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome? Patient is lying semiprone. Patient is lying on abdomen. Patient is lying on side. Patient is lying on back.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? Produces hemoglobin. Regulates tidal volume. Carries out gas exchange. Stores oxygen.

A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? Outcomes of health conditions Incidence of diseases Accessibility of health care services Prevalence of complications

A nurse is assessing the skin of an immobilized patient. What will the nurse do? Assess the skin every 4 hours. Limit the amount of fluid intake. Use a standardized tool such as the Braden Scale. Have special times for inspection so as to not interrupt routine care.

A nurse is caring for a patient who is receiving pain medication through a saline lock. After flushing the patient's peripheral IV and obtaining a good blood return, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm and tender to the touch. What is the nurse's initial action? Apply a warm compress to the site. Apply a cool compress to the site. Do not administer the pain medication. Administer the pain medication slowly.

A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing? Sleep assessment Sensation assessment Pulse oximetry assessment Muscular strength assessment

A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? Administer pain medication only when nonpharmacological measures have failed. Give pain medication after the pain is a 7/10 on the pain scale. Give pain medications around the clock. Administer pain medication before any activity.

A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care? Skilled nursing facility Long-term care facility Home health Intensive care unit

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? Patient's side rails are up with bed alarm activated. Patient wanders halls only at night. Patient correctly states names of family members in the room. Patient denies pain while ambulating with assistance.

A nurse is providing care to a group of patients. Which patient will the nurse see first? A bedridden patient who has a reddened area on the buttocks who needs to be turned A patient on bed rest who has renal calculi and needs to go to the bathroom A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea A patient after knee surgery who needs range of motion exercises

A nurse is providing medication education to a patient who just started been prescribed ibuprofen. Which information will the nurse include in the teaching session? Ibuprofen binds with opiate receptors to reduce your pain. Ibuprofen reduces anxiety, which will help you cope with your pain. Ibuprofen inhibits the development of inflammation. Ibuprofen helps to depress the central nervous system to decrease pain perception.

A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? Each movement is repeated 5 times by the patient. Each movement is completed quickly and smoothly by the nurse. Each movement is moved just to the point of resistance by the nurse. Each movement is performed until the patient reports pain.

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? Moves patient's arm in a full circle. Moves patient's arm behind body, keeping elbow straight. Moves patient's arm until thumb is upward and lateral to head with elbow flexed. Moves patient's arm cross the body as far as possible.

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? Identification of several actual health problems Documentation of patient's ability to meet the goal Nurse's assumptions about hospital discharge Patient's outcomes for learning

A nurse is teaching a patient identified as having low health literacy about chronic obstructive pulmonary disease (COPD). Which technique is most appropriate for the nurse to use? Ask for feedback to assess understanding of COPD at the end of the session. Offer pamphlets about COPD written at the eighth-grade level with large type. Include the most important information on COPD at the beginning of the session. Use complex analogies to describe COPD.

A patient experiencing a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? The patient reports pain at the chest tube insertion site that increases with movement. Fifty milliliters of blood gushes into the drainage device after the patient coughs. No bubbling is present in the suction control chamber of the drainage device. Yellow purulent discharge is seen leaking out from around the dressing site.

A patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? Observe the cardiac monitor for increased heart rate. Have the patient describe the effect of pain on the ability to cope. Ask the patient to rate the level of pain. Assess the patient's body language.

A patient who recently had a stroke is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care? Obtain an order for antidepressant medications. Make the patient talk as much as possible. Teach the patient about special assistive devices. Place a consult for a home health nurse.

A pediatric oncology nurse floats to an orthopedic trauma unit. Which action should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? Assign nursing assistive personnel to assist with care. Allow the nurse to choose which mealtime works best. Determine patient acuity and care the nurse can safely provide. Provide a complete orientation to the functioning of the entire unit.

A prescription is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the health care provider meant to write hydromorphone. What action should the nurse take? Refuse to give the medication and notify the nurse supervisor. Administer the medication and monitor the patient frequently. Call the health care provider to clarify the order. Give the patient hydromorphone, as it was meant to be written.

A teen diagnosed with an anxiety disorder is referred for biofeedback training because the parents do not want their child to take anxiolytics. Which statement from the teen indicates successful learning? "Biofeedback will let me assess and redirect my energy fields." "Biofeedback will direct my energies in an intentional way when stressed." "Biofeedback will help me with my thoughts and physiological responses to stress." "Biofeedback will allow me to manipulate my stressed-out joints."

A teen female patient reports intermittent abdominal pain for 12 hours. No dysuria is present. Which action will the nurse take when performing an abdominal assessment? Avoid sexual references such as possible pregnancy. Recommend that the patient take more laxatives. Ask the patient about the color of her stools. Assess the area that is most tender first.

The nurse is caring for a postoperative patient recovering from a medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? Monitor vital signs every 15 minutes. Check pulses in the right foot. Apply ice. Keep the leg dependent.

The nurse is creating a plan of care for a patient diagnosed with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? Body image disturbance Fear Risk for falls Impaired socialization

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which finding best indicates the effectiveness of guided imagery? The patient's facial expressions are stoic during the procedure. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. The patient's need for analgesic medication decreases during the dressing changes. The patient asks for pain medication during the dressing changes only once throughout the procedure.

The nurse is examining a female presenting with vaginal discharge. Which position will the nurse place the patient for proper examination? Dorsal recumbent Sitting Lithotomy Knee-chest

The nurse is preparing to lift and reposition a patient. Which action will the nurse take first? Position a drawsheet under the patient. Attempt to manually lift the patient alone before asking for assistance. Assess weight to determine assistance needs. Delegate the task to a nursing assistive personnel.

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? Evaluation Planning Diagnosis Implementation

The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be performed. What is the nurse's best next step? Continue with preoperative education. Explain the procedure that will be completed. Notify the health care provider about the patient's question. Ask the patient to sign the form.

The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next? Delay referral to an abortion service. Refuse to provide a referral to an abortion service. Provide referral to an abortion service. Encourage the patient to speak with a "Right-to-Life" advocate.

The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially? Nonsteroidal antiinflammatory drugs. Milkshakes as a nutritious snack. Completion of antibiotic therapy. Avoidance of wheat and oats.

The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the most likely cause of the diarrhea? Bacterial contamination Antibiotic therapy Formula intolerance Clostridium difficile

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient? Thick, tenacious pulmonary secretions Elastic stockings (TED hose) Low-molecular-weight heparin doses SCDs wrapped around the legs

The patient presents to the clinic with dysuria and hematuria. How does the nurse proceed to assess for kidney inflammation? Inspects abdomen for abnormal movement or shadows using indirect lighting. Uses deep palpation posteriorly. Percusses posteriorly the costovertebral angle at the scapular line. Lightly palpates each abdominal quadrant.

Two 50-year-old men are discussing their Saturday activities. The first man describes how he tutors children as a volunteer at a community center. The other man says that he would never work with children and that he prefers to work out at the gym to meet young women to date. Which developmental stage is the second man exhibiting? Inferiority Generativity Self-absorption Mistrust

Upon assessment, the patient is breathing normally and has normal vesicular lung sounds. Which inspiratory-to-expiratory breath sounds will the nurse expect to hear? The expiration phase is longer than the inspiration phase. The inspiratory phase lasts exactly as long as the expiratory phase. The inspiratory phase is 3 times longer than the expiratory phase. The expiration phase is 2 times longer than the inspiration phase.

Which action demonstrates a nurse utilizing reflection to improve clinical decision making? Provides evidence-based explanations and research for care of assigned patients. Uses an objective approach in patient situations. Improves a plan of care while thinking back on interventions effectiveness. Obtains data in an orderly fashion.

Which information concerning a goal indicates a nurse has a good understanding of its purpose? A: It is a statement describing the patient's accomplishments without a time restriction. B: It is a measurable change in a patient's physical state. C: It is a broad statement describing a desired change in a patient's behavior. D: It is a realistic statement predicting any negative responses to treatments.

A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? Hold the shaft of the penis with the dominant hand. Hold the shaft of the penis at a 60-degree angle. Cleanse the meatus with circular strokes beginning at the meatus and working outward. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.

Cleanse the meatus with circular strokes beginning at the meatus and working outward.

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? Washing using a circular motion Cleansing from back to front Cleansing upward from rectum to pubic area Cleansing from pubic area to rectum

Cleansing from pubic area to rectum

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.) Close all doors. Move bedridden patients in their bed. Use type B fire extinguishers for electrical fires. Wait until the fire department arrives to act. Note oxygen shut-offs. Note evacuation routes.

Close all doors. Move bedridden patients in their bed. Note oxygen shut-offs. Note evacuation routes.

The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient's cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is most appropriate for the nurse to take? Complete the assessment, remove gloves, and silence the alarm. Discontinue the assessment, silence the alarm, and assess the intravenous site. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.

Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.

A nurse attends a workshop on current nursing issues provided by the American Nurses Association. Which type of education did the nurse receive? Graduate education Inservice education Continuing education Registered nurse education

Continuing education

A nurse is describing the therapeutic effects of imagery. Which information should the nurse include in the teaching session? (Select all that apply.) Controls pain. Improves social anxiety disorders. Reduces relapses in alcohol treatment. Helps with irritable bowel syndrome. Decreases nightmares.

Controls pain Helps with irritable bowel syndrome. Decreases nightmares.

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? Convection Radiation Conduction Evaporation

Convection

A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? Focus on illness treatment to provide fast recuperation. Allow people to continue current behaviors to reduce the stress of change. Create social and physical environments that promote good health. Focus only on health changes that will lead to better local communities.

Create social and physical environments that promote good health.

A nurse is using Campinha-Bacote's model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) Cultural skills Cultural desire Cultural transition Cultural knowledge Cultural encounters

Cultural skills Cultural desire Cultural knowledge Cultural encounters

A Native American patient is asking for a spiritual healer. Which person should the nurse try to contact for the patient? Vitalist Ayurvedic Curanderismo Shaman

A home health nurse notices that a patient's preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to the home and talks with the patient, but the situation continues. Which immediate action by the nurse is mandated by law? Tell the parents that the authorities will be contacted shortly. Discuss with both parents about the safety needs of their children. Take pictures of the children to support the overt child abuse. Contact the appropriate community child protection facility.

A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? Orientation Termination Preinteraction Working

A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care? Its focus is on ill individuals. It occurs in hospitals. It provides services primarily to the poor. Its priority is health promotion.

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? Mitral and pulmonic Aortic and mitral Mitral and tricuspid Aortic and pulmonic

A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? "My parenteral medication must be taken with food." "Once I start feeling better, I will stop taking my antibiotic." "If I am 30 minutes late taking my medication, I should skip that dose." "I will rotate the sites in my left leg when I give my insulin."

A nurse is teaching a patient about the use of biofeedback. Which goal should the nurse add to the care plan? Opens emotional channels. Uses music to calm the mind. Holds various postures with breathing. Controls autonomic physiological functions.

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node 5, 3, 4, 2, 1 4, 3, 5, 1, 2 5, 4, 3, 2, 1 4, 5, 3, 1, 2

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? A clinical information system must be installed by 2014 to obtain health care reimbursement. A "near miss" helps determine reimbursement issues for health care. HIPAA is the basis for establishing reimbursement for health care. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care.

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? A nurse needs to know how to find, evaluate, and use information effectively. Nursing informatics is a recognized specialty area of nursing practice. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. If a nurse has computer competency, the nurse is competent in informatics.

A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? American Indians Caucasians Alaska Natives Poor people

A nurse is using the Healthy People 2020 to establish goals for the community. Which goal is priority? Provide services close to where patients live. Isolate patients to prevent the spread of disease. Reduce health care costs. Increase life expectancy.

A nurse is using the holistic approach to care. Which goal is the priority? Integrate spiritual treatments. Use complementary and alternative therapies. Join physical care with a vegan diet. Incorporate the mind-body-spirit connection.

A nurse is working as a community health nurse. Which action is a priority for this nurse? Focus on the needs of the ill individual. Focus on providing care in various community settings. Provide first level of contact to health care systems. Provide direct care to subpopulations.

A nurse is working to prevent blindness. Which preventive action is a priority? Administer eye prophylactic antibiotics to newborns within 24 hours after birth. Screen young adults early for visual impairments. Instruct parents to report reduced eye contact from their child immediately. Include rubella and syphilis screening in the preconception care plan.

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.

A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? "Meditation will help me sleep through the pain because it opens the gate." "Meditation alters the chemical composition of pain neuroregulators, which closes the gate." "Meditation stops the occurrence of pain stimuli." "Meditation controls pain by blocking pain impulses from coming through the gate."

A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain? A baccalaureate degree in nursing Preparation at the basic entry level The same level of education as the community health nurse A graduate level education with a focus in public health science

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? Reading assignment with a written summary Reflective journaling Lecture and discussion Concept mapping

A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? "You are expected to perform at the level of a prudent nursing student." "You are practicing under the license of the hospital's insurance." "You are practicing under the license of the nurse assigned to the patient." "You are expected to perform at the level of a professional nurse."

The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for "ROM as needed." What should the nurse do next? Move all the patient's extremities. Realize the patient is unable to move extremities. Restrict patient's mobility as much as possible. Further assess the patient.

The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? Shallow respirations Disorientation Moaning with reports of pain Drop in pulse oximetry readings

The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take? Lightly rub the lower leg for redness and tenderness. Dorsiflex the foot while assessing for patient discomfort. Remove elastic stockings every 4 hours. Measure the calf circumference of both legs.

The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially? "What is going on?" "What did you have for dinner last night?" "Are you taking any medications?" "How are you sleeping?"

The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom, but I can't." Which nursing intervention will be most appropriate initially? Call the health care provider to obtain an order for catheterization. Encourage the patient to wait a minute and try again. Inform the patient that everyone feels this way after surgery. Assess the patient for bladder distention.

The nurse is caring for a patient in the sleep lab. Which assessment finding indicates to the nurse that the patient is in stage 4 NREM? The patient awakens easily. The patient's eyes rapidly move. The patient's vital signs are elevated. The patient is difficult to awaken.

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? Place the patient in a 30-degree supine position. Slide the patient into the new position. Elevate the head of the bed 45 degrees. Utilize a transfer device to lift the patient.

The nurse is caring for a patient who is prescribed oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? Setting up the oxygen Assessing lung sounds Adjusting the oxygen flow Applying the nasal cannula

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? Postoperative Perioperative Intraoperative Preoperative

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan? Impaired physical mobility Chronic pain Readiness for enhanced nutrition Impaired skin integrity

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? Elevated blood pressure Restlessness Increased pulse rate Cyanosis

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? Encourage the patient to sit up in the chair. Turn the patient every 3 hours while in bed. Explain the risks of immobility to the patient. Provide analgesic medication as ordered.

The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient? Infants cannot tolerate analgesics owing to an underdeveloped metabolism. Infants cannot be assessed for pain. Infants have a decreased sensitivity to pain when compared with older children. Infants respond behaviorally and physiologically to painful stimuli.

The nurse is preparing an older-adult patient's evening medications. Which treatment will the nurse recognize as relatively safe for difficulty sleeping in older adults? Antihistamine Kava Benzodiazepine Ramelteon

The nurse is preparing to administer an injection into the deltoid muscle of an adult patient weighing approximately 160 lb. Which needle size and length will the nurse choose? 18 gauge × 1 1/2 inch 23 gauge × 1/2 inch 27 gauge × 5/8 inch 25 gauge × 1 inch

The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? Explain use of the mouthpiece. Instruct the patient to inhale slowly. Place in the reverse Trendelenburg's position. Perform hand hygiene.

The nurse is providing an educational session on sleep regulation for new nurses in the Sleep Disorder Treatment Center. Which statement by the nurses will best indicate that the teaching is effective? "If the patient has a disease process in the cranial nerves, it can influence the functions of sleep." "If the patient has an interruption in the spinal reflexes, it can influence the functions of sleep." "If the patient has an interruption in the urinary pathways, it can influence the functions of sleep." "If the patient has a disease process in the central nervous system, it can influence the functions of sleep."

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? Overlook variations between an oximeter pulse rate and the toddler's pulse rate. Determine whether the toddler has a latex allergy. Place the sensor on the bridge of the toddler's nose. Secure the sensor to the toddler's earlobe.

Determine whether the toddler has a latex allergy.

The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? Capitation provides the hospital with a means of recovering variable charges. The hospital will be paid for the full cost of the patient's hospitalization. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. Medicare will pay the national average for the patient's condition.

Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost.

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? Grasp the cord when unplugging items. Use masking tape to secure cords to the floor. Disconnect items before cleaning. Run wires under the carpet.

Disconnect items before cleaning.

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? Measure bladder with head of bed raised to 90 degrees. Measure bladder with head of bed raised to 60 degrees. Measure bladder before the patient voids. Measure bladder within 15 minutes after the patient voids.

Measure bladder within 15 minutes after the patient voids.

A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? Encourage the patient to increase fluid intake to flush the obstruction. Administer narcotic medications to the patient for pain. Monitor the patient for fever, rash, and difficulty breathing. Turn the patient on the right side to alleviate pressure on the left kidney.

Monitor the patient for fever, rash, and difficulty breathing.

The nurse is caring for a patient in the intensive care unit who is having trouble sleeping. The nurse explains the purpose of sleep and its benefits. Which information will the nurse include in the teaching session? (Select all that apply.) During NREM sleep, biological functions increase. REM sleep decreases cortical activity. NREM sleep contributes to body tissue restoration. Restful sleep preserves cardiac function. Sleep contributes to cognitive restoration.

NREM sleep contributes to body tissue restoration. Restful sleep preserves cardiac function. Sleep contributes to cognitive restoration.

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? Anxiety Not seeing family members Not eating Mental health

Not eating

An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? Novice Proficient Competent Advanced beginner

Novice

A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? When the patient is ready. Close to the time of discharge. Upon admission to the hospital. After an order is written/prescribed.

Upon admission to the hospital.

A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? Start with a broad question. Use a PICOT format for the search. Make a general search of the Internet. Read all the articles found on the Internet.

Use a PICOT format for the search.

The nurse is participating in a "time-out." In which activities will the nurse be involved? (Select all that apply.) Perform the actual marking of the operative site. Perform "time-out" after surgery. Verify the correct procedure. Verify the correct patient. Verify the correct site.

Verify the correct procedure. Verify the correct patient. Verify the correct site.

The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) Vital signs IV fluids Insurance data Estimated blood loss Anesthesia provided Family location

Vital signs IV fluids Estimated blood loss Anesthesia provided

The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session? Wash and rinse lens storage case daily. Use tap water to clean soft lenses. Reuse storage solution for no longer than a week. Keep the lenses is a cool dry place when not being used.

Wash and rinse lens storage case daily.

The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? Wash hands with an antimicrobial soap and water. Clean hands with wipes from the bedside table. Use an alcohol-based waterless hand gel. Wipe hands with a dry paper towel.

Wash hands with an antimicrobial soap and water.

The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? Teaches the patient about good nutrition. Dons gloves when wearing artificial nails. Disposes an uncapped needle in the designated container. Wears eyewear when emptying the urinary drainage bag.

Wears eyewear when emptying the urinary drainage bag.

The nurse is monitoring for risks for injury identified in the health care environment. Which finding will alert the nurse that these safety risks are occurring? Tile floors, cold food, scratchy linen, and noisy alarms Dirty floors, hallways blocked, medication room locked, and alarms set Wet floors unmarked, failure to use lift for patient, and alarms not functioning properly Carpeted floors, ice machine empty, unlocked supply cabinet, and nurse call system in reach

Wet floors unmarked, failure to use lift for patient, and alarms not functioning properly

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.) Did you obtain an electronic safety alert device after the fall? What time did the fall occur? What were you doing when you fell? What types of injuries occurred after the fall? Where did you fall? What are your medical problems that may have caused the fall?

What time did the fall occur? What were you doing when you fell? What types of injuries occurred after the fall? Where did you fall?

The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.) While putting on the first glove, touch only the outside surface of the glove. With gloved dominant hand, slip fingers underneath second glove cuff. Remove outer glove package by tearing the package open. Lay glove package on clean flat surface above waistline. Glove the dominant hand of the nurse first. After second glove is on, interlock hands.

With gloved dominant hand, slip fingers underneath second glove cuff. Lay glove package on clean flat surface above waistline. Glove the dominant hand of the nurse first. After second glove is on, interlock hands.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and their spouse refuse to talk about it and reject the opportunity to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? Withdrawal Acceptance Shock Rehabilitation

Withdrawal

Which determination is the nurse trying to achieve by monitoring a patient's cardiac output? Peripheral extremity circulation Ventilation status Presence of cardiac dysrhythmias Oxygenation requirements

The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will have to cancel one or two of its nurses. The orthopedic unit has agreed to "float" two of its nurses to the oncology unit if oncology can "float" a nursing assistant to the orthopedic unit to help with obtaining vital signs. Which concepts does this situation entail? (Select all that apply.) Autonomy Informatics Accountability Political activism Teamwork and collaboration

autonomy accountability teamwork and collaboration

A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using? Code of ethics Standards of practice Standards of professional performance Quality and safety education for nurses

code of ethics

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? "Are you able to taste spices like before?" "Are you able to hear the tornado sirens in your area?" "Are you able to read your favorite book?" "Are you able to open a jar of pickles?"

"Are you able to hear the tornado sirens in your area?"

Which risk factor for cardiopulmonary disease should the nurse describe as modifiable? Allergies Family history Gender Stress

Which patient will the nurse assess most closely for an ileus? A patient with suppression of hydrochloric acid from medication A patient with chronic cathartic abuse A patient with a fecal impaction A patient with surgery for bowel disease and anesthesia

A patient with surgery for bowel disease and anesthesia

A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? An article about emotional needs of dying patients and their families An article about the percentage of new admissions on a new floor An article about infection rates after use of a new wound dressing An article about the number of falls after use of no side rails

An article about emotional needs of dying patients and their families

A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? Action Preparation Precontemplation Contemplation

Contemplation

The nurse is assessing an adult patient's patellar reflex. Which finding will the nurse record as normal? 1+ 4+ 3+ 2+

The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend? Doctor of Nursing Science degree (DNSc) Doctor of Philosophy degree (PhD) Doctor of Nursing Practice degree (DNP) Doctor in the Science of Nursing degree (DSN)

Doctor of Philosophy degree (PhD)

The nurse will anticipate which diagnostic examination for a patient with black tarry stools? Barium enema Ultrasound Endoscopy Anorectal manometry

Endoscopy

A community-based nursing is working with a family. For which key areas will the nurse need a strong knowledge base? (Select all that apply.) Individual-centered care Group dynamics Communication Family theory Cultural diversity

Group dynamics Communication Family theory Cultural diversity

A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.) Level thresholds between bathroom and bedroom Low-pile carpeting in the living room Bathtub with grab bars Stairway faintly lit Absence of smoke alarms Scatter rugs in the kitchen

Stairway faintly lit Absence of smoke alarms Scatter rugs in the kitchen

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? Dependent Independent Interdependent Physician-initiated

After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee's next step? Communicate to staff the results of this project. Evaluate the changes in 1 month. Wait a month before implementing the changes. Implement the changes as a pilot study.

Communicate to staff the results of this project.

A patient diagnosed with chronic emphysema (lung disease) states "I would be better off dead." The nurse learns that the patient, has recently become unemployed because of oxygen dependency. The patient's spouse will have to go to work to support the family. Which action should the nurse take? Contact psychiatric services for a referral. Assure the patient that things will work out. Focus the plan of care solely on maximizing patient function. Develop a plan of care for the family.

Develop a plan of care for the family.

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? Call the health care provider immediately to report a possible infection. Administer medication to lower the temperature further. Realize that this is a normal temperature variation. Provide another blanket to conserve body temperature.

Realize that this is a normal temperature variation.

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.) Creativity Safe environment Equipment Confidence Assistive personnel

Safe environment Equipment Assistive personnel

The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session? Smoke from tobacco products clings to your clothing and hair. Smoking affects the cilia lining the upper airways in the lungs. Smoking can affect the color of the patient's fingernails. Smoking tobacco products can be very expensive.

Smoking affects the cilia lining the upper airways in the lungs.

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? Respirations Pulse Temperature Blood pressure

Temperature

The patient is being admitted to the emergency department following a motor vehicle accident. The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? Axillary Oral Temporal Tympanic

Tympanic

Which activity will increase the need for the nurse to monitor for equipment-related accidents? Removing medications from a manual medication-dispensing device Using a patient-controlled analgesic pump Making an entry in a computer-based documentation record Using a plastic measuring device to accurately measure urine

Using a patient-controlled analgesic pump

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? "I should not get any urine on the stool I am testing." "If I eat red meat before my test, it could give me false results." "I should check with my doctor to stop taking aspirin before the test." "If I get a blue color that means the test is negative."

"If I get a blue color that means the test is negative."

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? "If my grandchild eats a plant, I should provide syrup of ipecac." "I should call 911 if my grandchild loses consciousness." "Never induce vomiting if my grandchild drinks bleach." "The number for poison control is 800-222-1222."

"If my grandchild eats a plant, I should provide syrup of ipecac."

A patient has approximately 6 months to live and asks about a do not resuscitate (DNR) order. Which statements by the nurse give the patient correct information? (Select all that apply.) "You will be resuscitated at any time to allow you the longest length of survival." "If you travel to another state, your living will should cover your wishes." "If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information." "You will be resuscitated unless there is a DNR order in the chart." "If you decide you want a DNR order, you will need to talk to your health care provider."

"If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information." "You will be resuscitated unless there is a DNR order in the chart." "If you decide you want a DNR order, you will need to talk to your health care provider."

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) "Patient education is an essential component of safe, patient-centered care." "Patient teaching is documented and part of the chart." "Patient teaching can increase health care costs." "Patient education is a standard for professional nursing practice." "Patient teaching falls within the scope of nursing practice." "Patient education is not effective with children."

"Patient education is an essential component of safe, patient-centered care." "Patient teaching is documented and part of the chart." "Patient education is a standard for professional nursing practice." "Patient teaching falls within the scope of nursing practice."

The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? "Smoking just to control stress is not good for my body." "I am young, so I can work nights and go to school with 2 hours' sleep." "Our campus is safe; we leave our dorms unlocked all the time." "As long as I have only two drinks, I can still be the designated driver."

"Smoking just to control stress is not good for my body."

What statement by the nurse demonstrates an understanding of food safety to be provided for a patient living alone? "It's best to allow cooked foods to thoroughly cool off before putting them into the refrigerator." "Your perishable left-over food should be stored in a refrigerator at below 45° F" "You can use the same cutting board for meats and for vegetables if it is washed between uses." "It's acceptable to eat unwashed fruits and vegetables if they are organically grown."

"Your perishable left-over food should be stored in a refrigerator at below 45° F"

The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission 2. An infectious agent or pathogen 3. A susceptible host 4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir 3, 2, 4, 1, 5, 6 1, 3, 5, 4, 6, 2 4, 2, 1, 6, 3, 5 2, 4, 6, 1, 5, 3

2, 4, 6, 1, 5, 3

A nurse is teaching the staff about Benner's levels of proficiency. In which order should the nurse place the levels from beginning level to ending level? 1. Expert 2. Novice 3. Proficient 4. Competent 5. Advanced beginner 2, 4, 5, 1, 3 2, 5, 4, 3, 1 4, 2, 5, 3, 1 4, 5, 2, 1, 3

2, 5, 4, 3, 1

A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one? 1. Obtain baseline vital signs. 2. Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 4. Identify patient using two identifiers. 5. Place patient on left side in Sims' position. 6. Massage around the feces and work down to remove. 4, 1, 2, 5, 3, 6 1, 4, 2, 5, 3, 6 1, 4, 5, 2, 3, 6 4, 1, 5, 2, 3, 6

4, 1, 5, 2, 3, 6

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? Cognitive Judgmental Interpersonal Psychomotor

A nurse is preparing to perform a lung assessment on a patient and discovers through the nursing history the patient smokes. The nurse figures the pack-years for this patient who has smoked two and a half (2 1/2) packs a day for 20 years. Which value will the nurse record in the patient's medical record? Record answer as a whole number. __ pack-years

50 Pack-years = Number of years smoking × Number of packs per day: 20 × 2.5 = 50.

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? 45 mm Hg 40 mm Hg 50 mm Hg 35 mm Hg

50 mm Hg

The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one? 1. Clean injection port .2. Inject prescribed solution. 3. Twist needleless syringe into port. 4. Remove clamp and allow to drain. 5. Clamp catheter just below specimen port. 6. Draw up prescribed amount of sterile solution ordered. 3, 2, 6, 1, 5, 4 5, 6, 1, 2, 3, 4 6, 5, 1, 3, 2, 4 1, 5, 6, 3, 2, 4

6, 5, 1, 3, 2, 4

A 9 year old is proudly telling the nurse about mastering the yellow belt in a martial arts class. Which developmental stage is the child exhibiting? Industry versus inferiority Autonomy versus shame and doubt Initiative versus guilt Identity versus role confusion

The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. 7. Nurse confirms that the problem is ethical in nature 7, 2, 5, 6, 1, 3, 4 5, 6, 7, 2, 3, 4, 1 1, 2, 5, 4, 7, 3, 6 6, 7, 1, 2, 5, 4, 3

The nurse is caring for a patient who has had a tracheostomy tube inserted. Which nursing intervention is most effective in promoting effective airway clearance? Administering humidified oxygen through a tracheostomy collar Instilling normal saline into the tracheostomy to thin secretions before suctioning Suctioning respiratory secretions several times every hour Deflating the tracheostomy cuff before allowing the patient to cough up secretions

The nurse is caring for a young-adult patient on the medical-surgical unit. When doing midnight checks, the nurse observes the patient awake, putting a puzzle together. Which information will the nurse consider to best explain this finding? The patient's sleep-wake cycle preference is late evening. The patient misses family and is lonely. The patient has been kept up with the noise on the unit. The patient was waiting to talk with the nurse.

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient? Depression Mild fatigue Hypertension Hypothyroidism

The nurse is creating a plan of care for an obese patient who is experiencing fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? Sleeping on two to three pillows at night Running 30 minutes every morning Sensibly reducing daily calorie intake Stopping smoking immediately

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? "I should report if I see continuous bubbling in the water-seal chamber." "I should notify the health care provider first, if the chest tube becomes dislodged." "I should clamp the chest tube when giving the patient a bed bath." "I should strip the drains on the chest tube every hour to promote drainage."

The nurse is giving an intramuscular (IM) injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? Withdraw the needle and prepare the injection again. Pull the needle back slightly and inject the medication. Administer the injection at a slower rate. Give the injection and hold pressure over the site for 3 minutes.

The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient's hand and lower arm to relieve a headache. What is the nurse's next action? Ask the mother and/or spouse to explain the procedure. Tell the spouse to stop and give the mother acetaminophen. Explain to the spouse that it will not work. Let the spouse finish and then give the mother medication.

The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch? A 50-year-old patient with prostate cancer An 80-year-old patient with a broken hip A 30-year-old adult with cellulitis A 15-year-old adolescent with a fractured femur

The nurse is providing nutrition education to a Korean patient using the five food groups. In doing so, what should be the focus of the teaching? Including racial and ethnic practices with food preferences of the patient Changing the patient's diet to a more conventional American diet Comparing the patient's ethnic preferences with American dietary choices Discouraging the patient's ethnic food choices

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend? High protein, high calorie High carbohydrate, low fat Fluid restricted, bland High vitamin A, high vitamin E

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? A 24 year old with acute respiratory distress syndrome requiring mechanical ventilation A 5 year old with excessive drooling from epiglottitis A 24 year old with a right pneumothorax following a motor vehicle accident A 5 year old with an asthma attack following severe allergies

The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? Blood pressure cuff Pulse oximeter Oxygen cannula Yankauer suction tip catheter

The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? Public health nursing Community health nursing Vulnerable population nursing Community-based nursing

The patient has had a stroke that has affected the ability to speak. The patient becomes extremely frustrated when trying to speak. The patient responds correctly to questions and instructions but cannot form words coherently. Which type of aphasia is the patient experiencing? Expressive Receptive Combination Sensory

The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient? Assist with ambulation and measure how far the patient walks. Obtain assistance and physically transfer the patient to the chair. Bring the patient to the cafeteria for group instruction on ambulation. Give pain medication after ambulation so the patient will have a clear mind.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action is best for the nurse to take? Check with the pharmacy for availability of the liquid forms of medications. Mix all medications together to decrease the number of administrations. Instill nonliquid medications without diluting. Irrigate the tube with 60 mL of water after all medications are given.

Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to? Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results Consulting the wound care nurse about the change in status and the potential for infection Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) Conferring with the charge nurse about the change in status and the potential for infection

Which action by a novice nurse will cause the preceptor to provide follow up instructions? Charts consecutively on every other line. Documents descriptively. Ends each entry with signature and title. Uses quotations to note patients' exact words.

Which action should the nurse take to best develop critical thinking skills? Actively participate in clinical experiences. Interview staff nurses about their nursing experiences. Study 3 hours more each night. Attend all in-service opportunities.

Which action should the nurse take when using critical thinking to make clinical decisions? Considers what is important in any given situation. Reads and follows the heath care provider's orders. Accepts one established way to provide care. Makes decisions based on intuition.

Which entry will require follow-up by the nurse manager?0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Nurse call system within reach. Bed monitor on.-------------------Jane More, RN0810 Notified primary care provider of patient's status. New orders received. -------------------Jane More, RN0815 Portable x-ray of L hip taken in room. States, "I feel fine." -------------------Jane More, RN0830 Incident report completed and placed on chart.-------------------Jane More, RN 0830 0800 0810 0815

Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep? Eyes closed, lying quietly, respirations 12, heart rate 60 Eyes closed, mumbling to self, respirations 16, heart rate 68 Eyes closed, tossing in bed, respirations 18, heart rate 80 Eyes closed, lying supine in bed, respirations 22, heart rate 66

Which patient does the nurse most closely monitor for an unintended synergistic effect? The 72 year old who is seeing four different specialists. The 4 year old who has mistakenly taken a half bottle of vitamins. The 50 year old who is prescribed a second blood pressure medication. The 35 year old who has ingested meth mixed with several household chemicals.

While assessing the skin of an 82-year-old patient, a nurse discovers nonpainful, ruby red papules on the patient's trunk. What is the nurse's next action? Document cherry angiomas as a normal older adult skin finding. Explain that the patient has basal cell carcinoma and should watch for spread. Record the presence of petechiae. Tell the patient that this is a benign squamous cell carcinoma.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? Left-sided heart failure Right-sided heart failure Myocardial ischemia Atrial fibrillation

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? To prevent fluid from accumulating in the wound To limit the amount of bleeding from the surgical site To eliminate the need for wound irrigations To provide a means for medication administration

A The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

Which patient is most at risk for increased peristalsis? An 80-year-old male in an assisted-living environment A 21-year-old female with three final examinations on the same day A 5-year-old child who ignores the urge to defecate owing to embarrassment A 40-year-old female with major depressive disorder

A 21-year-old female with three final examinations on the same day

A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.) A 47-year-old immigrant who speaks only Spanish A 35-year-old living in own home A 15-year-old rape victim A 40-year-old schizophrenic A 22-year-old pregnant woman

A 47-year-old immigrant who speaks only Spanish A 15-year-old rape victim A 40-year-old schizophrenic

Which patient will the nurse see first? A 1-month-old infant looking at a shiny, round battery just out of arm's reach A 56-year-old patient with oxygen with a lighter on the bedside table A 1-month-old infant with a pacifier that has no string around the baby's neck A 56-year-old patient with oxygen using an electric razor for grooming

A 56-year-old patient with oxygen using an electric razor for grooming

A nurse is checking orders. Which order should the nurse question? A hypertonic solution enema for a patient with fluid volume excess A normal saline enema to be repeated every 4 hours until stool is produced A Kayexalate enema for a patient with severe hypokalemia An oil retention enema for a patient with constipation

A Kayexalate enema for a patient with severe hypokalemia

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.) A circumcised male who is ambulatory A patient who has an indwelling catheter A patient with urinary and fecal incontinence A patient with rectal and genital surgical dressings A bariatric patient

A patient who has an indwelling catheter A patient with urinary and fecal incontinence A patient with rectal and genital surgical dressings A bariatric patient

The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? A patient who is in observation for chest pain. A patient who has been admitted with dehydration. A patient who is recovering from a right total hip surgery. A patient who has been admitted for stabilization of heart problems.

A patient who is recovering from a right total hip surgery.

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? Stage II pressure ulcer A surgical sponge is left in the patient's incision. Pulmonary embolism after lung surgery Lack of blood incompatibility with a blood transfusion.

A surgical sponge is left in the patient's incision.

A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question? A true PICOT question regardless of the number of elements Not a true PICOT question because the comparison comes after the intervention Not a true PICOT question because the time is not designated A true PICOT question because the intervention comes before the control

A true PICOT question regardless of the number of elements

The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next? Teach the patient how to use cotton-tipped applicators. Tell the patient to use a bobby pin to extract earwax. Apply gentle, downward retraction of the ear canal. Instill hot water into the ear canal to melt the wax.

Apply gentle, downward retraction of the ear canal.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? Obtaining an order for a restraint Applying the restraint Determining the need for restraints Assessing the patient's orientation

Applying the restraint

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? Sigmoid Ascending Transverse Descending

Ascending

A patient is experiencing oliguria. Which action should the nurse perform first? Increase the patient's intravenous fluid rate. Encourage the patient to drink caffeinated beverages. Request an order for diuretics. Assess for bladder distention.

Assess for bladder distention.

Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? Limit caloric and protein intake. Assess for pain during a bath. Insert an indwelling urinary catheter. Turn the patient every 2 hours.

Assess for pain during a bath.

The nurse is caring for an older-adult patient diagnosed with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess? Assess ankles for edema. Assess for reduced sensations. Assess room for drafts. Assess oral cavity.

Assess oral cavity.

A nurse identifies lice during a child's scalp assessment. The nurse teaches the parents about hair care. Which information from the parents indicates the nurse needs to follow up? We will use a vinegar hair rinse. We will use lindane-based shampoos. We will use the sink to wash hair. We will use a fine-toothed comb.

The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? Restrict the patient's dietary intake to reduce the number of times on the bedpan. Do not allow turning in bed because that may lead to re-dislocation of the leg. Keep the patient's blood pressure low to prevent overperfusion of tissue. Assess surfaces exposed to the edges of the cast for pressure areas.

Assess surfaces exposed to the edges of the cast for pressure areas.

The nurse is caring for a patient who will have a large abdominal bandage secured with an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) Assess the condition of current dressings. Inspect the skin for abrasions and edema. Mark the sites of all abrasions. Cover exposed wounds. Assess the skin at underlying areas for circulatory impairment. Cleanse the area with hydrogen peroxide.

Assess the condition of current dressings. Inspect the skin for abrasions and edema. Cover exposed wounds. Assess the skin at underlying areas for circulatory impairment.

The nurse is admitting an older adult to the surgical unit. What intervention is necessary when determining the safe use of side rails for this patient? Explain to the patient the need to call for assistance when side rails are up. Discuss whether the patient is accepting of having the side rails up. Assess the patient's ability to effectively follow instructions. Always keeping the bed in its lowest position to the floor.

Assess the patient's ability to effectively follow instructions.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take to minimize the patient's risk for injury? Call the health care provider for a restraint order. Try alternatives to restraint. Assess the patient. Gather restraint supplies.

Assess the patient.

A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first? Insert a urinary catheter. Ask for a diuretic medication. Assist to a standing position. Limit fluid intake.

Assist to a standing position.

A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take? Sit the child up for 2 to 3 minutes after instilling drops in ear canal. Pull the auricle down and back to straighten the ear canal. Sit the child up to insert the cotton ball into the innermost ear canal. Pull the auricle upward and outward to straighten the ear canal.

A health care provider orders lorazepam 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose? 3 2 4 1

A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? Ethics of care Utilitarianism Deontology Feminist ethics

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient after the fall? Counseling the nursing assistive personnel on duty when the patient fell Identifying factors interfering with goal achievement Removing the fall risk sign from the patient's door because the patient has suffered a fall Requesting that the more experienced charge nurse complete the documentation about the fall

A nurse is using caring-healing relationships to support whole person/whole systems healing. Which type of nursing is the nurse using? Complementary and alternative nursing Integrative nursing Interprofessional nursing Holistic nursing

A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management? "You should take your medication after you walk to make sure you do not fall while you are walking." "We should work together to create a schedule to provide regular dosing of medication." "When you experience severe pain, you will need to take oral pain medications." "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain."

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? Pulse Respirations Blood pressure Temperature

A nurse is caring for a patient whose tissue perfusion is poor as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? Whole wheat toast with butter and a side of bacon A cup of nonfat yogurt with granola and a handful of dried apricots Omelet with sausage, cheese, and onions A bowl of cereal with whole milk and a banana

A nurse is developing a drinking prevention presentation for adolescents. Which areas should the nurse include in the teaching session? Health problems and avoidance of conflict Stress management and improving self-esteem Stressful life events and scholarships Very high self-esteem and work failure

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma. 2. Writes a diagnostic label of impaired gas exchange. 3. Organizes data into meaningful clusters. 4. Interprets information from patient. 5. Writes an etiology. 1, 3, 4, 5, 2 1, 3, 4, 2, 5 1, 4, 3, 5, 2 1, 4, 3, 2, 5

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first? Reinforce the wound dressing as needed with 4 × 4-inch gauze. Observe wound appearance and edges. Perform the ordered dressing change twice daily. Document wound characteristics.

A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." "As adults age, their ability to perceive pain decreases." "Patients who have dementia probably experience pain, and their pain is not always well controlled." "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include? Pupils equal and reactive to light. Reports sharp pain of 8 on a scale of 1 to 10. Had poor results from the pain medication. "My family doesn't believe I'm in pain."

A nurse is preparing to perform a complete physical examination on a fragile, older-adult patient diagnosed with bilateral basilar pneumonia. Which position will the nurse use to facilitate the patient's breathing? Lateral recumbent Supine Prone Sims'

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? Provides care that is based on meanings generated by predetermined criteria. Provides care that fits the patient's valued life patterns and set of meanings. Provides care that makes the nurse the leader in determining what is needed. Provides care that is the same as the values of the professional health care system.

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide? "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections." "You need to drink plenty of fluids and eat a diet high in fiber." "Narcotics can be addictive, so do not take them unless you are in severe pain." "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer."

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? Refusing the assignment Asking for an orientation to the unit Admitting lack of knowledge and going home Assuming that patient care will be the same as on the other units

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? Socio-consultative Personal Intimate Public

A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the affective domain will the nurse add to the teaching plan? The patient will state three facts about healthy eating. The patient will verbalize the value of eating healthy. The patient will cook a meal with low-fat oil. The patient will identify two foods for a healthy snack.

A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. 2, 3, 1, 4 3, 1, 2, 4 3, 2, 1, 4 1, 3, 2, 4

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic 2, 4, 1, 3 3, 4, 1, 2 4, 3, 2, 1 1, 3, 2, 4

A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? Question and answer sessions Role play Demonstration Lecture

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing? Assigning clinical cues Diagnostic reasoning Diagnostic labeling Defining characteristics

The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next? Take no action for this normal occurrence. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. Refer the adolescent for counseling about alcohol abuse problems. Talk with the adolescent's parent about staying up with friends and the need for sleep.

The nurse is preparing for a rectal examination of a nonambulatory male patient. In which position will the nurse place the patient? Knee-chest Sims' Forward bending with flexed hips Dorsal recumbent

The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse request when consulting with the health care provider? A blood urea nitrogen (BUN) An international normalized ratio (INR) A radiological examination of the chest A serum sodium (Na)

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? Apply suction while gently rotating and inserting the catheter. Limit the length of suctioning to 10 seconds. Set suction regulator at 150 to 200 mm Hg. Liberally lubricate the end of the suction catheter with a water-soluble solution.

The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take? Suggest that the patient "Close your eyes." Offer to explain what they should expect. Wait until family is visiting to support the patient. Distract the patient with the television.

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? Self-regulation Interpretation Evaluation Explanation

The patient is a 50-year-old African American male who has come in for a routine annual physical. Which type of preventive screening does the nurse discuss with the patient? CA 125 blood test once a year Digital rectal examination of the prostate Complete eye examination every year Colonoscopy every 3 years

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? Experiences adequate oxygen saturation during exercise. Experiences chest pain after eating a heavy meal. Experiences tingling in the left arm that lasts throughout the morning. Experiences crushing chest pain for more than 20 minutes.

The patient is on parenteral nutrition is lethargic while reporting thirst and headache and has had increased urination. Which problem does the nurse prepare to address? Hypocapnia Hyperglycemia Hypoglycemia Hypercapnia

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe? Do by self if the bed is in the flat position. Use a friction-reducing device. Place the pillow under the patient's head and shoulders. Place the side rails in the up position.

The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse's priority? Change the dose to one that is within range. Notify the health care provider that the prescribed dose is below the therapeutic range. Notify the health care provider that the prescribed dose is in the toxic range. Administer the medication because it is within the therapeutic range.

The school nurse is urgently called to the gymnasium regarding an injured student. The student is crying in severe pain with a malformed fractured lower leg. Which proper sequence will the nurse follow to perform the initial assessment? Inspection, light palpation, and deep palpation Inspection and light palpation Light palpation, deep palpation, and inspection Auscultation and light palpation

When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)? Assessing a surgical patient for risk of pressure ulcers Applying a gauze bandage to secure a nonsterile dressing Treating a pressure ulcer on the buttocks of a medical patient Implementing negative-pressure wound therapy on a stable patient

When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan? Providing vitamin and mineral supplements Increasing carbohydrates to 55% to 60% of total intake Limiting water before and after exercise Decreasing protein intake to 0.75 g/kg/day

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? Depending on the charge nurse to determine priorities of care Using the nursing process Drawing on past clinical experiences to formulate standardized care plans Relying on recall of information from past lectures and textbook

Which action indicates a registered nurse is being responsible for making clinical decisions? Formulates standardized care plans solely for groups of patients. Takes immediate action when a patient's condition worsens. Uses only traditional methods of providing care to patients. Applies clear textbook solutions to patients' problems.

Which individual is most likely to need the nurse's assistance in coping with identity confusion? A 50-year-old self-employed woman A 35-year-old recently divorced mother of twins A 49-year-old male with stable employment A 22-year-old in the third year of college

Which intervention should be included as the nurse cleanses a wound? Utilize clean gauze and clean gloves to cleanse a site. Cleanse in a direction from the least contaminated area. Allow the solution to flow from the most contaminated to the least contaminated. Scrub vigorously when applying noncytotoxic solution to the skin.

Which medical diagnosis will cause the nurse to question an order for acupuncture? Osteoarthritis Acquired immunodeficiency syndrome (AIDS) Migraine headaches Low back pain

The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? Ambulatory surgery Ambulatory surgery—extended stay Acute care—intensive care unit Acute care—medical-surgical unit

An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance? The nurse acted appropriately and saved the patient's life. The nurse stayed within the guidelines of the Good Samaritan Law. The nurse took actions beyond those that are standard and appropriate. The nurse should have just stayed with the patient and waited for help.

An older-adult patient is being seen for chronic entropion. Which condition will the nurse assess for in this patient? Exophthalmos Ptosis Infection Borborygmi

Before giving the patient an intermittent gastric tube feeding, what should the nurse do? Make sure that the tube is secured to the gown with a safety pin. Check to make sure pH is at least 5. Have the tube feeding at room temperature. Inject air into the stomach via the tube and auscultate.

During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. Which skill is the nurse describing? Mindfulness Focusing Receptivity Passivity

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share? Unsaturated fats are found mostly in animal sources. Trans fat should be less than 7% of the total calories. Saturated fats are found mostly in animal sources. Polyunsaturated fats should be less than 7% of the total calories.

The nurse adds a nursing diagnosis of Ineffective Breathing Pattern to a patient's care plan. Which sleep condition likely caused the nurse to assign this nursing diagnosis? Narcolepsy Insomnia Obstructive sleep apnea Sleep deprivation

The nurse administers a central nervous system stimulant to a patient. Which assessment finding indicates to the nurse that an idiosyncratic event is occurring? Presents with a pruritic rash. Develops restlessness. Falls asleep during daily activities. Experiences alertness.

The nurse caring for a patient of Hispanic descent who speaks no English, is working with an interpreter. Which action should the nurse take? Look at only nonverbal behaviors when talking. Use long sentences when talking. Look at the patient when talking. Use breaks in sentences when talking.

The nurse caring for an immobile patient wants to decrease the risk of the formation of pressure ulcers. Which action will the nurse take first? Encourage increased quantities of carbohydrates and fats. Offer favorite fluids. Determine the patient's risk factors. Turn the patient every 2 hours.

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? Increased gastric motility Reduced esophageal stricture Reduced kidney functioning Increased liver mass

The nurse documents the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? Imbalanced nutrition: less than body requirements Risk for infection Ineffective peripheral tissue perfusion Acute pain

The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? Waste any unused medication according to policy. Notify the operating suite that the medication has been given. Instruct the patient to call for help to go to the restroom. Ask the patient to sign the consent for surgery.

The nurse has prepared a pain injection for a patient but was called to check on another patient. When asked to give the medication what action by the new nurse is best? Administer the medication just this once. Avoid the issue and pretend to not hear the request. Refuse to give the medication. Give the medication if the pain score greater than 8.

The nurse is assessing a patient diagnosed with emphysema. Which assessment finding requires further follow-up with the health care provider? Clubbing of the fingers Increased anterior-posterior diameter of the chest Hemoptysis Accessory muscle used for breathing

The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child? Ask the parents if they think their child is in pain. Have the child rate the level of pain on a 0 to 10 pain scale. Use the FACES scale. Check to see what previous nurses have charted.

The nurse is caring for a dying patient. Which intervention is considered futile? Providing oral care every 5 hours Supporting lower extremities with pillows Administering the influenza vaccine Giving pain medication for pain

The nurse is caring for a group of patients. Which patient will the nurse see first? A patient after knee surgery is wearing intermittent pneumatic compression devices and receiving heparin. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes twice, hourly for 2 hours then every 4 hours. A patient who had cataract surgery is coughing. A patient who had vascular repair of the right leg is not doing right leg exercises.

The nurse is caring for a group of patients. Which task may the nurse delegate to the unlicensed assistive personnel (UAP)? Assessment of vital signs in a patient receiving epidural analgesia. Assessment of pain for a patient reporting abdominal pain. Administer a back massage to a patient with pain. Administer patient-controlled analgesia for a postoperative patient.

The nurse is caring for a patient and is focusing on modifiable factors that contribute to pain. Which areas does the nurse focus on with this patient? Age and gender Culture and ethnicity Anxiety and fear Previous pain experiences and cognitive abilities

The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take? Clean injection port with alcohol 5 seconds before and after use. Take down a running bag of TPN after 36 hours. Wear a sterile mask when changing the central venous catheter dressing. Run lipids for no longer than 24 hours.

A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which statement made by the new graduate nurse requires the preceptor to intervene? "I will use the information from my assessment to figure out if your antihypertensive medication is working effectively." "Information gained from physical assessment helps nurses better understand their patients' emotional needs." "Nurses use data from their patient's physical assessment to determine a patient's educational needs." "Nursing assessment data are used only to provide information about the effectiveness of your medical care."

A nurse is assessing a group of adolescents. Which person is most likely to have the highest self-esteem? Caucasian boy who lives below federal poverty level. Adolescent who was suspended twice from high school. African-American adolescent male who has severe acne. Latino adolescent female who has strong ethnic pride.

A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? Superficial pain Idiopathic pain Chronic pain Visceral pain

A nurse is assessing culturally diverse population groups for the risk of suicide. Which assessment question will provide the most culturally relevant information? "Is suicide common in your culture?" "Do you know anyone who as committed suicide?" "Has anyone here every considered suicide?" "How is suicide viewed in your culture?"

A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn? "Do you feel strong enough to perform the tasks I will teach you?" "On a scale from 1 to 10, tell me where you rank your desire to learn." "What do you want to know about strokes?" "Please read this handout and tell me what it means.

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? The arms should be crossed over the chest or in the lap. The feet should be close together with toes pointed out. When observed posteriorly, the hips and shoulders form an "S" pattern. When observed laterally, the spinal curves align in a reversed "S" pattern.

A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs? A patient writhing and moaning from abdominal pain after abdominal surgery. A patient with severe pain who is nauseated and feels like he or she is about to vomit. A patient lying very still in bed who reports no pain but is pale with warm, dry skin. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg.

A nurse is caring for a group of patients. Which patient will the nurse see first? Patient receiving total parenteral nutrition of 2-in-1 for 50 hours Patient receiving continuous enteral feeding with same tubing for 24 hours Patient receiving continuous enteral feeding with same feeding bag for 12 hours Patient receiving total parenteral nutrition infusing with same tubing for 26 hours

A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management? "This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication." "The patient is sleeping, so I pushed the PCA button." "It wasn't time for the patient's medication, so when it was requested, I gave a placebo." "I need to reassess the patient's pain 1 hour after administering oral pain medication."

A nurse is caring for a postoperative mastectomy patient. Which action is a priority for increasing self-awareness? Solving problems for the patient before developing insight Rotating nursing personnel in the patient's care, so the patient can talk to many people Telling the patient that it will be fine because many others have survived Using communication skills to clarify family and patient expectations

A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve 1, 3, 4, 2, 5 1, 2, 4, 5, 3 1, 5, 2, 4, 3 1, 4, 3, 2, 5

A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing? Community assessment Community health Public health Community-based

A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? The patient who is cooperative, depressed, and hard of hearing The patient who is oriented, pain free, and blind The patient who is alert, hungry, and has strong self-esteem The patient who is dyspneic, anxious, and has a tracheostomy

A nurse is performing a mental status examination and asks an adult patient what the statement "Don't cry over spilled milk" means. Which area is the nurse assessing? Knowledge Recent memory Long-term memory Abstract thinking

A nurse is preparing an intravenous (IV) piggyback infusion. In which order will the nurse perform the steps, starting with the first one? 1. Compare the label of the medication with the medication administration record at the patient's bedside. 2. Connect the tubing of the piggyback infusion to the appropriate connector on the upper Y-port. 3. Hang the piggyback medication bag above the level of the primary fluid bag. 4. Clean the main IV line port with an antiseptic swab. 5. Connect the infusion tubing to the medication bag. 6. Regulate flow. 1, 5, 4, 3, 2, 6 5, 2, 1, 3, 4, 6 5, 2, 1, 4, 3, 6 1, 5, 3, 4, 2, 6

A nurse is preparing to administer an antibiotic medication at 1000 to a patient but gets busy in another room. When should the nurse give the antibiotic medication? By 1200 By 1130 By 1100 By 1030

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? Pulse 75 Pulse 80 Oxygen saturation 91% Oxygen saturation 88%

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? Discuss the surgical procedure and reason for the pain. Offer to notify the health care provider after morning rounds are completed. Explain to the patient that nothing else has been ordered. Explore other options for pain relief.

A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? "Your disease often makes patients lose mental status." "Your disease will be helped if you pursed-lip breathe." "Your disease affects both your lungs and your heart, and not enough blood is being pumped." "Your disease doesn't send enough oxygen to your fingers."

A patient experiencing left-sided hemiparesis has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? Risk for skin breakdown Risk for infection Activity intolerance Impaired gas exchange

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

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? Hemiplegia Lower extremity paralysis Muscle sprain Impaired balance

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? Diuretics Chest physiotherapy Vasodilators Intravenous (IV) fluids

A patient is being discharged home. Which information should the nurse include? Acuity level Standardized care plan Signature for verbal order Community resources

A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient's safety? Apply a gauze dressing to the epidural catheter insertion site. Restrict fluid intake. Ask the nursing assistive personnel to check on the patient at least once every 2 hours. Label the tubing that leads to the epidural catheter.

A patient is taking an antidepressant medication. The nurse discovers that the patient uses herbs. Which herb will cause the nurse to intervene? Garlic Saw palmetto Aloe Chamomile

A patient needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide). Which action will the nurse take? Suction the patient's respiratory secretions. Suggest voiding every 2 hours. Increase fluid intake. Encourage the patient to cough and deep-breathe.

A school nurse recognizes a belt buckle-shaped ecchymosis on a 7-year-old student. When privately asked about how the injury occurred, the student described falling on the playground. Which action will the nurse take next? Talk to the principal about how to proceed. Interview the patient in the presence of the teacher. Disregard the finding based upon child's response. Contact social services and report suspected abuse.

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? Transcutaneous electrical nerve stimulation (TENS) Herbal supplements with analgesic effects Pudendal block (regional anesthesia) Relaxation and guided imagery

After a teaching session on taking blood pressures, the nurse tells the patient, "You took that blood pressure like an experienced nurse." Which type of reinforcement did the nurse use? Entrusting Pleasurable activity Tangible reward Social acknowledgment

After providing care, a nurse charts in the patient's record. Which entry will the nurse document? Appears restless when sitting in the chair. Drank adequate amounts of water. Apparently is asleep with eyes closed. Skin pale and cool.

During a routine physical examination of a 70-year-old patient, a blowing sound is auscultated over the carotid artery. Which assessment finding will the nurse report to the health care provider? Right-sided heart failure Phlebitis Thrill Bruit

On admission, a patient weighs 250 lb. The weight is recorded as 256 lb on the second inpatient day. Which condition will the nurse assess for in this patient? Anorexia Increased nutritional intake Weight loss Fluid retention

The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, "Why is it that not all poor people are considered members of vulnerable populations?" How should the nurse respond? "All poor people are members of a vulnerable population." "Poor people are members of a vulnerable population only if they are homeless." "Poor people are members of a vulnerable population only if they take drugs." "Members of vulnerable groups frequently have a combination of risk factors."

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

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal? Hyperactive bowel sounds in all four quadrants 1+ pitting edema Pulse strength 3 Constricting pupils when directly illuminated

The nurse considers several new female patients to receive additional teaching on the need for more frequent Pap testing and gynecological examinations. Which assessment findings reveal the patient at highest risk for cervical cancer and having the greatest need for patient education? 13 years old, nonsmoker, not sexually active 50 years old, stopped smoking 30 years ago, has history of multiple pregnancies 15 years old, social smoker, celibate 22 years old, smokes 1 pack of cigarettes per day, has multiple sexual partners

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? Inform the patient of the importance of finishing the entire dose of antibiotics. Schedule patient to get annual tuberculosis skin testing. Create an exercise routine to run 45 minutes every day. Encourage the patient to stay up-to-date on all vaccinations.

The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? "Stay with ice chips for several hours. After that, you can have whatever you want." "Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet." "Stay on clear liquids for 24 hours. Then you can progress to a normal diet." "Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated."

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? Surfactant Perfusion Ventilation Diffusion

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on the count of three shift weight from the front to back leg. 4, 1, 3, 5, 6, 2 5, 6, 3, 1, 4, 2 1, 4, 5, 6, 3, 2 3, 4, 1, 5, 6, 2

The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit? Diabetic retinopathy Peripheral neuropathy Dysequilibrium Xerostomia

The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about management of the condition. Which information from the patient will cause the nurse to intervene? Takes antidepressant medications. Naps shorter than 20 minutes. Chews gum regularly. Sleeps in hot, stuffy room.

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? Encourage the patient to do self-care. Encourage the patient to perform ROM. Keep the patient as mobile as possible. Assist the patient with comfort measures.

The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely administer the feeding? Nasointestinal tube Percutaneous endoscopic gastrostomy (PEG) tube Nasogastric tube Jejunostomy tube

The patient is experiencing right-sided heart failure. Which finding will the nurse expect when performing an assessment? Cyanosis Basilar crackles Chest pain Peripheral edema

The patient is to receive phenytoin at 0900. When will be the ideal time for the nurse to schedule a trough level? 0930 0800 0900 0830

The patient who has been diagnosed with cardiovascular disease and placed on a low-fat diet, asks the nurse, "How much fat should I have? I guess the less fat, the better." Which information will the nurse include in the teaching session? Fats have no significance in health and the incidence of disease. All fats come from external sources, so this can be easily controlled. Cholesterol intake needs to be less than 300 mg/day. Deficiencies occur when fat intake falls below 10% of daily nutrition.

The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? This is done to complete the first action in a head-to-toe assessment. This is done to ensure that the medical-surgical nurse checks on the postoperative patient. This is done to follow hospital policy and procedure for care of the surgical patient. This is done to compare and monitor for vital sign variation during transport.

When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? So fact is separated from opinion. So judgmental attitudes can be provoked. So the group identifies the one correct solution. So different perspectives are respected.

Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? Provides care to surgical patients. Provides care to restore relationships. Provides care to patients that is individualized. Provides care to transgender patients.

Which action will the nurse take when taking a telephone order? Verify that the health care provider will write the order within 24 hours. Print out a copy of the order once entered into the electronic health record. Ask that another registered nurse listen to the call over an extension line. Read back the order as written to the health care provider for verification.

Which assessment finding will best indicate that the patient is ready to learn? The ability to grasp and apply the elastic bandage. Demonstrates sufficient coordination to handle a syringe safely. Has sufficient upper body strength to move from a bed to a wheelchair. Expresses the motivation to walk with an assistive device.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that requires epinephrine therapy? The patient will identify the main ingredients in several foods. The patient will learn about food labels. The patient will list the side effects of epinephrine. The patient will administer epinephrine.

Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? Hands placed on the chest wall with fingers extended will separate as the chest wall contracts. The patient will feel upward movement of the diaphragm during inspiration. The patient will feel downward movement of the diaphragm during expiration. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts.

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? Decrease fluid intake to 300 mL a shift. Monitor oxygen saturation, and frequently auscultate lung bases. Discontinue the humidification delivery device to keep excess fluid from lungs. Assist the patient to cough, turn, and deep breathe every 2 hours.

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? Ate two thirds of breakfast Capillary refill is less than 2 seconds A raised red rash on the right shin Fecal incontinence

While recovering from a severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. Which response by the nurse is most appropriate? "You are not allowed to ever change a living will after signing it." "Check with your admitting health care provider whether a copy is on your chart." "Your living will can be changed only once each calendar year." "Let me check with someone here in the hospital who can assist you."

A nurse is following the How-to Guide to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) Daily oral care with chlorhexidine Daily "sedation vacations" Heart failure prophylaxis Clean technique when suctioning Delirium monitoring Head of bed elevation to 90 degrees at all times

Daily oral care with chlorhexidine Daily "sedation vacations" delirium monitoring?

A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff? Xerostomia Pediculosis Dandruff Alopecia

Dandruff

The nurse is caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, who is also experiencing peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? Decreased pain sensation and increased risk of skin impairment High risk for impaired venous return and dementia Decreased caloric intake and accelerated wound healing High risk for skin infection and low saliva pH level

Decreased pain sensation and increased risk of skin impairment

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care? Deficient knowledge Risk for suffocation Risk for falls Impaired physical mobility

Deficient knowledge

The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) Dispose of supplies to prevent the spread of microorganisms. Wash hands before entering and leaving both of the patients' rooms. Be consistent in nursing interventions since there is only one difference in the precautions. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. Have patients in airborne precautions wear a mask during transportation to other departments. Check the working order of the negative-pressure room for the airborne precaution patient on admission and at discharge.

Dispose of supplies to prevent the spread of microorganisms. Wash hands before entering and leaving both of the patients' rooms. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. Have patients in airborne precautions wear a mask during transportation to other departments.

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? Discomfort while changing position Disruption of tissue integrity Dull headache Reports pain as a 7 on a 0 to 10 scale

Disruption of tissue integrity

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) Document results of goal achievement. Set priorities for patient care. Determine whether outcomes or standards are met. Ambulate patient 25 feet in the hallway. Use self-reflection and correct errors.

Document results of goal achievement. Determine whether outcomes or standards are met. Use self-reflection and correct errors.

The health care provider prescription reads "Metoprolol 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic." The patient's blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? Does not inform the health care provider that the medication was held. Documents only what the blood pressure was. Does not tell the patient what the blood pressure is. Documents that the medication was not given because of low blood pressure.

Documents that the medication was not given because of low blood pressure.

A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? Allows the spigot to touch the receptacle when emptying the drainage bag. Drapes the urinary drainage tubing with no dependent loops. Places the urinary drainage bag gently on the floor below the patient. Washes the drainage tube toward the meatus with soap and water.

Drapes the urinary drainage tubing with no dependent loops.

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? Cecum Duodenum Stomach Ileum

Duodenum

A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior? EBP is a guide for nurses in making clinical decisions. EBP is easily attained at the bedside. EBP is always right for all situations. EBP is based on the latest textbook information

EBP is a guide for nurses in making clinical decisions.

The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? Malaise, anorexia, enlarged lymph nodes, and increased white blood cells Chest pain, shortness of breath, and nausea and vomiting Dizziness and disorientation to time, date, and place Edema, redness, tenderness, and loss of function

Edema, redness, tenderness, and loss of function

A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective? Screening Education Dependence Counseling

Education

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? Saline wound irrigation Appropriate use of gloves Effective hand hygiene When eye protection is needed

Effective hand hygiene

A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) Esophagus Temporal artery Rectal Tympanic Pulmonary artery

Esophagus Tympanic Pulmonary artery

A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? Sengstaken-Blakemore Miller-Abbott Ewald Dobhoff

Ewald

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) Managed emotions Feeling very tired Trouble concentrating Reactive responses Tense muscles

Feeling very tired Trouble concentrating Reactive responses Tense muscles

Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine? Fever with chills Increased blood pressure Reduced urine specific gravity Abnormal blood sugar

Fever with chills

Which methods will the nurse use to administer an intravenous (IV) medication that is incompatible with the patient's IV fluid? (Select all that apply.) Administer slowly with the IV fluid. Flush with 10 mL of sterile water before and after administration. Start another IV site. Flush with 10 mL of normal saline before and after administration. Do not give the medication and chart.

Flush with 10 mL of sterile water before and after administration. Start another IV site. Flush with 10 mL of normal saline

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) Gives a change-of-shift report to the oncoming nurse about the patient. Reads the progress notes of assigned patient's record. Writes the patient's room number and date of birth on a paper for school. Discusses patient care with the hospital volunteer. Prints/copies material from the patient's health record for a graded care plan. Reviews assigned patient's record and another unassigned patient's record.

Gives a change-of-shift report to the oncoming nurse about the patient. Reads the progress notes of assigned patient's record.

The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? Passes flatulence. Has a bowel movement. Experiences pain relief. Reports decreased diarrhea.

Has a bowel movement.

The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? Head lice may spread to furniture and other people. Products containing lindane are most effective. Manual removal is not a realistic option as treatment. Treatment is use of regular shampoo.

Head lice may spread to furniture and other people.

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.) Health care provider renews orders for restraints every 24 hours. Health care provider orders restraints prn (as needed). Health care provider specifies the duration and circumstances under which the restraint will be used. Health care provider performs a face-to-face assessment prior to the order. Health care provider writes the type and location of the restraint.

Health care provider specifies the duration and circumstances under which the restraint will be used. Health care provider performs a face-to-face assessment prior to the order. Health care provider writes the type and location of the restraint.

The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? Hematocrit level of 45% Red blood cell count of 5.0 million/mm3 Pulse oximetry of 95% Hemoglobin level of 8.0 g/100 mL

Hemoglobin level of 8.0 g/100 mL

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do? Cleanse the urethral meatus from the area of most contamination to least. Drink fluids 5 minutes before collecting the urine specimen. Hold the labia apart while voiding into the specimen cup. Initiate the first part of the urine stream directly into the collection cup.

Hold the labia apart while voiding into the specimen cup.

A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) Patient satisfaction level Hospital readmission rates Nursing hours per patient day Patient falls/falls with injuries Value stream analysis for quality

Hospital readmission rates Nursing hours per patient day Patient falls/falls with injuries

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? Hyperthermia and fever are the same thing. Hyperthermia results from a reduction in thermoregulatory mechanisms. Hyperthermia occurs when the body cannot reduce heat production. Hyperthermia is an upward shift in the set point.

Hyperthermia occurs when the body cannot reduce heat production.

Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.) Ensures that subjects complete the study. Identifies risks and benefits of participation. Understands how confidentiality is maintained. Allows free choice to participate or withdraw. Gives complete information about the purpose.

Identifies risks and benefits of participation. Understands how confidentiality is maintained. Allows free choice to participate or withdraw. Gives complete information about the purpose.

A nurse is assessing a patient's self-concept. Which areas will the nurse include? (Select all that apply.) Identity Significant others' support Coping behaviors Body image Availability of insurance

Identity Body image Significant others' support Coping behaviors

The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. Immediately wash the site with soap and running water and seek guidance from the manager. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. Delay washing of the site until the nurse is finished providing care to the patient.

Immediately wash the site with soap and running water and seek guidance from the manager.

The patient is asking the nurse about the best way to stay healthy. The nurse explains to the patient which teaching points? (Select all that apply.) Increase physical activity. Choose and prepare foods with little salt. Keep total fat intake to 10% or less. Maintain body weight in a healthy range. Increase intake of meat and other high-protein foods.

Increase physical activity. Choose and prepare foods with little salt. Maintain body weight in a healthy range.

The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) Increase the frequency of skin assessment. Administer ordered analgesic 1 hour before bath time. Reduce triggers in the environment. Be as quick as possible. Keep the room temperature cool.

Increase the frequency of skin assessment. Reduce triggers in the environment.

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? Increased energy levels Elevated blood pressure Increased skin dryness Distended abdomen

Increased skin dryness

After licensure, the nurse wants to stay current in knowledge and skills. Which programs are the most common ways nurses can do this? (Select all that apply.) Master's degree Inservice education Doctoral preparation Continuing education National Council Licensure Examination retake

Inservice education Continuing education

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.) Instruct the family to reorient and reassure the patient after consciousness is regained. Instruct the family to move the patient to a bed during a seizure. Discuss with the family steps to take if the seizure does not discontinue. Teach the family how to insert a tongue depressor during the seizure. Demonstrate how to restrain the patient in the event of a seizure.

Instruct the family to reorient and reassure the patient after consciousness is regained. Discuss with the family steps to take if the seizure does not discontinue.

A patient reports severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test? Intravenous pyelogram Mid-stream urinalysis Cystoscopy Bladder scan

Intravenous pyelogram

The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? Results Methods Literature review Introduction

Introduction

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy? Keep the patient on fall risk until discharge. Check on the patient once a shift. Place all four side rails in the "up" position. Encourage visitors in the early evening.

Keep the patient on fall risk until discharge.

The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) Withholding all patient medications for the day Keeping the urine collection container on ice when indicated Testing the urine sample with a reagent strip by dipping it in the urine Asking the patient to void and discarding that urine to start the collection Irrigating the sample as needed with sterile solution

Keeping the urine collection container on ice when indicated Asking the patient to void and discarding that urine to start the collection

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? Bladder, kidney, urethra, ureters Bladder, kidney, ureters, urethra Kidney, urethra, bladder, ureters Kidney, ureters, bladder, urethra

Kidney, ureters, bladder, urethra

The nurse is caring for a patient diagnosed with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? Review the procedure with the patient. Position the patient comfortably. Maintain surgical aseptic technique. Gather available supplies.

Maintain surgical aseptic technique.

The nurse is reviewing nursing research literature related to a potential practice problem on the nursing unit. What is the rationale for the nurse's action? (Select all that apply.) Nursing research identifies new knowledge. Nursing research enhances effective use of resources. Nursing research improves professional practice. Nursing research leads to decreases in budget expenditures. Nursing research ensures the nurse's promotion.

Nursing research identifies new knowledge. Nursing research enhances effective use of resources. Nursing research improves professional practice.

A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? Observe the patient for decreased activity tolerance. Assume the patient is in pain and treat accordingly. Provide the patient ice chips as requested. Maintain the room temperature at 65° F.

Observe the patient for decreased activity tolerance.

The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse-midwife, the patient asks for a referral to a pediatrician for the newborn. Which action should the nurse-midwife take initially? Provide the referral as requested. Offer to provide the newborn care. Refer the patient to the supervising provider. Tell the patient that is not allowed to make referrals.

Offer to provide the newborn care.

The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority? Oral cavity Nail beds Feet Perineum

Oral cavity

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? Urinary continence 55 years old 20/20 vision Orthostatic hypotension

Orthostatic hypotension

A graduate of a baccalaureate degree program plans to start working as a registered nurse (RN) in the emergency department. Which action must the nurse take first? Obtain certification for an emergency nurse. Pass the National Council Licensure Examination. Take a course on genomics to provide competent emergency care. Complete the Hospital Consumer Assessment of Healthcare Providers Systems.

Pass the National Council Licensure Examination.

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? Wellness education Passive health promotion Illness prevention Active health promotion

Passive health promotion

The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? (Select all that apply.) Patient is placed in bilateral wrist restraints at 0815. Straps with quick-release buckle attached to bed side rails. Released from restraints, active range-of-motion exercises completed. Attempts to distract the patient with television are unsuccessful. Family member has left room and gone to lunch. Bilateral radial pulses present, 2+, hands warm to touch.

Patient is placed in bilateral wrist restraints at 0815. Released from restraints, active range-of-motion exercises completed. Attempts to distract the patient with television are unsuccessful. Bilateral radial pulses present, 2+, hands warm to touch.

he nurse is administering ibuprofen to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) Patient experiences respiratory depression after administration of an opioid medication. Patient states joint pain is 2/10 and intermittent. Patient reports past medical history of gastric ulcer. Patient reports last bowel movement was 4 days ago. Patient states allergy to aspirin.

Patient reports past medical history of gastric ulcer. Patient states allergy to aspirin.

A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response? Drink cranberry juice. Perform pelvic floor exercises. Avoid voiding frequently. Wear an adult diaper.

Perform pelvic floor exercises.

A nurse is using research findings to improve clinical practice. Which technique is the nurse using? Performance scores Integrated delivery networks Nursing-sensitive outcomes Utilization review committees

Performance scores

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? Increase room temperature to 90 degrees. Place a cap on their heads. Double the clothing. Apply just a diaper.

Place a cap on their heads.

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? Place the patient on oxygen. Increase the patient's metabolic rate. Restrict the patient's fluid intake. Encourage the patient to cough.

Place the patient on oxygen.

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? Risk factor prevention Primary prevention Secondary prevention Tertiary prevention

Primary prevention

A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene? Securing the catheter tubing to the patient's thigh Kinking the catheter tubing to obtain a urine specimen Emptying the drainage bag when half full Placing the drainage bag on the side rail of the patient's bed

Placing the drainage bag on the side rail of the patient's bed

A nurse is a member of the ethics committee. Which roles will the nurse fulfill in this committee? (Select all that apply.) Purchasing Agent Direct patient care provider Policy reviewer and recommender Educator Case consultant

Policy reviewer and recommender Educator Case consultant

A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care? Older adult Preschooler Adult Adolescent

Preschooler

A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? Prevent constipation. Prevent lower bowel inflammation. Prevent gaseous distention. Prevent colon infection.

Prevent colon infection.

The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) Private room Negative-pressure airflow in room Surgical mask, gown, gloves, eyewear N95 respirator, gown, gloves, eyewear Communication signs for droplet precautions Communication signs for airborne precautions

Private room Negative-pressure airflow in room N95 respirator, gown, gloves, eyewear Communication signs for airborne precautions

Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.) Professional standards review organizations Prospective payment systems Diagnosis-related groups Third-party payers "Never events"

Professional standards review organizations Prospective payment systems Diagnosis-related groups

The nurse is caring for a patient diagnosed with C. difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? Proper hand hygiene techniques Mandatory cultures on all patients Appropriate disposal of contaminated items in biohazard bags Monthly inservices about contact precautions

Proper hand hygiene techniques

While receiving a shift report on a female patient, the nurse is informed that the patient has been experiencing urinary incontinence. Upon assessment, which finding will the nurse expect? Reddened irritated skin on buttocks An indwelling Foley catheter Tiny blood clots in the patient's urine Foul-smelling discharge indicative of infection

Reddened irritated skin on buttocks

A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? Administering a colon cleansing product 6 hours before the examination Obtaining an order for a pain medication before the test is performed Removing all of the patient's metallic jewelry Ensuring that the patient does not eat or drink 2 hours before the examination

Removing all of the patient's metallic jewelry

The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? Washing hands after removing gloves Disinfecting endoscopes in the workroom Removing gloves to transfer the endoscope Placing the endoscope in a container for transfer

Removing gloves to transfer the endoscope

Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response? Vigorous range-of-motion exercises Turn, cough, and deep breathe Orient to date, time, and place Rest, ice, and elevation

Rest, ice, and elevation

The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? Secondary acute Continuing Restorative Tertiary

Restorative

The nursing assistive personnel (NAP) is taking vital signs and reports that a patient's blood pressure is abnormally low. What should the nurse do next? Instruct the NAP to assess the patient's other vital signs. Retake the blood pressure personally and assess the patient's condition. Ask the NAP to retake the blood pressure. Disregard the report and have it rechecked at the next scheduled time.

Retake the blood pressure personally and assess the patient's condition.

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? Risk for injury: Check on patient every 15 minutes. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. Disturbed body image: Encourage patient to express concerns about body. Risk for suffocation: Place "Oxygen in Use" sign on door.

Risk for injury: Check on patient every 15 minutes.

The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) The risk of obtaining an inaccurate reading is decreased. Self-monitoring helps with compliance and treatment. Blood pressures can be obtained if pulse rates become irregular. Patients can provide information about patterns to health care providers. Patients can actively participate in their treatment.

Self-monitoring helps with compliance and treatment. Patients can provide information about patterns to health care providers. Patients can actively participate in their treatment.

The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? Sending to central sterile for cleaning and sterilization Sending to central sterile for cleaning and disinfection Sending to central sterile for cleaning and boiling Sending to central sterile for cleaning

Sending to central sterile for cleaning and sterilization

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select all that apply.) Serves no meat or fish to a Hindu patient. Serves no ham products to a Muslim patient. Allows fasting on Yom Kippur for a Jewish patient. Serves kosher foods to a Christian patient. Allows caffeine drinks for a Mormon patient.

Serves no meat or fish to a Hindu patient. Serves no ham products to a Muslim patient. Allows fasting on Yom Kippur for a Jewish patient.

The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? Should be unnecessary because the patient is uncircumcised. Should be done by the nurse. Should be postponed because it may cause embarrassment. Should be done by the patient.

Should be done by the patient.

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) Smoking in bed helps me relax and fall asleep. We use the RACE method when using the fire extinguisher. We never leave candles burning when we are gone. We use the same space heater my grandparents used. There is a fire extinguisher in the kitchen and garage workshop.

Smoking in bed helps me relax and fall asleep. We use the RACE method when using the fire extinguisher. We use the same space heater my grandparents used.

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? Caffeine increases BP for up to 15 minutes. Smoking result in vasoconstriction, falsely elevating BP. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement. Smoking increases BP for up to 3 hours.

Smoking result in vasoconstriction, falsely elevating BP.

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? Urine output of 80 mL/hr pH of 6.4 Protein level of 2 mg/100 mL Specific gravity of 1.036

Specific gravity of 1.036

Which finding indicates the best quality improvement process? Staff identifies the wait time in the emergency department is too long. Administration identifies the design of the facility's lobby increases patient stress. Director of the hospital identifies the payment schedule does not pay enough for overtime. Health care providers identify the inconsistencies of some of the facility's policy and procedures.

Staff identifies the wait time in the emergency department is too long.

The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? Stand to the side of the patient's eye and observe the cornea. Notify the ambulance personnel for missing glasses. Ask the patient where the glasses are. Conclude that the glasses were lost during the accident.

Stand to the side of the patient's eye and observe the cornea.

A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene? Turning patient's head with neck injury to side when giving oral care Not offering to wash the hair of a patient with neck trauma Turning off the television while giving a backrub to the patient Not offering a backrub to a patient with fractured ribs

Turning patient's head with neck injury to side when giving oral care

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? Stoma is moist. Stoma is flush with the skin. Stoma is purple. Stoma is protruding from the abdomen.

Stoma is purple.

The nurse is providing oral care to an unconscious patient. Which action should the nurse take to protect the patient from injury? Suction the oral cavity. Moisten the mouth using lemon-glycerin sponges. Use foam swabs to help remove plaque. Hold the patient's mouth open with gloved fingers.

Suction the oral cavity.

A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) Tachypnea—regular, rapid respirations Hyperventilation—labored, increased in depth and rate respirations Biot's—irregular with alternating periods of apnea and hyperventilation respirations Cheyne-Stokes—abnormally slow and depressed ventilation respirations Kussmaul's—abnormally deep, regular, fast respirations Apnea—no respirations

Tachypnea—regular, rapid respirations Kussmaul's—abnormally deep, regular, fast respirations Apnea—no respirations

The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? Teaching the patient about fall prevention Teaching the patient to take a temperature Teaching the patient to select nutritious foods Teaching the patient about the effects of alcohol

Teaching the patient to select nutritious foods

Upon completing a history, the nurse finds that a patient has risk factors for developing lung disease. How should the nurse interpret this finding? A person with the risk factor will get the disease. The chances of getting the disease are increased. The disease is guaranteed not to develop if the risk factor is controlled. Risk modification will have no effect on disease prevention.

The chances of getting the disease are increased.

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? This home is not furnished with a microwave oven. The electricity was turned off 3 days ago. A son and family recently moved into the home. The water comes from the county water supply.

The electricity was turned off 3 days ago.

The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) The family is not allowed in the operating suite. The nurses will be there to assist you through this process. The surgical staff will be dressed in special clothing with hats and masks. The operative suite will be very dark. The operating table or bed will be comfortable and soft.

The family is not allowed in the operating suite. The nurses will be there to assist you through this process. The surgical staff will be dressed in special clothing with hats and masks.

The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? The family member places the used dressings in a plastic bag. The family member saves part of the dressing because it is clean. The family member removes gloves and gathers items for disposal. The family member wraps the used dressing in toilet tissue before placing in trash.

The family member places the used dressings in a plastic bag.

A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. What should the nurse realize? Legislation is politics beyond the nurse's control. National programs have no bearing on state politics. The individual nurse can influence legislative decisions. Focusing on nursing care provides the best patient benefit.

The individual nurse can influence legislative decisions.

The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? The nurse is responsible for providing a safe environment for the patient. Different scopes of practice allow modification of procedures. Allowing the water to run is a waste of resources and money. This is a key step in the procedure for washing hands.

The nurse is responsible for providing a safe environment for the patient.

A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void? The patient is lonely and calling the nurse in under false pretenses is a way to get attention. The patient does not recognize the physiological signals that indicate a need to void. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. The patient is not drinking enough fluids to produce adequate urine output.

The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the temporary need for a restraint? The patient continues to remove the nasogastric tube. The patient does not sleep and continues to ask for items. The patient gets confused regarding the time at night. The patient refuses to call for help to go to the bathroom.

The patient continues to remove the nasogastric tube.

The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? The patient has chronic obstructive pulmonary disease (COPD). The patient has possible hemorrhage or bleeding. The patient has calcium channel blockers or digitalis medication prescriptions. The patient has a fever.

The patient has calcium channel blockers or digitalis medication prescriptions.

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) The patient is mildly anxious about their condition. The patient is reporting being fatigued. The patient is asking numerous questions about their health status. The patient is in the acceptance phase of dealing with their medical diagnosis. The patient's pain is not controlled. The patient is currently febrile with an oral temperature of 101.2° F.

The patient is reporting being fatigued. The patient's pain is not controlled. The patient is currently febrile with an oral temperature of 101.2° F.

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation? The nurse hears bowel sounds in all four quadrants. The patient's lower left quadrant is tender to the touch. The patient reports eliminating a soft, formed stool. The patient has quit taking opioid pain medication.

The patient reports eliminating a soft, formed stool.

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? The patient will return to the contemplation or precontemplation phase. The patient does not want to and will never quit smoking. The patient will need to adopt a new lifestyle for change to be effective. The patient must pick up the attempt right where the patient left off.

The patient will return to the contemplation or precontemplation phase.

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) It is safe for adults with acute febrile illnesses. The vaccines are recommended for all people 6 months and older. It is given in a series of four doses. It is safe for children allergic to eggs. It is given yearly. The live, attenuated nasal spray is given to people over 50.

The vaccines are recommended for all people 6 months and older. It is given yearly.

A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition? Blood pressure cuff Sphygmomanometer Stethoscope Thermometer

Thermometer

A nurse is assessing a patient's cranial nerve IX. Which items does the nurse gather before conducting the assessment? (Select all that apply.) Tongue blade Lemon applicator Snellen chart Vial of sugar Ophthalmoscope

Tongue blade Lemon applicator Vial of sugar

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.) Transfer a patient to another hospital unit. Order chest x-ray for suspected arm fracture. Reposition a patient who is on bed rest. Prescribe antibiotics for a wound infection. Teach a patient preoperative exercises.

Transfer a patient to another hospital unit. Reposition a patient who is on bed rest. Teach a patient preoperative exercises.

A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy? Eggs over easy, whole wheat toast, and orange juice with pulp Chicken fried rice with fresh pineapple and iced tea Turkey sandwich on whole wheat bread and iced tea Fish sticks with sweet corn and soda

Turkey sandwich on whole wheat bread and iced tea

The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) Apply sterile gloves. Keep soiled linen close to uniform. Turn clean pillowcase inside out over the hand holding it. Advise patient will feel a lump when rolling over. Make a modified mitered corner with sheet, blanket, and spread.

Turn clean pillowcase inside out over the hand holding it. Advise patient will feel a lump when rolling over. Make a modified mitered corner with sheet, blanket, and spread.

The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care-associated infection? Use local anesthetic on reddened areas. Use nonallergenic tape on dressings. Use a chlorhexidine wash. Use filtered water.

Use a chlorhexidine wash.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs? Administer a soapsuds enema every 2 hours. Use a mobility device to place the patient on a bedside commode. Give the patient a pillow to brace against the abdomen while bearing down. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan.

Use a mobility device to place the patient on a bedside commode.

A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? (Select all that apply.) Remove needle and dispose in sharps box. Use clearly marked sharps disposal containers. Recap the needle after giving an injection. Use needleless devices whenever possible. Never force needles into the sharps disposal.

Use clearly marked sharps disposal containers. Use needleless devices whenever possible. Never force needles into the sharps disposal.

The nurse is bathing a patient and notices movement in the patient's hair. Which action will the nurse take? Shave the hair off of the patient's head. Ignore the movement and continue. Use gloves to inspect the hair. Apply a lindane-based shampoo immediately.

Use gloves to inspect the hair.

A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) Use informatics. Use transparency. Apply globalization. Apply quality improvement. Use evidence-based practice

Use informatics. Apply quality improvement. Use evidence-based practice.

Which nursing action will most likely increase a patient's risk for developing a health care-associated infection? Uses surgical aseptic technique to suction an airway. Uses a clean technique for inserting a urinary catheter. Uses a cleaning stroke from the urinary meatus toward the rectum. Uses a sterile bottled solution more than once within a 24-hour period.

Uses a clean technique for inserting a urinary catheter.

Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) Uses humility. Exhibits supportiveness. Demonstrates independent attitude. Instills faith. Portrays self-confidence.

Uses humility. Demonstrates independent attitude. Portrays self-confidence.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? Identifies patient with one identifier before transporting to x-ray department. Initiates an intravenous (IV) catheter using clean technique on the first try. Uses medication bar coding when administering medications. Obtains vital signs to place on a surgical patient's chart.

Uses medication bar coding when administering medications.

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first? Plan to change the surgical dressing during the shift. Utilize SBAR to notify the primary health care provider. Reevaluate the temperature and white blood cell count in 4 hours. Check to see what solution was used for skin preparation in surgery.

Utilize SBAR to notify the primary health care provider.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.) Set priorities based solely on physiological factors. Do not change priorities once they've been established. Utilize critical thinking. Rank all the patient's nursing diagnoses in order of priority. Consider time as an influencing factor.

Utilize critical thinking. Rank all the patient's nursing diagnoses in order of priority. Consider time as an influencing factor.

A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? Utilizing the power of suggestion by turning on the faucet and letting the water run Obtaining an order for a Foley catheter Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress Administering diuretic medication

Utilizing the power of suggestion by turning on the faucet and letting the water run

A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing? Educator Manager Advocate Caregiver

manager

A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts? Protects the nurse. Protects the public. Protects the provider. Protects the hospital.

protects the public

A patient is experiencing a fecal impaction. Which portion of the colon will the nurse assess? Transverse Ascending Descending Rectum

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