Final: Funds
The nurse is discharging a client home after mastoid surgery. What should the nurse include in discharge teaching?
"Don't blow your nose for 2 to 3 weeks."
Diagnostic tests show that a client's bone density has decreased over the past several years. The client asks the nurse which factors contribute to bone density decreasing. Which response by the nurse would be best?
"For many people, a lack of proper nutrition can cause a loss of bone density."
A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding?
"I need to call the doctor if I see flashing lights."
The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?
"I'm certainly going to keep a close eye on my blood pressure from now on."
A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond?
"In fact, glaucoma usually requires lifelong treatment with medications."
The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by making what statement?
"Increased LDL and decreased HDL increase my risk of coronary artery disease."
A client got a sliver of glass in his/her eye when a glass container at work fell and shattered. The glass had to be surgically removed and the client is about to be discharged home. The client asks the nurse for a topical anesthetic for eye pain. What should the nurse respond?
"Overuse of these drops could soften your cornea and damage your eye."
A 56-year-old client has come to the clinic for a routine eye examination and is told bifocals are needed. The client asks the nurse what change in the eyes has caused this need for bifocals. How should the nurse respond?
"There is a gradual thickening of the lens of the eye and it can limit the eye's ability for accommodation."
A nurse is caring for a client who has been scheduled for a bone scan. Which statement should the nurse include when educating the client about this diagnostic test?
"You will be encouraged to drink water after the administration of the radioisotope injection."
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?
0.45% sodium chloride (1/2 NS)
A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?
0.9% sodium chloride (NS)
The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve.
1, 2, 3, 4 without, with, solution, tubing
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 APP, ASS, Moisten gently, loosely cover
A nurse is preparing to administer an enteral feeding. In which order will the nurse implement the steps, starting with the first one? 1. Elevate head of bed to at least 30 degrees. 2. Check for gastric residual volume. 3. Flush tubing with 30 mL of water. 4. Verify tube placement. 5. Initiate feeding.
1, 4, 2, 3, 5 EV CFI
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, 4, 3, 2, 5 eighth bony
A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?
125 drops/min
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?
2 hours or less at any one time
The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?
20
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
23
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed?
2345 Monday
A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device.
3, 2, 4, 1, 5, 7, 6 apply, select, release, clean, reapply, insert, advance APPs, Rel CR, IA
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
3, 4, 1, 2 (we're out of) TP MA
A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse?
4 hours
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 LT BC
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, 5, 2, 3, 6 identify, obtain, place, apply, insert, massage
A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve
4, 2, 1, 3, 5 start with cornea**
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
4, 3, 5, 1, 2 SIA(s) BP
The nurse is calculating a cardiac client's pulse pressure. If the client's blood pressure is 122/76 mm Hg, what is the client's pulse pressure?
46 mm Hg
A patient has 250 mL of a jejunostomy feeding with 30 mL of water before and after feeding and 200 mL of urine. Thirty minutes later the patient has 100 mL of diarrhea. At 1300 the patient receives 150 mL of blood and voids another 200 mL. Calculate the patient's intake. Record your answer as a whole number. mL
460
The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye?
5 minutes
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 Attach, have, insert, apply, encourage, rinse AH (attach), IA, ER
The patient has a catheter that must be irrigated. The nurse is using a needle less 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.
6, 5, 1, 3, 2, 4 DCC TIR.. (remember DRAW first)
A nurse is asked how many kcal/g are provided by fats. How should the nurse answer?
9
While auscultating a client's heart sounds, the nurse hears an extra heart sound immediately after the second heart sound (S2). An audible S3 would be considered an expected finding in which client?
A 20-year-old client
Which patient is most at risk for increased peristalsis?
A 21-year-old female with three final examinations on the same day
In which patient will the nurse expect to see a positive Chvostek's sign?
A 24-year-old adult admitted for chronic alcohol abuse
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
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
The nurse will anticipate inserting a Coudé catheter for which patient?
A 56-year-old male admitted for bladder irrigation
The nurse should recognize the greatest risk for the development of blindness in which of the following clients?
A 58-year-old Caucasian woman with macular degeneration
The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?
A 70-year-old patient with stool incontinence
A nurse is checking orders. Which order should the nurse question?
A Kayexalate enema for a patient with severe hypokalemia
As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat?
A Stage I
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?
A cup of nonfat yogurt with granola and a handful of dried apricots
The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see?
A decrease
A nurse is providing care to a group of patients. Which patient will the nurse assess first?
A dehydrated older patient about to receive a hypertonic enema
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
A nurse is caring for a client whose cancer metastasis has resulted in bone pain. What should the nurse expect the client to describe?
A dull, deep ache that is "boring" in nature
The nurse is caring for a client who has a history of heart disease. What factor should the nurse identify as possibly contributing to a decrease in cardiac output?
A heart rate of 54 bpm
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
Which patient is demonstrating a refractive error sensory problem?
A patient who frequently reports the incorrect time from the clock across the room.
The nurse is caring for a group of patients. Which patient will the nurse see first?
A patient who had cataract surgery is coughing.
A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs?
A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg.
The nurse is caring for a group of patients. Which patient will the nurse see first?
A patient with D5W hanging with the blood
The nurse anticipates a suprapubic catheter for which patient?
A patient with a urethral stricture
The nurse is caring for a group of patients. Which patient will the nurse see first?
A patient with appendicitis using a heating pad
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 nurse is providing care to a group of patients. Which patient will the nurse see first?
A patient with reflex incontinence with elevated blood pressure and pulse rate
Which patient will the nurse assess most closely for an ileus?
A patient with surgery for bowel disease and anesthesia
The nurse hears a health care provider say to the charge nurse that a certain nurse cannot care for patients because the nurse is stupid and won't follow orders. The health care provider also writes in the patient's medical records that the same nurse, by name, is not to care for any of the patients because of incompetence. Which torts has the health care provider committed? (Select all that apply.) a. Libel b. Slander c. Assault d. Battery e. Invasion of privacy
A, B Libel Slander
A nurse is conducting an examination of a client's inner eye. When viewing the retina, which structure(s) would the nurse identify as a retinal landmark? Select all that apply. A. optic disk B. macula C. posterior chamber D. vitreous humor E. ciliary body
A, B (MO)
The nurse is providing care for a client who has benefited from a cochlear implant. The nurse should understand that this client's health history likely includes which of the following? Select all that apply. A. The client was diagnosed with sensorineural hearing loss. B. The client's hearing did not improve appreciably with the use of hearing aids. C. The client has deficits in peripheral nervous function. D. The client's hearing deficit is likely accompanied by a cognitive deficit. E. The client is unable to lip-read.
A, B diagnosed appreciably
A nurse is explaining a client's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A. Thyroid hormone B. Growth hormone C. Estrogen D. Vitamin B12 E. Luteinizing hormone
A, B, C (its ET G)
A client is scheduled for audiometry to evaluate hearing. When teaching the client about this test, which characteristic would the nurse include as being evaluated? Select all that apply. A. pitch B. frequency C. intensity D. compliance E. postural control capabilities
A, B, C IF Pitch
The nurse is participating in a ―time-out.‖ In which activities will the nurse be involved? (Select all that apply.) a. Verify the correct site. b. Verify the correct patient. c. Verify the correct procedure. d. Perform ―time-out‖ after surgery. e. Perform the actual marking of the operative site.
A, B, C VerifyX3 (no preform)
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.) a. Hemostasis b. Maturation c. Inflammatory d. Proliferative e. Reproduction f. Reestablishment of epidermal layers
A, B, C, D No RR (or M (is) HIP)
A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a. A risk factor is smoking. b. A risk factor is high intake of animal fats or red meat. c. A warning sign is rectal bleeding. d. A warning sign is a sense of incomplete evacuation. e. Screening with a colonoscopy is every 5 years, starting at age 50. f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50.
A, B, C, D no screening (X2)
A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply. A. Dropping of word endings B. Disinterest in conversations C. Social withdrawal D. Domination of conversations E. Quick decision making
A, B, C, D NO quick decision
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. ―Can you easily change your position?‖ b. ―Do you have sensitivity to heat or cold?‖ c. ―How often do you need to use the toilet?‖ d. ―What medications do you take?‖ e. ―Is movement painful?‖ f. ―Have you ever fallen?‖
A, B, C, E No What/have (or CHID)
The nurse is caring for a patient who has not been able to sleep well while in the hospital, leading to a disrupted sleep-wake cycle. Which assessment findings will the nurse monitor for in this patient? (Select all that apply.) a. Changes in physiological function such as temperature b. Decreased appetite and weight loss c. Anxiety, irritability, and restlessness d. Shortness of breath and chest pain e. Nausea, vomiting, and diarrhea f. Impaired judgment
A, B, C, F (no short nausea)
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.) a. ―You will be resuscitated unless there is a DNR order in the chart.‖ b. ―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.‖ c. ―You will be resuscitated at any time to allow you the longest length of survival.‖ d. ―If you decide you want a DNR order, you will need to talk to your health care provider.‖ e. ―If you travel to another state, your living will should cover your wishes.‖
A, B, D
When hemodynamic monitoring is ordered for a client, a catheter is inserted into the appropriate blood vessel or heart chamber. When assessing a client who has such a device in place, the nurse should check which of the following components? Select all that apply. A. A transducer B. A flush system C. A leveler D. A pressure bag E. An oscillator
A, B, D (F TP)
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.) a. ―Drinking coffee at 7 PM could interrupt my sleep.‖ b. ―Staying up late for a party can interrupt sleep patterns.‖ c. ―Exercising 2 hours before bedtime can decrease relaxation.‖ d. ―Changing the time of day that I eat dinner can disrupt sleep.‖ e. ―Worrying about work can disrupt my sleep.‖ f. ―Taking an antacid can decrease sleep.‖
A, B, D, E (W DCS, no ET)
A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a. Record times when the patient is incontinent. b. Help the patient to the toilet at the designated time. c. Lean backward on the hips while sitting on the toilet. d. Maintain normal exercise within the patient's physical ability. e. Apply pressure with hands over the abdomen, and strain while pushing. f. Choose a time based on the patient's pattern to initiate defecation-control measures.
A, B, D, F everything except LA
A nurse is teaching a health class about the nutritional requirements throughout the life span. Which information should the nurse include in the teaching session? (Select all that apply.) a. Infants triple weight at 1 year. b. Toddlers become picky eaters. c. School-age children need to avoid hot dogs and grapes. d. Breastfeeding women need an additional 750 kcal/day. e. Older adults have altered food flavor from a decrease in taste cells.
A, B, E TIO (or no BS)
A critical care nurse is caring for a client with a hemodynamic monitoring system in place. For what complications should the nurse assess? Select all that apply. A. Pneumothorax B. Infection C. Atelectasis D. Bronchospasm E. Air embolism
A, B, E (Air IP)
The operating room nurse is providing a hand-off report to the post-anesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a. IV fluids b. Vital signs c. Insurance data d. Family location e. Anesthesia provided f. Estimated blood loss
A, B, E, F NO family insurance
The nurse is administering ibuprofen to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) a. Patient states allergy to aspirin. b. Patient states joint pain is 2/10 and intermittent. c. Patient reports past medical history of gastric ulcer. d. Patient reports last bowel movement was 4 days ago. e. Patient experiences respiratory depression after administration of an opioid medication.
A, C allergen, history
The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply.) a. Habit training uses a bladder diary. b. Timed voiding is based upon the patient's urge to void. c. Prompted voiding includes asking patients if they are wet or dry. d. Elevation of feet in patients with edema can decrease nighttime voiding. e. Bladder retraining teaches patients to follow the urge to void as quickly as possible.
A, C (HP or NO bet)
When assessing patient with nutritional needs, which patients will require follow-up from the nurse? (Select all that apply.) a. A patient with infection taking tetracycline with milk b. A patient with irritable bowel syndrome increasing fiber c. A patient with diverticulitis following a high-fiber diet daily d. A patient with an enteral feeding and 500 mL of gastric residual e. A patient with dysphagia being referred to a speech-language pathologist
A, C, D infection, diverticulitis, enteral
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.) a. NREM sleep contributes to body tissue restoration. b. During NREM sleep, biological functions increase. c. Restful sleep preserves cardiac function. d. Sleep contributes to cognitive restoration. e. REM sleep decreases cortical activity.
A, C, D (RNS rest or no REM during)
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.) a. Stairway faintly lit b. Bathtub with grab bars c. Scatter rugs in the kitchen d. Absence of smoke alarms e. Low pile carpeting in the living room f. Level thresholds between bathroom and bedroom
A, C, D (SAS)
The client has a homocysteine level ordered. What aspects of this test should inform the nurse's care? Select all that apply. A. A 12-hour fast is necessary before drawing the blood sample. B. Recent inactivity can depress homocysteine levels. C. Genetic factors can elevate homocysteine levels. D. A diet low in folic acid elevates homocysteine levels. E. An ECG should be performed immediately before drawing a sample.
A, C, D 12 genetic diet ( or A2 G)
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.) a. Increase physical activity. b. Keep total fat intake to 10% or less. c. Maintain body weight in a healthy range. d. Choose and prepare foods with little salt. e. Increase intake of meat and other high-protein foods.
A, C, D physical MC (or no intake X2)
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.) a. Age b. Race c. Obesity d. Nutrition e. Pregnancy f. Ambulatory surgery
A, C, D, E Age PON
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.) a. Cover exposed wounds. b. Mark the sites of all abrasions. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. e. Cleanse the area with hydrogen peroxide. f. Assess the skin at underlying areas for circulatory impairment.
A, C, D, F Cover AAI (or no M cleanse)
The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) a. Place moist sterile gauze over the site. b. Gently place the organs back. c. Contact the surgical team. d. Offer a glass of water. e. Monitor for shock.
A, C, E Contact, Place, Monitor (CPM or NO GO)
A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common cause(s) of blindness and visual impairment among adults over the age of 40? Select all that apply. A. Diabetic retinopathy B. Trauma C. Macular degeneration D. Cytomegalovirus E. Glaucoma
A, C, E (DM G, or no TC)
A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.
A, C, F check, minimal, flexion
Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch
A, C, F edema, skin x2 (no RPP)
The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be based upon the drug book's information. The pediatrician is contacted and says to administer the medication as ordered. Which actions should the nurse take next? (Select all that apply.) a. Notify the nursing supervisor. b. Administer the medication as ordered. c. Give the amount listed in the drug book. d. Ask the mother to give the drug to her child. e. Check the chain of command policy for such situations.
A, E No AG or Nursing Chain
A client is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the client? Select all that apply. A. Application of topical antibiotic ointment B. Maintenance of a supine position for the first 48 hours' postoperative C. Fluid restriction to prevent orbital edema D. Administration of loop diuretics to prevent orbital edema E. Use of an ocular pressure dressing
A, E (Application use)
The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) a. Keeping the urine collection container on ice when indicated b. Withholding all patient medications for the day c. Irrigating the sample as needed with sterile solution d. Testing the urine sample with a reagent strip by dipping it in the urine e. Asking the patient to void and discarding that urine to start the collection
A, E (Keep asking)
The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a. Maintain normoglycemia. b. Use a straight razor to remove hair. c. Provide bath and linen change daily. d. Perform first dressing change 2 days postoperatively. e. Perform hand hygiene before and after contact with the patient. f. Administer antibiotics within 60 minutes before surgical incision.
A, E maintain hygiene
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.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The live, attenuated nasal spray is given to people over 50. f. The vaccines are recommended for all people 6 months and older.
A, F yearly vaccines
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the sinoatrial (SA) node and then proceeds in which sequence?
AV node to bundle of His to Purkinje fibers
A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?
Abdominal distention
A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. Which assessment findings are most consistent with this diagnosis?
Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder?
Activities of daily living
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?
Acute care—intensive care unit
A nurse caring for a diabetic patient with a bowel obstruction has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate?
Add a potassium supplement to replace loss from output.
A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
Administer a Mini-Mental State Examination (MMSE).
The nurse is caring for a group of patients. Which task may the nurse delegate to the unlicensed assistive personnel (UAP)?
Administer a back massage to a patient with pain.
The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)?
Administering an enema
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
A lipid profile has been ordered for a client who has been experiencing cardiac symptoms. When should a lipid profile be drawn in order to maximize the accuracy of results?
After a 12-hour fast
The nurse is caring for a patient at risk for skin impairment. Which initial action should the nurse take to decrease this risk?
After cleansing thoroughly dry the skin.
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?
Air-fluidized
A nurse is caring for a client with a diagnosis of cancer that has metastasized to the bone. Which laboratory value would the nurse expect to be elevated in this client?
Alkaline phosphatase
The nurse is preparing to apply an external catheter. Which action will the nurse take?
Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter.
A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis?
Altered serum calcium levels
A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. Which other laboratory result is most consistent with this finding?
An elevated parathyroid hormone level
Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?
An infant with temperature of 102.2F and diarrhea for 3 days
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?
An international normalized ratio (INR)
The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97 F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care?
Anesthesia lowers metabolism.
The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action?
Anesthetics can decrease bladder contractility and cause urinary retention.
During a follow-up visit, a female patient is describing new onset of marital discord with her terminally ill spouse to the hospice nurse. Which Kübler-Ross stage of dying is the patient experiencing?
Anger
The nurse is discussing lack of sleep with a middle-aged adult. Which area should the nurse most likely assess to determine a possible cause of the lack of sleep?
Anxiety
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?
Anxiety and fear
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
Aortic and pulmonic
The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area?
Appling a warm blanket
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.
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?
Apply ice.
When caring for a group of patients, which task can the nurse delegate to the nursing assistive personnel (AP)?
Applying a gauze bandage to secure a nonsterile dressing
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?
Applying the nasal cannula
A client has informed the home health nurse that he/she has recently noticed distortions when looking at the Amsler grid that is mounted on the refrigerator. What is the nurse's most appropriate action?
Arrange for the client to be assessed for macular degeneration.
An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response?
Arrange for the client to visit an ophthalmologist .
The nurse working on a cardiac care unit is caring for a client whose stroke volume has increased. The nurse is aware that afterload influences a client's stroke volume. The nurse recognizes that which factor increases afterload?
Arterial vasoconstriction
A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability. The nurse should focus on what health problem?
Arthritis
A client has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate what diagnostic procedure?
Arthrocentesis
The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?
Ascending
The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient's preparation?
Ascertain that the surgical site has been correctly marked.
A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's next best action?
Ask the health care provider to verify the dosage and frequency of the medication.
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?
Ask the patient to rate and describe the pain.
A patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain?
Ask the patient to rate the level of pain.
During discharge teaching the nurse realizes that the client is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene?
Ask the social worker to investigate community support agencies.
A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate?
Assess and promote the client's coping skills during interactions with the client.
A patient is experiencing oliguria. Which action should the nurse perform first?
Assess for bladder distention.
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.
The nurse is caring for a client who has central venous pressure (CVP) monitoring in place. The nurse's most recent assessment reveals that CVP is 7 mm Hg. What is the nurse's most appropriate action?
Assess the client for fluid overload and inform the health care provider.
The nurse is caring for a patient in the post-anesthesia 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?
Assess the patient for bladder distention.
A client has just arrived to the floor after an enucleation procedure following a workplace accident in which the client's left eye was irreparably damaged. Which of the following should the nurse prioritize during the client's immediate postoperative recovery?
Assessing and addressing the client's emotional needs
A client with mastoiditis is admitted to the postsurgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care?
Assessing for mouth droop and decreased lateral eye gaze
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
Assist the patient to cough, turn, and deep breathe every 2 hours.
A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?
Assist to a standing position.
After mastoid surgery, an 81-year-old client has been identified as needing assistance in her home. What would be a primary focus of this client's home care?
Assisting the client with ambulation as needed to avoid falling
The nurse is providing health education to a client diagnosed with glaucoma. The nurse teaches the client that this disease has a familial tendency. The nurse knows that clinical examinations for family members at risk for glaucoma should occur how often?
At least once every 2 years
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?
Avoiding the use of cotton swabs
A nurse is preparing a presentation for a group of elementary school parents about ways to promote the health of the ears and hearing in their children. When describing the structure and function of the ears, which structure would the nurse most likely include as part of the middle ear? Select all that apply. A. pinna B. tympanic membrane C. oval window D. cochlea E. organ of Corti
B tympanic membrane
Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.) a. Increasing fluid intake b. Dribbling of urine c. Voiding in small amounts d. Voiding within 6 hours of catheter removal e. Burning with the first couple of times voiding
B, C (dribbling small)
A nurse administers an antimuscarinic to a patient. A decrease in which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.) a. Dysuria b. Urgency c. Frequency d. Prostate size e. Bladder infection
B, C (frequent urge)
The nurse is relating the deficits in a client's synchronization of the atrial and ventricular events to his diagnosis. What are the physiologic characteristics of the nodal and Purkinje cells that provide this synchronization? Select all that apply. A. Loop connectivity B. Excitability C. Automaticity D. Conductivity E. Independence
B, C, D (C EA)
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) a. The patient's expectations are not being met. b. Skin is intact with no redness or swelling. c. Non-blanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present.
B, C, D, E everything EXCEPT expectations
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin
B, C, D, E everything EXCEPT vision
A nurse is following the How-to Guide to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Delirium monitoring d. Clean technique when suctioning e. Daily ―sedation vacations‖ f. Heart failure prophylaxis
B, C, E triple D
Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Allowing the patient adequate time and privacy to void d. Wearing gown, gloves, and mask for all specimen handling e. Transporting specimens to the laboratory in a timely manner f. Collecting the specimen from the drainage bag of an indwelling catheter
B, C, E (LAT)
A community health nurse is providing an educational session at the senior center on how to promote sleep. Which practices should the nurse recommend? (Select all that apply.) a. Take a nap in the afternoon. b. Sleep where you sleep best. c. Use sedatives as a last resort. d. Watch television right before sleep. e. Decrease fluids 2 to 4 hours before sleep. f. Get up if unable to fall asleep in 20 minutes.
B, C, E, F (G SUD, no TW)
A nurse is teaching the staff about professional negligence or malpractice. Which criteria to establish negligence will the nurse include in the teaching session? (Select all that apply.) a. Injury did not occur. b. That duty was breached. c. Nurse carried out the duty. d. Duty of care was owed to the patient. e. Patient understands benefits and risks of a procedure.
B, D
A nurse is documenting end-of-life care. Which information will the nurse include in the patient's electronic medical record? (Select all that apply.) a. Reason for the death b. Time and date of death c. Special preparations of the body d. Location of body identification tags e. Time of body transfer and destination
B, D, E Time 2 locate
The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a. Induce shivering. b. Reduce blood loss. c. Induce pressure ulcers. d. Reduce cardiac arrests. e. Reduce surgical site infection.
B, D, E ReduceX3 (no induce)
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.) a. The operative suite will be very dark. b. The family is not allowed in the operating suite. c. The operating table or bed will be comfortable and soft. d. The nurses will be there to assist you through this process. e. The surgical staff will be dressed in special clothing with hats and masks.
B, D, E family surgical nurse (no operativeX2)
A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.
B, E, F stop, keep, 2-3
A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?
Bacteria
During an assessment, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
Balance deficit
The nurse is teaching a health class about the My Plate program. Which guidelines will the nurse include in the teaching session?
Balancing calories
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)
Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity?
Be aware of clients' medication regimens and collaborate with other professionals accordingly.
How can a nurse assigned to a medical unit at a local hospital best address issues related to the delivery of quality nursing care?
Become active in professional nursing organizations at the state level.
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?
Benzodiazepine
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?
Bleeding
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
A client has symptoms of osteoporosis and is being assessed during an annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of osteoporosis. The nurse should anticipate which diagnostic test?
Bone densitometry
A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture?
Bone densitometry
A patient's father died a week ago. Both the patient and the patient's spouse talk about the death. The patient's spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and cries frequently. How should the nurse interpret these findings as the basis for a follow-up assessment?
Both the patient and the spouse are likely grieving.
Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?
Bright red urine turns pink in the tubing
The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?
Burning upon urination
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.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)
C, D BC (or no SAP)
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this client be taught about this diagnosis? Select all that apply. A. Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously. B. Cholesteatomas are usually the result of metastasis from a distant tumor site. C. Cholesteatomas are often the result of chronic otitis media. D. Cholesteatomas, if left untreated, result in intractable neuropathic pain. E. Cholesteatomas usually must be removed surgically.
C, E removed chronic
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern?
Calcium of 15.5 mg/dL
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?
Call the health care provider; a blockage is present in the tubing.
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.
The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?
Cardiac
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?
Carries out gas exchange.
A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse teach the patient?
Catheterizing the pouch
A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion?
Cecum, ascending, transverse, descending, sigmoid, and rectum
The nurse is caring for an acutely ill client who has central venous pressure monitoring in place. What intervention should be included in the care plan of a client with CVP in place?
Change the site dressing whenever it becomes visibly soiled.
A newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. Which action by the nurse is best?
Check the policy and procedure manual for the facility's method.
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.
A nurse is caring for a patient in the last stages of dying. Which finding indicates the nurse needs to prepare the family for death?
Cheyne-Stokes breathing
The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications?
Cholinergics
Which intervention should be included as the nurse cleanses a wound?
Cleanse in a direction from the least contaminated area.
A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take?
Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Following a motorcycle accident, an adolescent client is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
Clear, watery fluid is draining from the client's ear.
A hearing-impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client?
Client is likely unable to hear the nurse during test.
During assessment, a client reports experiencing rhythmic muscle contractions when the nurse performs passive extension of the wrist. The nurse should recognize the presence of which condition?
Clonus
The nurse is assessing a patient for nutritional status. Which action will the nurse take?
Combine multiple objective measures with subjective measures.
The nurse is performing an assessment of a client's musculoskeletal system and is appraising the client's bone integrity. Which action should the nurse perform during this phase of assessment?
Compare parts of the body symmetrically.
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
The patient has been diagnosed with Helicobacter pylori. The nurse should encourage which action initially?
Completion of antibiotic therapy
A nurse is called into the supervisor's office regarding deteriorating work performance since the loss of a spouse 2 years ago. The nurse begins sobbing and says, ―I'm falling apart at home as well‖. Which type of grief is the nurse experiencing?
Complicated grief
A patient is receiving opioids for pain. Which bowel assessment is a priority?
Constipation
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 talk with the patient, but the situation continues. Which immediate action by the nurse is mandated by law?
Contact the appropriate community child protection facility.
A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action?
Contact the primary provider immediately.
A patient has experienced a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?
Coronary artery
A client injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of which tissue is the diaphysis of the femur mainly constructed?
Cortical bone
The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
Cyanosis
The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a. Patient with abdominal surgery has patent airway. b. Patient with knee surgery has approximated incision. c. Patient with femoral artery surgery has strong pedal pulse. d. Patient with lung surgery has 20 mL/hr of urine output via catheter. e. Patient with bladder surgery has bloody urine within the first 12 hours. f. Patient with appendix surgery has thready pulse and blood pressure is 90/60.
D, F lung bladder
A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result?
Decrease in cardiac output
A nurse participating in a research project associated with pressure ulcers will assess for what predisposing factor that tends to increase the risk for pressure ulcer development?
Decreased level of consciousness
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?
Deficiencies occur when fat intake falls below 10% of daily nutrition.
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?
Determine patient acuity and care the nurse can safely provide.
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?
Determine the patient's risk factors.
The nurse's assessment of a client with significant visual losses reveals that the client cannot count fingers. How should the nurse proceed with assessment of the client's visual acuity?
Determine whether the client is able to see the nurse's hand motion.
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?
Diffusion
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.
A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action?
Discontinue the IV.
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?
Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness.
A client's ocular tumor has necessitated enucleation and the client will be fitted with a prosthesis. The nurse should address what nursing diagnosis when planning the client's discharge education?
Disturbed body image
A client is scheduled to have an electronystagmography as part of a diagnostic workup for Ménière disease. What question is most important for the nurse to ask the client in preparation for this test?
Do you currently take any tranquilizers or stimulants on a regular basis?
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)?
Drapes the urinary drainage tubing with no dependent loops.
A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by an assistive personnel (NAP) demonstrates understanding of the needs of this patient?
Dressing the left side first
The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient's skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?
Drink more water to prevent further dehydration.
While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient?
Drink plenty of fluids throughout the day to stay hydrated.
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?
Drop in pulse oximetry readings
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?
Duodenum
A nurse is caring for a dying patient. When is the best time for the nurse to discuss end-of-life care?
During assessment
The nurse is preparing to check the gastric aspirate for pH. Which equipment will the nurse obtain?
ENFit syringe
A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding?
Effusion
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
A client is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. Which client status would be most important for the nurse to verify before the client's scan?
Empty bladder
A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate?
Emptying the pouch at least once every 7 days.
The nurse is caring for a patient who reports having difficulty sleeping. Which action will the nurse take?
Encourage deep breathing.
The nurse is caring for an adolescent post-appendectomy who is reporting difficulty falling asleep. Which intervention will be most appropriate?
Encourage the discontinuation of a soda and chocolate as a nightly snack.
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?
Encourage the patient to stay up to date on all vaccinations.
In preparation for the eventual death of a hospice patient, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. Which information will be included in the plan?
Encourage the patient's family and friends to verbally express their needs.
The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
Endoscopy
A palliative team is caring for a dying patient in severe pain. Which action is the priority?
Enhance the patient's quality of life.
A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?
Ensuring that there are no metal objects on or in the client
Which nursing goal is a priority for assessing the patient before surgery?
Establish a patient's baseline of normal function.
A client has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the client for this test, what action should the nurse perform?
Establish peripheral IV access.
A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment?
Evaluating the effects of the musculoskeletal disorder on the client's function
A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain?
Ewald
The nurse is caring for a patient who has been in holding in the emergency department for 24 hours. The nurse is concerned about the patient's experiencing sleep deprivation. Which action will be best for the nurse to take?
Expedite the process of obtaining a medical-surgical room for the patient.
The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?
Experiences chest pain after eating a heavy meal.
A client has had a sudden loss of vision after head trauma. How should the nurse best describe the placement of items on the dinner tray?
Explain the location of items using clock cues.
A client with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the client administers the pilocarpine, the client states that the client's vision is blurred. Which nursing action is most appropriate?
Explaining that this is an expected adverse effect
The nurse in the ED is caring for a child brought in by the parents who state that the child will not stop crying and pulling at the child's ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis?
External otitis is characterized by aural tenderness.
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
―I know it seems strange, but I feel guilty being pregnant after the death of my son last year,‖ said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her realize bonding with this unborn child will not mean she is replacing the one who died. Which nursing technique does this demonstrate?
Facilitating mourning
A nurse encounters a family who experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. Which nursing principle does the nurse's action best demonstrate?
Facilitation of normal mourning
The nurse's assessment of an older adult client reveals the following data: Lying BP 144/82 mm Hg; sitting BP 121/69 mm Hg; standing BP 98/56 mm Hg. The nurse should identify the priority nursing diagnosis of a risk for which outcome in the client's plan of care?
Falls related to orthostatic hypotension
The nurse's musculoskeletal assessment of a client reveals involuntary twitching of muscle groups. How would the nurse document this observation in the client's chart?
Fasciculations
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
Fecal incontinence
A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the client to monitor closely for what postprocedure complication?
Fever
Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?
Fever with chills
The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a ―Do not disturb‖ sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate?
Firmly explain that the patient does not wish to have visitors at this time.
The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find?
Flashing lights in the visual field
A client has sustained traumatic injuries that involve several bone fractures. A fracture of what type of bone may interfere with the protection of the client's vital organs?
Flat bones
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
Flex head with chin down.
A nurse assessing a patient who is receiving a blood transfusion finds that the patient is anxiously fidgeting in bed. The patient is afebrile but dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?
Fluid volume excess
In providing prenatal care to a pregnant patient, what does the nurse teach the expectant mother?
Folic acid is needed to help prevent birth defects and anemia.
A client has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the client should be kept in a prone position until otherwise ordered. What should the nurse do?
Follow the order because this bed position is correct.
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?
Formula intolerance
The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?
Frequency
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction?
From intracellular to extracellular
The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
From the tip of the nose to the earlobe to the xiphoid process
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
Full thickness wound repair
Cytomegalovirus (CMV) is the most common cause of retinal inflammation in clients with AIDS. What drug, surgically implanted, is used for the acute stage of CMV retinitis?
Ganciclovir
A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client?
Generously flush the affected eye with normal saline or water.
A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take?
Give pain medications around the clock.
Upon examination via otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
Glomus tympanicum
The nurse is caring for a patient who is experiencing a full thickness wound repair. Which type of tissue will the nurse expect to observe when the wound is healing?
Granulation
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
Grape and walnut chicken salad sandwich on whole wheat bread
A 6-month-old infant is brought to the ED by the parents for inconsolable crying and pulling at the right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
Gray
Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly?
Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts.
A client is brought into the emergency department (ED) by family members, who tell the nurse the client grabbed their chest and reported substernal chest pain. The care team recognizes the need to monitor the client's cardiac function closely while interventions are performed. Which form of monitoring should the nurse anticipate?
Hardwire continuous electrocardiogram (ECG) monitoring
The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect?
Has a bowel movement.
Before giving the patient an intermittent gastric tube feeding, what should the nurse do?
Have the tube feeding at room temperature.
A nurse is teaching a nutrition class about the different daily values. When teaching about the referenced daily intakes (RDIs), which information should the nurse include?
Have values for protein, vitamins, and minerals.
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?
Healing Stage III pressure ulcer
The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?
Hearing
A group of high school students is attending a concert, which will be at a volume of 80 to 90 dB. What is a health consequence of this sound level?
Hearing loss may occur with a decibel level in this range.
A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?
Heart failure
The nurse is assessing a patient diagnosed with emphysema. Which assessment finding requires further follow-up with the health care provider?
Hemoptysis
To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?
Hold the labia apart while voiding into the specimen cup.
A severely depressed patient cannot state any positive attributes to life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. Which spiritual concept is the nurse trying to promote?
Hope
A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations?
How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?
Which coughing technique will the nurse use to help a patient clear central airways?
Huff
The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient's edema?
Hydrostatic
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?
Hyperglycemia
A client has been admitted to the intensive care unit (ICU) after an ischemic stroke, and a central venous pressure (CVP) monitoring line was placed. The nurse notes a low CVP. Which condition is the most likely reason for a low CVP?
Hypovolemia
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 inhibits the development of inflammation.
The nurse will irrigate a patient's nasogastric (NG) tube. Which action should the nurse take?
Immediately aspirate after instilling fluid.
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?
Impaired gas exchange
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
Impaired night vision
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?
Impaired peripheral tissue perfusion
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 skin integrity
A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
Impaired socialization
A nurse is working to prevent blindness. Which preventive action is a priority?
Include rubella and syphilis screening in the preconception care plan.
The nurse is providing nutrition education to a newly immigrated 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
Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy?
Increase fluid intake.
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?
Increased metabolic demands
The nurse is caring for a patient experiencing fluid volume overload. Which physiological effect does the nurse most likely expect?
Increased preload
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect?
Increased skin dryness
When planning care for an adolescent who plays sports, which modification should the nurse include in the care plan?
Increasing carbohydrates to 55% to 60% of total intake
A nurse is teaching a patient about proteins that must be obtained through the diet since they cannot be synthesized in the body. Which term used by the patient indicates teaching is successful?
Indispensable amino acids
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 respond behaviorally and physiologically to painful stimuli.
The health care provider has ordered a high-sensitivity C-reactive protein (hs-CRP) drawn on a client. The results of this test will allow the nurse to evaluate the role of what process that is implicated in the development of atherosclerosis?
Inflammation
A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?
Inform the client that the client will remain on bed rest following the procedure.
A nurse works full time on the oncology unit at the hospital and works part time on weekends giving immunizations at the local chain pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. What initial action should the nurse take to initiate an effective legal defense?
Inform the insurance company that is providing one's professional licensure defense insurance.
The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP?
Informing the nurse if the patient is unwilling to perform exercises
A client has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the client about what process?
Injection of a contrast agent into the knee joint prior to ROM exercises
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered?
Insertion of a ventilation tube
The patient presents to the clinic with reports of irritability and anxiety, being sleepy during the day, chronically not being able to fall asleep, and being fatigued. Which nursing diagnosis will the nurse document in the plan of care?
Insomnia
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
Inspect the wound for bleeding.
A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action?
Instill the medication in the conjunctival sac.
The nurse is caring for a client who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?
Instruct the client to protect the ear from water for several weeks.
The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment?
Instruct the client to walk away from the nurse for a short distance and then toward the nurse.
The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next?
Instruct the patient to call for help to go to the restroom.
A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct?
Instruct the patient to talk with parents about the desire to donate organs.
The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record?
Intake 255; output 375
A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment?
Intracellular
A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?
Intravenous (IV) fluids
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
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.
Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?
Isolate affected residents from residents who have not developed conjunctivitis.
A patient diagnosed with terminal cancer asks the nurse what the criteria are for hospice care. Which information should the nurse share with the patient?
It is for those expected to live less than 6 months.
Which is the best explanation for the nurse to provide when teaching the patient, the reason for the binder after an open abdominal aortic aneurysm repair?
It supports the abdomen.
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?
Jejunostomy tube
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?
Keep a day-by-day calendar at the patient's bedside.
A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?
Kidney, ureters, bladder, urethra
A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition?
Kyphosis
A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient's safety?
Label the tubing that leads to the epidural catheter.
A client presents to the ED reporting a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The client mentions to the nurse experiencing a sudden hearing loss. What would the nurse suspect the client's diagnosis will be?
Labyrinthitis
The nurse is planning the care of a client who is adapting to the use of a hearing aid for the first time. What is the most significant challenge this client is likely to experience?
Learning to cope with amplification of background noise
A nurse is providing postmortem care. Which action will the nurse take?
Leave dentures in the mouth.
A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?
Left midclavicular line of the chest at the fifth intercostal space
A critical care nurse is caring for a client with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill clients?
Left ventricular preload
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
The nurse caring for a postoperative patient will encourage what activity to prevent venous stasis and the formation of thrombus?
Leg exercises
The patient diagnosed with cardiovascular disease is receiving dietary instructions from the nurse. Which information from the patient indicates teaching is successful?
Limit cholesterol to less than 300 mg/daily.
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?
Limit fluid and caffeine intake before bed.
The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?
Limit the length of suctioning to 10 seconds.
A nurse is caring for a dying patient. One of the nurse's goals is to promote dignity and validation of the dying person's life. Which action will the nurse take to best achieve this goal?
Listen to family stories about the person.
A patient is using laxatives 3 times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.
The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem?
Lordosis
Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube?
Lubricate the nares with water-soluble lubricant.
The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?
Maintain the irrigation fluid at a warm temperature.
A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection?
Maintaining a closed urinary drainage system
A nursing assistive personnel (NAP) is caring for a dying patient. Which action by the NAP will cause the nurse to intervene?
Making the patient eat
The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing?
Malignant hyperthermia
The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented?
Managing patient care activities in the OR suite
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
A client with hearing loss is scheduled to undergo aural rehabilitation. When describing this therapy, the nurse would include which information as the primary purpose?
Maximize ability to communicate.
The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?
Meaning of pain
The nurse is monitoring a patient in the post-anesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
Measure and record all intake and output.
The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?
Measure bladder within 15 minutes after the patient voids.
The nurse is planning care for a group of stable patients receiving enteral nutrition. Which task will the nurse assign to the nursing assistive personnel?
Measuring capillary blood glucose level
A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
Metabolic alkalosis
A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool?
Microscopic
A patient is experiencing carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?
Moderate-carbohydrate
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?
Monitor the patient for fever, rash, and difficulty breathing.
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication?
Muscle atrophy
The physical therapist notifies the nurse that a client with coronary artery disease (CAD) experienced a significant increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a client with CAD may result in which outcome?
Myocardial ischemia
A client has had a myocardial infarction and has been diagnosed as having damage to the layer of the heart responsible for the pumping action. This client experienced damage to which area of the heart?
Myocardium
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?
Nasal cannula
Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?
Natural light
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?
No bubbling is present in the suction control chamber of the drainage device.
The nurse is reviewing the health history of a newly admitted client and reads that the client has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the client's plan of care?
No specific assessments or interventions are necessary to address exostoses.
The mother of a child who died recently keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. Which type of grief will the home health nurse recognize the mother is experiencing?
Normal
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?
Notify the health care provider about the patient's question.
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.
The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding?
Obese
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?
Obstructive sleep apnea
A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (AP)?
Obtaining a midstream urine specimen
The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action?
Obtaining an order for digital removal of stool
When administering a client's eye drops, the nurse recognizes the need to prevent absorption by the nasolacrimal duct. How can the nurse best achieve this goal?
Occlude the puncta after applying the medication.
A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?
Offer the patient a back rub.
The patient appears anxious as the nurse is preparing to change their wound dressing. Which action should the nurse take?
Offer to explain what they should expect.
A nurse preparing to start a blood transfusion will use which type of tubing?
One with a filter to ensure that clots do not enter the patient
The patient is prescribed phenazopyridine. When assessing the urine, what will the nurse expect?
Orange color
The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?
Osmosis
A 10-year-old client is growing at a rate appropriate for the client's age. Which cells are responsible for the secretion of bone matrix, which eventually results in bone growth?
Osteoblasts
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?
Oxygen saturation 88%
A bone biopsy has just been completed on a client with suspected bone metastases. The nurse should prioritize assessments for which common complication of bone biopsy?
Pain
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis?
Pain on manipulation of the auricle
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 drinks 1 to 2 glasses of wine every night.
A nurse is caring for a group of patients. Which patient will the nurse see first?
Patient receiving total parenteral nutrition infusing with same tubing for 26 hours
The nurse is caring for a patient diagnosed with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?
Patient will communicate nonverbally.
A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, ―Ow, that was sharp!‖ What conclusion about the child will the nurse come to when interpreting the child's response?
Perception is intact.
A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?
Perceptual
The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?
Perform hand hygiene.
A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?
Perform pelvic floor exercises.
The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond?
Perioperative nursing includes activities before, during, and after surgery.
The patient is experiencing right-sided heart failure. Which finding will the nurse expect when performing an assessment?
Peripheral edema
Which determination is the nurse trying to achieve by monitoring a patient's cardiac output?
Peripheral extremity circulation
A nurse establishing a relationship with the patient who is severely visually impaired is teaching the patient how to contact the nurse for assistance. Which action will the nurse take?
Place a raised Braille sticker on the call button.
The nurse is caring for a patient on the medical-surgical unit who is experiencing an exacerbation of asthma. Which intervention will be most appropriate to help this patient sleep?
Place bed in semi-Fowler's position.
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?
Places colored stickers on faucet handles to indicate temperature.
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?
Placing the drainage bag on the side rail of the patient's bed
The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification?
Poorly controlled hypertension with implanted pacemaker
Before being administered a cleansing enema an 80-year-old patient says ―I don't think I will be able to hold the enema.‖ Which is the next priority nursing action?
Positioning the patient in the dorsal recumbent position on a bedpan
Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?
Postural hypotension
A nurse administering a diuretic to a patient is teaching about foods to increase in the diet. Which food choices by the patient will best indicate successful teaching?
Potatoes and fresh fruit
A nurse is teaching the staff about the sleep cycle. Which period lasts 10 to 30 minutes?
Pre-sleep
Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?
Prealbumin
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?
Preoperative
The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?
Presence of blood in the stool
The nurse caring for an unconscious patient who was involved in an automobile accident 2 weeks ago will give priority to which element when planning care to decrease the development of a decubitus ulcer?
Pressure
The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority?
Pressure points
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve?
Prevent atelectasis.
A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve?
Prevent colon infection.
A nurse on the orthopedic unit is assessing a client's peroneal nerve. The nurse should perform this assessment by doing what action?
Pricking the skin between the great and second toe
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
Primary intention
A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?
Promote positive nitrogen balance.
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
The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian?
Protein
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?
Provide analgesic medication as ordered.
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?
Provide analgesic medications as ordered.
In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?
Provide breast milk or formula for the first 4 to 6 months.
The nurse is providing home care for a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
Provide small, frequent nutrient-dense meals for maximizing kilocalories.
The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient?
Provide the patient with earplugs.
The critical care nurse is caring for a client who has had an MI. The nurse should expect to assist with establishing what hemodynamic monitoring procedure to assess the client's left ventricular function?
Pulmonary artery pressure monitoring (PAPM)
A nurse is caring for a patient with a wound. Which assessment data will be most relevant with regard to wound healing?
Pulse oximetry assessment
The nurse is assessing a patient and notes crackles in the lung bases and neck vein distention. Which action will the nurse take first?
Raise head of bed.
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?
Raising the head of the bed
The nurse is preparing an older-adult patient's evening medications. Which treatment will the nurse recognize as relatively safe for treatment of older adults experiencing sleeping dysfunction?
Ramelteon
A previously toilet trained toddler has started wetting again. A nurse is gathering a health history from the grandparent. Which health history finding will the nurse most likely consider as the cause of the wetting?
Recent parental death
The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
Receptive
A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?
Recording intake and output
A patient is experiencing a fecal impaction. Which portion of the colon will the nurse assess?
Rectum
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
Which health care team member will the nurse consult when a patient has received a nursing diagnosis of Impaired skin integrity?
Registered dietitian
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
A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?
Relaxation and guided imagery
A client's fracture is healing and compact bone is replacing spongy bone around the periphery of the fracture. This process characterizes what phase of the bone healing process?
Remodeling
A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important?
Removing all of the patient's metallic jewelry
A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?
Renal
A nurse is caring for a patient diagnosed with cancer who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?
Replace fluid, electrolytes, and nutrients.
The nurse performing a fecal occult blood test should take what action?
Report a positive finding to the provider.
Which finding will alert the nurse to a potential wound dehiscence?
Report by patient that something has given way
A recent immigrant who does not speak English is alert but requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained?
Request an official interpreter to explain the terms of consent.
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?
Respirations
A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?
Respiratory acidosis
A patient is diagnosed with obstructive sleep apnea. Which assessment is the priority?
Respiratory status
While performing an assessment, the nurse notes that a client has soft subcutaneous nodules along the extensor tendons of the fingers. Which disorder does this client most likely have?
Rheumatoid arthritis
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?
Right ventricle, left atrium, left ventricle
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?
Risk for falls
The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care?
Risk for falls
While reviewing the health history of an older adult experiencing hearing loss the nurse notes the client has had no trauma or loss of balance. What aspect of this client's health history is most likely to be linked to the client's hearing deficit?
Routine use of quinine for management of leg cramps
A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?
SA node
The critical care nurse is caring for a client who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located?
SA node
A client is being discharged home after mastoid surgery. What topic should the nurse address in the client's discharge education?
Safe use of analgesics and antivertiginous agents
A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression?
Salem sump
In providing diabetic teaching for a patient diagnosed with type 1 diabetes mellitus, which instructions will the nurse provide to the patient?
Saturated fat should be limited to less than 7% of total calories.
In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?
Saturated fats are found mostly in animal sources.
Which nursing observation will indicate the patient's wound healed by the process of secondary intention?
Scarring that may be severe
A nurse's assessment reveals that a client has shoulders that are not level and one prominent scapula that is accentuated by bending forward. The nurse should expect to read about which health problem in the client's electronic health record?
Scoliosis
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?
Scope and Standards of Nursing Care
The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient?
Secondary intention
The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown?
Securing attachments to the operating table with foam padding
The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received regional anesthesia in the form of a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient?
Sensation decreased in the left leg
A client has been diagnosed with hearing loss related to damage of the cochlea. What term is used to describe this condition?
Sensorineural hearing loss
The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?
Serum sodium concentration returns to normal.
A nurse is watching a nursing assistive personnel (AP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up?
Sets the scanner to female.
A client is receiving ongoing nursing care for the treatment of Parkinson disease. When assessing this client's gait, which finding is most closely associated with this health problem?
Shuffling gait
A client with a diagnosis of retinal detachment has undergone a vitreoretinal procedure on an outpatient basis. What subject should the nurse prioritize during discharge education?
Signs and symptoms of increased intraocular pressure
A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client?
Sit or stand in front of the client when speaking.
A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?
Situational loss
The nurse is caring for a postpartum patient whose labor lasted over 28 hours. The patient has not slept since delivering and is disoriented to date and time. Which nursing diagnosis will the nurse document in the patient's care plan?
Sleep deprivation
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
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?
Sleeps in hot, stuffy room.
The patient has just started on enteral feedings and is now reporting abdominal cramping. Which action will the nurse take next?
Slow the rate of tube feeding.
The nurse is laboratory blood results will expect to observe which cation in the most abundance?
Sodium
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?
Softly plays music that the patient finds relaxing.
A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record?
Somatic pain
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?
Speaking with hands, face, and expressions
A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?
Specific gravity of 1.036
The nurse is caring for a postoperative patient with an abdominal incision. When the nurse provides a pillow to use during coughing, which activity is the nurse promoting?
Splinting
Which assessment finding is consistent with the diagnosis of malnutrition?
Spoon-shaped nails
The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Stage II
A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action?
Start normal saline at rate to keep vein open using new tubing.
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
The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?
Stoma is purple.
The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response?
Stop the test and monitor the client closely.
Which risk factor for cardiopulmonary disease should the nurse describe as modifiable?
Stress
Which patient diagnosis increases the risk for developing neurogenic dysphagia?
Stroke
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 X heart rate
A client is admitted to a cardiac unit with the diagnosis of syncope. Orthostatic blood pressures are ordered every 8 hours. Which blood pressure readings would best indicate that the nurse should notify the health care provider of a positive finding?
Supine 138/76 mm Hg, sitting 132/66 mm Hg, standing 122/52 mm Hg
The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient?
Surgical debridement of the wound
A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?
Surgical intervention
A nurse is describing the process by which blood is ejected into circulation as the chambers of the heart become smaller. The instructor categorizes this as what action?
Systole
A young adult has been hospitalized for an irregular heartbeat (dysrhythmia). The night nurse makes rounds and finds the patient awake. Which action by the nurse is most appropriate?
Take time to sit and talk with the patient about his/her inability to sleep.
The patient is having at least 75% of nutritional needs met by enteral feeding, so the health care provider has ordered the parenteral nutrition (PN) to be discontinued. However, the nurse notices that the PN infusion has fallen behind. What should the nurse do?
Taper infusion gradually.
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?
Teach the patient about special assistive devices.
A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?
Temperature 101.3F
A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the client's room?
That all furniture remains in the same position
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 CPR procedure was done incorrectly.
The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma?
The client has diabetes.
A nurse is planning preoperative teaching for a client with hearing loss due to otosclerosis. The client is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the client's preoperative teaching?
The client is likely to experience resolution of conductive hearing loss after the procedure.
A client has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this client's health status?
The client needs to be assessed for nasopharyngeal cancer.
An advanced practice nurse has performed a Rinne test on a new client. During the test, the client reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?
The client's hearing is likely normal.
A client's declining cardiac status has been attributed to decreased cardiac action potential. Interventions should be aimed at restoring what aspect of cardiac physiology?
The cycle of depolarization and repolarization
A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client?
The hearing loss will likely resolve with time after the drug is discontinued.
The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation related to the incision will indicate the patient is experiencing a complication of wound healing?
The incision appears both swollen and bluish in color.
The nurse is teaching a client to care for a new ocular prosthesis. What should the nurse emphasize during the client's health education?
The need to perform thorough hand hygiene before handling the prosthesis
A nurse facilitates the transplant coordinator in make a request for organ and tissue donation from the patient's family. What is the primary rationale for the nurse's action?
The nurse is following a federal law.
The registered nurse taking shift report learns that an assigned client is blind. How should the nurse best communicate with this client?
The nurse should state the nurse's name and role immediately after entering the client's room.
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 took actions beyond those that are standard and appropriate.
A resident of a long-term care facility has reported chest pain to the nurse. What aspect of the resident's pain would be most suggestive of angina as the cause?
The pain occurs immediately following physical exertion.
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 can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.
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 is difficult to awaken.
The nurse is evaluating outcomes for the patient diagnosed with insomnia. Which key principle will the nurse consider during this process?
The patient is the best evaluator of sleep.
The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment?
The patient needs increasingly higher doses of opioid to control pain.
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 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 patient reports eliminating a soft, formed stool.
A nurse is caring for a patient diagnosed with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
The patient turns one ear toward the nurse during conversation.
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 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 burns at the grounding pad.
When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient?
The patient will remain free of odorous or purulent drainage from the wound.
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior?
The patient's culture is possibly influencing the patient's experience of pain.
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 need for analgesic medication decreases during the dressing changes.
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 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 nurse is discussing the results of a client's diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?
The sound is heard better in the ear in which hearing is better.
A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?
The test is noninvasive, and nothing will be inserted into the client's body.
A client is postoperative day 6 following tympanoplasty and mastoidectomy. The client has phoned the surgical unit and states experiencing occasional sharp, shooting pains in the affected ear. How should the nurse best interpret this client's report?
These pains are an expected finding during the first few weeks of recovery.
A client comes to the ophthalmology clinic for an eye examination. The client tells the nurse that the client often sees floaters in the client's vision. How should the nurse best interpret this subjective assessment finding?
This is a normal aging process of the eye.
The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?
This is an accurate indicator of myocardial injury.
The post-anesthesia 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 compare and monitor for vital sign variation during transport.
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
Tingling of extremities with possible tetany
The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. The nurse should explain that cardiac catheterization is most commonly done for which purpose?
To assess how blocked or open a client's coronary arteries are
The critical care nurse is caring for a client with a pulmonary artery pressure monitoring system. In addition to assessing left ventricular function, what is an additional function of a pulmonary artery pressure monitoring system?
To assess the client's response to fluid and drug administration
The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why they have to take an aspirin every day if they don't have any pain. Which rationale for this intervention would be the best?
To help prevent blockages that can cause chest pain or heart attacks
A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. Which is the best action by the nurse at this time?
Try other approaches to prevent the patient from touching these care items.
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?
Turkey sandwich on whole wheat bread and iced tea
When assessing a client's peripheral nerve function, the nurse uses an instrument to prick the fat pad at the top of the client's small finger. This action will assess what nerve?
Ulnar
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?
Undercooked ground beef
An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care?
Urge urinary incontinence
A terminally ill patient is experiencing constipation secondary to pain medication. Which is the best method for the nurse to improve the patient's constipation problem?
Use a laxative.
Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?
Use a mobility device to place the patient on a bedside commode.
To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do?
Use room temperature irrigation solution.
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?
Use the FACES scale.
A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. Which action is most appropriate for the nurse to take?
Use the book as needed while keeping it away from individuals not involved in patient care.
A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?
Uses chlorhexidine skin antisepsis prior to insertion.
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?
Utilize a transfer device to lift the patient.
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
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
The nurse is concerned about pulmonary aspiration when providing care to the patient with an intermittent tube feeding. Which action is the priority?
Verify tube placement before feeding.
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?
Visceral pain
The nurse is completing a sleep assessment on a patient. Which tool will the nurse use to complete the assessment?
Visual analog scale
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
Warfarin
The nurse is caring for a patient receiving total parenteral nutrition (TPN). Which action will the nurse take?
Wear a sterile mask when changing the central venous catheter dressing.
The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?
Weigh the patients every morning before breakfast.
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.
The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment?
Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately
A child goes to the school nurse and reports being unable to hear the teacher. What test could the school nurse perform that would preliminarily indicate hearing loss?
Whisper test
A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure?
Wrap the joint in a compression dressing.
A patient has had two family members die during the past 2 days. Which coping strategy is most appropriate for the nurse to suggest to the patient?
Writing in a journal
A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?
X-ray
The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
Xerostomia
Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. Which phase does the nurse determine the family is in according to the Attachment Theory?
Yearning and searching
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
The critical care nurse is caring for a client with a central venous pressure (CVP) monitoring system. The nurse notes that the client's CVP is increasing. This may indicate:
hypervolemia.
A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause?
infection
A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure?
lacrimal apparatus
A nurse is interviewing a middle-aged client at the clinic. During the interview, the client states, "I've noticed that I keep having to move the newspaper farther away to read it. Soon my arms will be too short!" The nurse interprets this finding as indicative of which age-related change?
loss of accommodation
A nurse is assisting the ophthalmologist who is performing direct ophthalmoscopy. When conducting this examination, which structure would the nurse expect to be examined last?
macula
The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?
pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?
pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L
While inspecting the external eye of a client, the nurse notes that the client's right eyelid droops. Which term would the nurse use to document this finding?
ptosis
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of:
spasticity.
The nurse is providing discharge education for a client with a new diagnosis of Ménièredisease. What food should the client be instructed to limit or avoid?
sweet pickles
A older adult client comes to the clinic for an evaluation. The client says, "It just doesn't seem like I hear as well as I used to hear." As part of the assessment, the nurse evaluates the client's gross auditory acuity. Which test would the nurse most likely conduct?
whisper test
Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?
―Are you able to prepare a meal or write a check?‖
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?
―As adults age, their ability to perceive pain decreases.‖
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?
―Deep breathing and coughing will clear your lungs of the anesthesia.‖
Which assessment question should the nurse ask if stress incontinence is suspected?
―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?
―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?
―Drink your nightly glass of milk earlier in the evening.‖
An Orthodox Jewish rabbi has been pronounced dead. The nursing assistive personnel respectfully ask family members to leave the room and go home as postmortem care is provided. Which statement from the supervising nurse is best?
―Family members stay with the body as part of the mourning ritual.‖
The nurse is beginning a sleep assessment on a patient. Which question will be most appropriate for the nurse to ask initially?
―How are you sleeping?‖
A patient receiving chemotherapy has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate?
―How many times a day do you urinate?‖
The nurse is describing the My Plate program to a patient. Which statement from the patient indicates successful learning?
―I can use this to make healthy lifestyle food choices.‖
A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?
―I feel less anxiety about the possibility of overdosing.‖
A patient is experiencing sleep deprivation. Which statement by the patient will indicate to the nurse that outcomes are being met?
―I feel rested when I wake up in the morning.‖
A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management?
―I need to reassess the patient's pain 1 hour after administering oral pain medication.‖
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 really need a bath and linen change right; I feel so awful.‖
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.‖
The nurse is teaching a new mother about the sleep requirements of a neonate. Which comment by the patient indicates a correct understanding of the teaching?
―I will ask my mom to come after the first week, when the baby is more alert.‖
Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching?
―I will be anesthetized so that I lie perfectly still during the procedure.‖
The nurse explains the pain-relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic?
―I will have minimal pain because of the anesthesia.‖
A patient cancels a scheduled appointment because they will be attending a Shivah for a family member. Which response by the nurse is best?
―I'm so sorry for your loss.‖
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?
―If I get a blue color that means the test is negative.‖
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 central nervous system, it can influence the functions of sleep.‖
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?
―If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot.‖
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
―It is important to do breathing exercises every hour to prevent atelectasis.‖
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?
―Let me check with someone here in the hospital who can assist you.‖
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 controls pain by blocking pain impulses from coming through the gate.‖
A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse ―Should I stop driving?‖ Which response by the nurse is most therapeutic?
―No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.‖
A parent is discussing the sleep needs of a preschooler with the nurse. Which information will the nurse share with the parent?
―Preschoolers may have trouble settling down after a busy day.‖
A nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient?
―Rinse your mouth several times a day to hydrate your taste buds.‖
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?
―Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated.‖
The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?
―Use your hand to support your incision.‖
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?
―We recommend including family members at this appointment.‖
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?
―We should work together to create a schedule to provide regular dosing of medication.‖
The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate?
―What activities, if any, has your pain prevented you from doing?‖
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?‖
Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate?
―When was the last time you voided?‖
The nurse has brought a patient the scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?
―Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?‖
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 professional nurse.‖
A female nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while working as a nursing assistant. Which advice is best for the nursing faculty member to give to the nursing student?
―You are not allowed to perform any procedures other than those in your job description even with the nurse's permission.‖
The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching?
―You cannot use a pain scale to compare the pain of my patient with the pain of your patient.‖
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?
―You need to drink plenty of fluids and eat a diet high in fiber.‖
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 doesn't send enough oxygen to your fingers.‖