Fun Exam 3 Practice Test/Questions/Study
Levels of preventive care
primary, secondary, tertiary
A pt who has an indwelling catheter reports the need to urinate. What action should the nurse take?
Check to see whether the catheter is patent (A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate)
A nurse is implementing a bladder retraining program for a client. What action should the nurse take?
Encourage the client to hold their breath when feeling the urge to urinate (The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate)
What strategy should the nurse use to establish a helping relationship with a pt?
Encourage the pt to communicate his thoughts and feelings. (Therapeutic communication facilitates a helping relationship that maximizes the pt's ability to express his thoughts and feelings openly)
A nurse is assessing a client who reports acute pain. The nurse should anticipate:
An increased heart rate. (Acute pain stimulates the sympathetic nervous system and can cause an increase in heart rate)
A pt who is having burn debridement states "you are the worst nurse i've ever seen. All you do is hurt me" What response should the nurse make?
"Tell me more about that" (This statement asks the pt to talk about the problem. The nurse is not threatened and is open to hearing more about the problem. Whether the pt's statement is true or false, the pt will be able to open up and talk about the feelings that caused the outburst. The nurse will be able to adapt care based upon better input and insight into the pt's problem)
A nurse is caring for a pt within the intimate zone of the pt's personal space. What activities can be performed in this space?
-Auscultating heart sounds (Auscultating heart sounds within 18 inches of the pt, which is within the intimate zone of the pt) -Changing a dressing. (Dressing changes occur within 18 inches of the pt's intimate space)
A nurse is caring for a 3 year old child whose parents report that she has an intense fear of painful procedures like injections. What strategies should the nurse add to the client's plan of care?
-Have a parent stay with the child during the procedure. (Maintaining parent-child contact is one of the more supportive interventions for toddlers and preschoolers undergoing painful procedures) -Perform the procedure as quickly as possible. (Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures) -Allow the child to keep a toy from home with her. (Having familiar and cherished objects nearby is therapeutic for children during hospitalization)
A nurse is providing palliative care to a client whose partner asks why music therapy might help her. How should the nurse respond?
-Music therapy can help her verbally express emotions. (Music therapy helps improve communication and develop emotional expression) -Music therapy works as a distraction and can help alleviate her pain. (Music therapy helps distract people from pain. Music often calms and relaxes clients, diverting their attention away from the pain) -Music therapy can help facilitate movement in some clients who have mobility limitations. (Music therapy improves physical movement, especially for clients who are ill or have disabilities)
A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. What actions should the nurse take?
-Offer the pt a back rub (non pharmacological comfort measures can improve pain management) -Remind the pt to use incisional splinting (holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain) -Identify the pt's pain level. (nurse should use a standard scale to determine and document the severity of the pt's pain) -Change the client's position (Non pharmacological measures for managing pain include repositioning, imagery, and distraction)
Sequence of actions to preparing suction to a pt who has a tracheostomy.
1. Adjust suction 2. Don sterile drugs 3. Check the function of the suction catheter by suctioning a small amount of solution into the tubing. 4. Ask a peer to hyper oxygenate the pt by using a manual resuscitation bag valve mask connected to oxygen. 5. Insert the suction catheter w/o suction 6. Apply suction for no more than 10 seconds while rotating the catheter. 7. Assess for clearance of secretions.
What is the correct sequence for taking blood glucose on a diabetic pt?
1. Check expiration date on test strips 2. Perform a quality control test 3. Perform hand hygiene. 4. Cleanse puncture site 5. Apply blood sample to test strip 6. Document results.
A nurse is preparing to administer penicillin IM to an adult pt. What angle should the nurse use for injection into the pt's ventrogluteal muscle?
90 degree angle. (With this angle, the nurse will deposit the medication deeply into the muscle to ensure rapid absorption of the medication due to the vascularity of the muscle)
Basic Learning Principals: Motivation to learn
Address the pt's desire or willingness to learn
A nurse is caring for an older adult pt who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. What action should the nurse take first?
Allow the pt to take a bath in the evening (When providing nursing care, the nurse should use the least restrictive intervention. Of these options, allowing the pt to follow their usual bedtime routine represents the least change, so it is the first intervention to try)
Basic Learning Principals: Learning Environment
Allows a person to attend to instruction.
A nurse is caring for a pt who has urinary incontinence. What action should the nurse implement to prevent the development of skin breakdown?
Apply a moisture barrier ointment to the pt's skin. (Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the pt's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine)
A nurse is caring for a pt who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. What action should the nurse take?
Apply the bag for 30 minutes at a time. (The nurse should leave the ice bag on for 30 minutes, but should check the pt's skin after 15 minutes to make sure there are no adverse effects)
A nurse is caring for a who has a mental health disorder. The pt asks about his medication and their effects. The nurse asks the client why he needs to know this. What non therapeutic communication technique is the nurse using?
Asking for an explanation. (The use of a "why" question requires that the pt provide an explanation that he may not have, causing him to become defensive. A better response would be to give a reasonable answer to the question and clarify any additional concerns the pt has)
Barriers to effective communication
Asking irrelevant personal questions Offering personal opinions Giving advice Giving false reassurance Minimizing feelings Changing the topic Asking "why" questions Offering value judgments Excessive questioning Responding approvingly or disapprovingly Testing Judging Being defensive Offering sympathy Arguing
A nurse is applying a cold compress for a pt who has pain and minor swelling in a sutured laceration on the forearm. What assessment should the nurse use to determine whether the treatment is effective?
Asking the pt to rate the pain. (Pain is a subjective experience. The nurse should encourage the pt to quantify the pain on a scale before, during, and after cold application to determine it's effectiveness)
A nurse is preparing to administer a pre-packaged oral medication to a pt and complete the final check of medication. Where should the nurse perform the final medication check?
At the pt's bedside before administration. (The nurse should perform the final med check at the bedside while reviewing the packages label)
Cleaning skin and drain sites
Basic Skin Cleaning Clean from least contaminated to the surrounding skin Use gentle friction When irrigating, allow the solution to flow from the least to most contaminated area
A nurse is monitoring a pt who is receiving opioid analgesia for adverse effects of the medication. Which effects should the nurse anticipate?
Bradypnea (respiratory depression is common. the nurse should monitor the pt's respiratory rate, and administer naloxone if needed) Orthostatic hypotension (The nurse should monitor the pt for dizziness or lightheadedness when changing positions) Nausea The nurse should monitor for and treat these complications PRN)
A nurse is caring for a pt who is receiving hydromorphone HCL via a PCA pump and reports continuous pain of 6 on a scale of 1-10. What action should the nurse preform first?
Check the display on the PCA pump. (The first action the nurse should take would be assessing the pt, which would mean assessing the display on the PCA pump would be first to determine the amount of medication that is being administered. Some pt's are fearful of developing an addiction to narcotics and may be reluctant to the use of the PCA)
A nurse is caring for a pt who has a wound infection. What action should the nurse take when obtaining a wound-drainage specimen for culture?
Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (The nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results).
Interpersonal communication
Communication between two people. Most common in nursing, requires an exchange of information with another individual. * Note: messages the receiver perceives can differ from what the sender intended*
Transpersonal Communication
Communication that addresses spiritual needs and provides interventions to meet these needs (prayer, meditation).
Public Communicaton
Communication with groups of people.
intrapersonal communication
Communication within an individual, "self talk"
A pt who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. What action should the nurse take?
Cover the area with saline-soaked sterile dressings (the nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene) Position the pt supine with his hips and knees bent (This position minimizes pressure on the abdominal area)
A nurse is caring for a pt who requires removal of surgical sutures. What action should the nurse take when removing the sutures?
Cut the sutures as close to the skin as possible. (The nurse should grasp the surgical knot with tweezers and gently lift while cutting below the suture knot. To avoid contamination, the nurse should never pull the visible portion of a suture through underlying tissue. The part of the sutures that is exposed on the skin surface harbors micro-organisms and debris and pulling on the contaminated portion of the suture through the tissue can lead to infection).
A nurse in a provider's office is evaluating a pt who reports losing control of urine whenever she coughs, laughs, or sneezes. The pt relates a history of three vaginal births, but no serious accidents or illnesses. What intervention should the nurse suggest for helping to control or eliminate the pt's incontinence?
Decrease or avoid caffeine Avoid drinking alcohol (both are bladder irritators and can worsen urinary incontinence)
Basic Learning Principals: Ability to learn
Depends on physical and cognitive abilities, developmental level, physical wellness, thought process.
Internal Variables that influence health and health beliefs/practices
Developmental stage Intellectual Background (education) Perception of functioning (how they think) Emotional factors (stress, coping, illness) Spiritual factors
A nurse is caring for a pt who has a prescription for 24 hour urine collection. What action should the nurse take?
Discard the first voiding. (The nurse should discard the first voiding of the 24 hour urine specimen and note the time)
A nurse is caring for a pt who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material.
Dispose of the dressing in a biohazards waste container. (The nurse should discard potentially infective material, such as the dressing containing pus, in a biohazards materials container separate from regular trash.
A nurse in a provider's office is caring for a pt who states that, for the past week, she has felt tired during the day and cannot sleep at night. What should the nurse ask when collecting data about the pt's difficulty sleeping?
Does your lack of sleep interfere with your ability to function during the day? (Daytime sleepiness, which can interfere with functioning, is common during the day when people can not sleep at night) Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day? (Caffeinated drinks act as a stimulant and can interfere with sleep) Has anyone ever told you that you seem to stop breathing for a few seconds while you sleep? Periods of apnea warrant a prompt referral for diagnostic sleep studies) Tell me about any personal stress you are experiencing. (Emotional stress is the most common cause of short term sleep problems)
A nurse is developing a plan of care for a pt who has cellulitis of the leg. What intervention should the nurse include in the plan?
Elevate the affected leg on two pillows. (Cellulitis is an acute inflammation of the deep connective tissue of the ski, caused by infection. The edema of the inflammatory response puts the pt at risk for skin breakdown. Elevation of the affected area and frequent repositioning reduces dependent edema and assists in the healing process).
Interpersonal variables (communication)
Factors that influence communication between the sender and the receiver, such as educational and developmental levels.
External Variables that influence health and health beliefs/practices
Family practices Socioeconomic factors Cultural background
A pt who has a femur fracture states "I can't stay in this bed any longer. I need to go home so I can take care of my family." The nurse responds with "you have talked about your family several times. Can you tell me more about your specific concerns?" What type of therapeutic communication is the nurse using?
Focusing. (The open-ended statement is means of focusing in on the problem and obtaining more information about the pt's concerns. Focusing helps the nurse to zero in on a topic to identify the issues and concerns clearly)
A nurse is reviewing factors that increase the risk of UTI's with a pt who has recurrent UTI's. Which of the following factors should the nurse include?
Frequent sexual intercourse (both men and women) Location of the urethra in relation to the anus (The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs) Frequent catheterization
A nurse withdrawals porphine 2 mg from a 4 mg/mL vial to inject IM for a pt. What action should the nurse take for wasting the excess medication?
Have a second nurse witness the disposal of the excess medication. (Morphine is a controlled substance. Policies vary with the facility, but the nurse must have another nurse witness the disposal of unused portions of doses of controlled substances)
A nurse is preparing to initiate a bladder-retraining program for a pt who has incontinence. What actions should the nurse take?
Have the pt record urination times (The nurse should ask the pt to keep track of urination times as a record of progress towards the goal of 4 hour intervals between urination) Gradually increase the urination intervals (Gradually increasing the urination intervals helps the pt progress towards the goal of 4 hour intervals between urination) Remind the pt to hold urine until the next urination time. (The nurse should remind the pt to hold urine until the next scheduled urination as part of progressing towards the goal of 4 hour intervals between urination).
A nurse is preparing to administer ophthalmic solution to a pt. What action should the nurse take?
Hold the ophthalmic solution 2 cm above the lower conjunctival sac. (Lower inner corner of the eye)
A nurse is teaching a pt who is perimenopausal and has recurrent lower back pain. What client statement indicates an understanding of the teaching from the nurse?
I should keep my weight within 10 percent of my ideal weight. (Excessive body weight can place increased stress on the structures of the lower back. The nurse should evaluate the pmts weight and make a plan for weight reduction if needed to ease the stress on the clients lower back)
A nurse is teaching a pt who had a total knee arthroplasty about self administering morphine via a PCA infusion device. What pt statement indicates an understanding of the teaching?
I should tell the nurse if i can't control my pain with this device. (PCA is a method of delivering pain medication through an electronic infusion device that allows the pt to self-administer pain meds on an as needed basis. The pt should notify the nurse if pain control is not achieved. The nurse can initiate a re-evaluation of the pt's pain management plan)
A nurse is caring for a pt who is receiving morphine via a PCA infusion device after abdominal surgery. What statement indicates that the pt knows how to use the device?
I should tell the nurse if the pain doesn't stop while I'm using the device. (PCA allows the pt to self-administer pain medication on an as-needed basis. If the pt is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the pt's pain management plan and possible dosage change)
A nurse is providing information about pain control to a pt who has acute pain following a subtotal gastric resection. What pt statement indicates an understanding of pain control?
I will call for pain medication before the previous dose wears off. (Before the pain becomes severe).
A nurse is instructing a client who has a new diagnosis of narcolepsy about measures that might help with self-management. What statement should the nurse identify as an indication that the client understands the instructions?
I'll take a short nap whenever i feel a little sleepy (PT's who have narcolepsy should take short naps to reduce the feelings of drowsiness).
A nurse instructs a female pt about collecting a midstream urine sample. What would the pt say that would indicate an understanding of the procedure?
I'll use a cleansing wipe from front to back. (The client should cleanse the peri area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus)
A nurse is caring for an adolescent pt who is 2 days postoperative following an appendectomy and has type 1 diabetes. The pt is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain meds every 6-8 hours while reporting the pain at a 2 on a scale of 0-10 after receiving the medication. His incision is approximated and free of redness, with can't serous drainage on the dressing. The nurse should recognize that the pt has what risk factor for impaired wound healing?
Impaired circulation (due to diabetes, he pt has impaired circulation) Impaired/suppressed immune system (due to diabetes)
A nurse is collecting data from a pt who is 5 days post-op following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. What findings should the nurse expect?
Increase in incisional pain (an increase in pain and tenderness at the wound sight would be expected with an incisional infection) Fever and chills (Expected with incisional infection) Reddened wound edges (Reddened or inflamed edges are expected with an incisional infection).
When administering regular insulin mixed with NPH insulin, what is the first action a nurse should take?
Inject air into the NPH first (Inserting air into the NPH insulin occurs first because this insulin is intermediate-acting insulin, which will be drawn up last in order to avoid contaminating the regular insulin with NPH insulin).
A nurse is planning on administering an IM injection into a pt's deltoid muscle. What action should the nurse take?
Inject the medication at a 90 degree angle. (The nurse should inject the medication at a 90 degree angle to reduce the risk of injecting into subcutaneous tissue)
A nurse is caring for a pt who reports difficulty sleeping while in the hospital. How can the nurse instruct the assistive personal in creating an environment that aids in the pt's ability to sleep?
Instruct the AP to not flush the toilet while the pt is asleep. (Clients often do not get enough sleep while in the hospital. One of the biggest reasons for sleep deprivation is due to noise. Staff should avoid flushing toilets, reduce the volume of telephones and paging systems, and turn down alarms when possible)
A nurse is caring for an older adult pt who is at risk for developing pressure ulcers. Which intervention should the nurse use to help maintain the integrity of the pt's skin?
Keep the head of the bed elevated 30 degrees. (The nurse should slightly elevate the head of the bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels) Have the pt sit on a gel cushion when in a chair (The nurse should have the client sit on gel, air, or foam cushion to redistribute weight away from ischial areas)
A nurse is working in an ER room assessing a pt who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue is visible. How should she document this wound?
Laceration (Lacerations are open wounds of varying depths caused by a tearing of soft body tissues. The edges are often jagged or irregular. Lacerations are often considered contaminated wounds before of the introduction of bacteria or debris that can be in the wound).
A nurse is preparing medication for a pt when another pt has an emergency. What should the nurse do with the medication?
Lock the medication in a room and finish preparing it after returning from the emergency. (No one else should have access to or administer medications the nurse has prepared. Securing them and returning later to finish preparing and administering them decreases the risk of medication errors)
A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male pt. What would indicate intervention needed by charge nurse?
Lubricates the first 2.5-5 cm of the catheter. (The nurse should lubricate the first 15 to 17.5 cm (6-7 inches) of the catheter when inserting it into a male pt)
A nurse is preparing to administer nalbuphine to a postoperative client who is experiencing pain. The nurse should monitor the pt for what potential adverse effect of this medication?
Miosis (Adverse effects of nalbuphine include visual disturbances such as miosis, blurred vision, and diplopia).
A nurse is assessing a pt with a pressure ulcer. The nurse should recognize it as being a stage 3 pressure ulcer how?
Necrotic subcutaneous tissue. (Manifestations of a stage 3 pressure ulcer can include full thickness skin loss with necrotic subcutaneous tissue).
A nurse is collecting data from a pt who is reporting pain despite taking analgesia. What action should the nurse take to determine the intensity of the pt's pain?
Offer the pt a pain scale to measure his pain. (The nurse should use a pain rating scale to help the pt report the intensity of his pain. The nurse should use a numeric, verbal, or visual analog scale to appropriate the pt's individual needs)
Scientific Knowledge Base: Wound Classifications-Wound healing
Partial thickness wounds: shallow in depth, moist and painful, wound base generally appears red Full thickness wounds: Extends into the subcutaneous layer, and the depth and tissue type will depend on body location.
When entering a pt's room to change a surgical dressing, a nurse notes that the pt is coughing and sneezing. What action should the nurse take when preparing the sterile field?
Place a mask on the pt to limit the spread of micro-organisms into the surgical wound. (This prevents the micro-organisms from entering the wound during the wound cleaning)
Risk Factor Modification and Changing Health Behaviors
Pre-contemplation, contemplation, preparation, action, maintenance.
A nurse at a clinic is collecting data about pain from a pt who reports severe abdominal pain. The nurse asks the pt whether he has nausea and has been vomiting. What pain characteristics is the nurse attempting to determine?
Presence of associated manifestations. (The nurse should attempt to identify manifestations that occur along with the pt's pain, such as nausea, fatigue, or anxiety)
A nurse is caring for an older pt who is at risk for skin breakdown. What intervention should the nurse use to help maintain the integrity of the pt's skin?
Provide the client with a diet high in protein. (Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown).
A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, what characteristics should the nurse include?
REM sleep provides cognitive restoration (cognitive and brain tissue restoration occur during REM sleep) It's difficult to awaken a person in REM sleep (In this stage, awakening is difficult. Awakening is relatively easy in stages 1 and 2 of non-REM sleep) Vivid dreams are common during REM sleep (Dreaming does occur in other stages, but it is less vivid and possibly less colorful)
Elements of the communication process Functional Components
Referent: The incentive or motivation for communication btwn two people Sender: Person who initiates the message Receiver: Person who the sender aims the message and who interprets the message. Message: Verbal or nonverbal information the sender expresses and intends for the receiver Channel: Method of transmitting and receiving message (sight, touch, hearing, facial expression, body language) Environment: Emotional and physical climate in which the communication takes place Feedback: Can be verbal, nonverbal, positive or negative. Interpersonal variables: factors that influence communication btwn the sender and receiver, such as educational and developmental levels.
A nurse is caring for a pt who states "I have to check with my wife and see if she thinks i'm ready to go home." The nurse replies with "How do you feel about going home today?" What clarifying technique is the nurse using to communicate with the pt?
Reflecting (Reflecting directs the focus of the conversation back to the pt so that he can further explore his own feelings)
A nurse is planning care for a pt who is confined to a bed. What should the nurse include in the plan?
Reposition every two hours. (Changing positions every two hours help stimulate circulation and prevent pressure ulcers).
A nurse is preparing to administer an IM injection of meperidine to a pt. What priority assessment should the nurse complete?
Respiratory Rate (ABC's are the priority focus of the nurse at this time. Meperidine can cause respiratory depression and the client's respiratory rate should be monitored prior to administering this medication)
A nurse is caring for a pt who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hours as needed. Before administering this medication, the nurse should complete which priority assessment?
Respiratory Rate (The priority action the nurse should take when using the ABC's approach to pt care is to evaluate the pt's respirations. The resp. rate is especially important because of opioid analgesics like morphine can cause respiratory depression.
Clarifying techniques
Restating: uses the pt's exact words Reflecting: Directs the focus back to the pt for him to examine his feelings Paraphrasing: restates the pt's feelings and thoughts for him to confirm what he has communicated Exploring: Allows the nurse to gather more information about important topics the pt has mentioned.
A nurse is monitoring a pt who is postoperative and unable to respond to questions. What nonverbal behaviors should the nurse identify as indications that the pt has pain?
Restlessness (pt's who have uncontrolled pain often become restless and anxious in response to the discomfort) Grimacing (Facial movements such as grimacing, tightly closed eyes, and biting the lower lip are behavioral indications of pain) Clenching (Clenching the teeth and biting the lower lip are common findings in pt's who have pain)
A nurse is assessing a pt who has a new skin lesion that has a wavy border. The nurse should document the lesion using what description?
Serpiginous (wavy boarder that resembles a snake).
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, what action should the nurse take?
Sit at eye level with the child (Sitting at the child's eye level helps facilitate effective communication while making the child feel comfortable)
Scientific Knowledge Base: Surgical Risk Factors
Smoking Age Nutrition Obesity Obstructive sleep apnea Immunosuppression Fluid and electrolyte imbalance Postoperative nausea and vomiting Venous thromboembolism
Stages of pressure ulcer
Stage 1- skin is unbroken but appears red and no blanching when pressured. Stage 2- skin is broken and their is superficial skin loss. Stage 3- crater like wound with loss of dermis, epidermis, and subcutaneous tissue. Stage 4- deep wound that involves dermis, epidermis, subcutaneous and muscle and or bone.
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which alterations for wound healing by secondary infection?
Stage III pressure ulcer (open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges) Open burn area (Open burn areas heal by secondary intentions, which is the process for wounds that have tissue loss and widely separated edges)
A nurse is caring for a pt who is receiving heat applications using an aquathermia pad. What action should the nurse take when applying the pad?
Stop the treatment if the pt's skin becomes red (reactions such as unusual pain or redness are indications for removing the pad and notifying the provider)
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. What action should the nurse take?
Suction 2-3 times with a 60 second pause between passes (Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia)
A nurse is caring for a pt who reports lower back pain and asks the nurse for specific exercise recommendations. What should the nurse suggest?
Swimming (Some exercises, like swimming and walking, can help pt's who have lower back pain because they can strengthen back muscles)
A nurse is teaching a pt who has a new prescription for ibuprofen to treat hip pain. What instruction should the nurse include in teaching?
Take meds with food (To minimize gastric irritation, the pt should take the ibuprofen with food or immediately after a meal)
A nurse is administering nasal decongestant drops for a pt. What action should the nurse take?
Tell the pt to blow their nose gently before instillation. (Prior to instillation, the nurse should instruct the pt to blow their nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication)
A nurse is caring for a pt who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the pt's pain?
The clients self-report of pain severity. (Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the pt says it is, and to intervene accordingly)
A nurse has removed a sterile pack from outside its cover and placed it on a clean work surface in preparation for an invasive procedure. Which flap should the nurse unfold first?
The flap furthest from the body. (The priority goal in setting up a sterile field to maintain sterility and thus reduce the risk to the pt safety. Unless the nurse pulls the top flap (furthest from body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it).
A nurse is reviewing the lab results of a pt who has a pressure ulcer. An elevation of what lab value is an indication that the pt has developed an infection?
WBC count (An elevation of WBC count (leukocytosis) indicates that the pt's immune system is defending them against the pathogens causing an infection)
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. What object can the nurse touch without breaching sterile technique?
The inner wrapping of an item on the sterile field (The inner wrappings are sterile and can be touched while maintaining sterility) An irrigation syringe on the sterile field (Since the nurse dropped it into the sterile field, it can be touched) One gloved hand with the other gloved hand (one sterile gloved hand may touch the other sterile glove because they are both sterile)
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. What event should the nurse recognize as contaminating the sterile field?
The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field (Fluid permeation of the sterile drape or barrier contaminates the field) The procedure is delayed 1 hour because the provider receives an emergency call (Prolonged exposure to air contaminates the sterile filed) The nurse turns to speak to someone who enters through the door behind the nurse. (Turning away from a sterile field contaminates the field because the nurse can not see if a piece of clothing or hair made contact with the field)
A nurse is discussing the care of a group of pt's with a newly licensed nurse. Which of the following pt's should the newly licensed nurse identify as experiencing chronic pain? A pt who has a broken femur and reports her pain. A pt who has incisional pain 72 hr following pacemaker insertion. A pt who has food poisoning and reports abdominal cramping. A pt who has episodic back pain following a fall 2 years ago.
The pt who has episodic back pain following a fall two years ago. (A pt that has pain that lasts more than 6 months and continues beyond that time of tissue healing is experiencing chronic pain. The nurse should identify this pt's pain as chronic, and assist with planning interventions to relieve manifestations associate with the pain)
A nurse provides a back massage as a palliative care measure to a pt who is unconscious, grimacing, and restless. What should the nurse identify as indicating a therapeutic response?
The shoulders drop (A back rub promotes relaxation, relieves muscle tension, and decreases perception of pain. Relaxation or dropping of the shoulders is a positive response to the backrub) The facial muscles relax (Relaxed facial muscles are a positive response to a back rub). The pulse is within the expected range (Pulse rates increase with acute pain. A pulse within the expected range indicates a positive response to the back rub).
A nurse is engaging in relationship counseling with a male client. What is a characteristic of men that the nurse should consider when beginning the nurse-client relationship?
They are more direct when discussing issues. (Men focus on issues and discuss them more directly and readily than women do)
What actions should the nurse take when using the communication technique of active listening?
Use an open posture (Having an open posture, facing the pt, and leaning forward are ways the nurse can demonstrate active listening) Establish and maintain eye contact Respond positively when giving feedback.
A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. What instruction should the nurse include?
Use soap and water to clean the catheter after each use (washing and storing in a clean container after every use will help minimize the chance of infection)
A nurse is teaching a pt about how to use a PCA (patient controlled analgesia) pump. What instruction should the nurse give?
Use the pain scale to determine if you need to self administer. (The nurse should instruct the pt to use the pain scale to rate his pain level before self-administering a bolus dose. A bolus dose is the amount of medication received when the client self-administers the opioid. The nurse should monitor the client to determine if the bolus dose is too high or low or if the interval is too short or too long)
A nurse is providing teaching to a pt who has a skin infection and a new prescription for gentamicin topical cream. What instruction should the nurse provide?
Wash the affected area with soap and water before applying cream. (Washing it with soap and water, and drying it thoroughly before applying the cream removes any oils or moisture, so the medication can be used to its maximal potential)
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). What instruction should the nurse include when discussing hand washing?
Wash the hands with soap and water for at least 15 seconds (This is the amount of time it takes to remove transient flora from hands. For soiled hands the recommendation is two minutes) Use a clean paper towel to turn off faucets. (If the sink does not have a foot or knee pedals, the AP's should turn off the water with a clean paper towel and not with their hands).
A nurse is administering 1 mg of hydromorpone IV to a pt. The available dose is 2 mg/ml. What should the nurse do with the remaining medication?
Waste the medication in the presence of another nurse. (Immediately following administration, the nurse should ask another nurse to witness the disposal of the unused medication. If paper records are used, each nurse should sign his/her name. If computerized systems are used, each nurse should sign his/her name electronically)
A charge nurse is observing a nurse performing a Mantoux TB skin test for a pt. Why would a nurse need to intervene?
When the nurse administering the test withdrawals the needle and massages the site gently. (The nurse should apply gentle pressure, not massage, after the injection. massage can dispose the testing substance beyond the bleb or cause it to leak out of the puncture site).
A nurse is teaching a pt who has a new prescription for codeine. What instructions should the nurse include in teaching?
You should change positions slowly. (To avoid the risk of falls. Codeine is an opioid analgesic that causes CNS depression and orthostatic hypotension)
A nurse is teaching a pt who has a UTI and is taking ciprofloxacin. What instruction should the nurse provide?
You should report any tension discomfort you experience while taking this medication. (Tendon discomfort, swelling, and inflammation of the tendons is due to the risk of tendon rupture and should be reported to the provider)
A nurse is caring for a pt who is concerned about his impending discharge home with a new colostomy because he is an avid swimmer. What statements should the nurse make?
Your daily routines will be different when you get home. (Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made) Tell me about your support system you'll have after you leave the hospital. (Asking open ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the pt to express feelings through dialogue and offer additional information). Let me tell you about a friend of mine with a colostomy who also enjoys swimming. (Offering self is an effective communication technique that can convey understanding and share another's experience with the pt. However, the nurse should return the focus to the pt as soon as she communicates the relevant point)
A nurse is caring for a pt who is using a PCA pump for postoperative pain management. The nurse entered the room to find the pt asleep and his partner pressing the button to dispense another dose. What should the nurse's response be?
Your husband should decide when more medication is needed. (The nurse should explain to the pt's partner that the pt is the only one who should operate the PCA pump. In situations where the pt is not able to do so, the provider may authorize a nurse or family member to operate the pump)
Complications of wound healing
hemorrhage, infection, dehiscence, evisceration
Risk factors for pressure ulcer development
impaired sensory perception, impaired mobility, altered level of consciousness, shear, friction, moisture
