Fundamentals Exam 1: Hope McDonald

A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the patient teaching? (Select all that apply.) 1. "The organism is usually transmitted through the fecal-oral route." 2. "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer." 3. "Everyone coming into the room must wear a gown and gloves." 4. "While I am in Contact Precautions, I cannot leave the room." 5. "C. difficile dies quickly once outside the body."

. Answer: 1, 2, 3. Clostridium difficile is transmitted through the oral fecal route and spread through contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile. The organism develops a hard spore, which can live for long periods on surfaces, making it extremely hard to eradicate. If a patient with C. difficile is continent of stool and first cleans hands and changes gown, the patient may leave the room.

A patient with heart failure is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions? (Select all that apply.) 1. Lower the head of the bed and return the patient to the supine position. 2. Obtain vital signs.3 . Encourage the patient to try to sit on the side of the bed and then stand. 4. Allow the patient to rest for 20 to 30 minutes. 5. Raise the head of the bed again and obtain blood pressure readings.

. Answer: 1, 2, 4, 5. Lowering the head of the bed and returning the patient to the supine position provides for patient safety. Obtaining vital signs identifies any changes from the patient's baseline. Giving the patient an opportunity to rest is important before trying to sit up again. Obtaining BP after raising the head of the bed, but before positioning the patient on the side of the bed, will identify any positional orthostatic hypotension. Encouraging the patient to sit on the side of the bed and stand without knowing whether the patient has orthostatic hypotension is unsafe and increases the patient's risk for falls.

Vulnerable populations (e.g., infants, children, older adults, persons with chronic disease) are especially at risk for alterations in safety because....

of reduced access to health care, fewer resources, and increased morbidity

You prepare a patient psychologically for an examination by ......

offering a thorough explanation of the purpose and steps of each assessment technique, letting a patient know what to expect and how to cooperate.

• Evidence-based alternatives to physical restraints include ...

offering diversional activities, using de-escalation techniques, providing visual and auditory stimuli, and promoting relaxation techniques.

. Afterload is the...

opposing pressure that the ventricle must generate to open the aortic valve against the higher aortic pressure.

Use the Banner Mobility Assessment Tool (BMAT) or Timed Up and Go (TUG) test to determine a patient's ability to...

walk, need for assistance, and progress of balance, sit to stand, and walking.

The examination room should be ...

warm, comfortable, quiet, private, and well lit. Before beginning the examination, ensure that all your equipment is within easy reach and laid out in an organized fashion.

A procedure-related accident is less likely to occur when ....

you strictly follow policies and procedures or standards of nursing practice, and when you minimize distractions and interruptions.

Administering therapies to relieve symptoms such as ____ or ______ before hygiene better prepares patients for any procedure.

pain or nausea

The cardiac impulse originates in the ....

sinoatrial node

Understanding the four physiological processes of nociceptive pain ____, ____, ____, ____, helps you recognize factors that cause pain, the accompanying symptoms, and the rationale for selecting therapies to treat or manage pain.

(transduction, transmission, perception, and modulation)

The spleen

, in the left upper quadrant of the abdomen, destroys old red blood cells, produces antibodies, stores red blood cells, and filters organisms from the blood.

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) 1. Use fluoride toothpaste. 2. Brush teeth 4 times a day. 3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients. 4. Use a soft toothbrush for oral care. 5. Avoid cleaning the gums and tongue.

. Answer: 1, 3, 4. The American Dental Association guidelines (2020) for effective oral hygiene include brushing the teeth at least twice a day with an American Dental Association-approved fluoride toothpaste. Use antimicrobial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor oral hygiene (e.g., older adults and patients with cognitive impairments and who are immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Patients should clean the gums and the surface of the tongue.

A health care provider writes the following order for a patient who is opioid naïve who returned from the operating room after a total hip replacement: "Fentanyl patch 100 mcg; change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

. Answer: 1. The nurse needs to call the health care provider about the order because fentanyl patches are not indicated for acute pain. They are indicated for patients with chronic pain who are opioid tolerant.

Categorize the patient fall risks on the with the correct risk factor category ( A: Intrinsic or B: Extrinsic) ___1. A 42-year-old patient who is recovering from anesthesia refuses assistance with walking to the bathroom. ___2. A 60-year-old patient with a history of falling in the last 6 months. ___3. A patient's walking path has spilled fruit juice on the floor. __4. A 68-year-old patient recovering from a colon resection uses an IV pole to walk. _ __5. Patient is unable to identify own fall risks. ___6. The physical therapist has not yet fitted a 62-year-old patient for a prescribed walker.

. Answer: 1A, 2A, 3B, 4B, 5A, 6B. The risk factors for falls include two categories: patient related (intrinsic) and hospital environment and working process related (extrinsic). The intrinsic factors are predisposing factors, whereas extrinsic factors increase the susceptibility of an individual to fall.

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions

. Answer: 2. Because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, Droplet Precautions are most appropriate.

A new medical resident writes an order for oxycodone hydrochloride controlled release (CR) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

. Answer: 2. Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn, to provide a base of continuous opioid analgesia.

. Place the following steps for applying a wrist restraint in the correct order: 1. Pad the skin overlying the wrist. 2. Insert two fingers under the secured restraint to be sure that it is not too tight. 3. Be sure that the patient is comfortable and in correct anatomical alignment. 4. Secure restraint straps to bedframe with quick-release buckle. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.

. Answer: 3, 1, 5, 2, 4.

8. The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patient says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.) 1. Ask the health care provider to order a restraint. 2. Recommend insertion of a urinary catheter. 3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Institute a routine exercise program for the patient. 5. Keep the bed in high position with side rails down. 6. Keep the pathway from the bed to the bathroom clear.

. Answer: 3, 4, 6. There are no appropriate conditions for this patient to be restrained. Patients who repeatedly wander may require the temporary use of restraints to keep them safe. However, the use of alternatives to restraints is preferred, and if a restraint is required, use the least restrictive. A urinary catheter is not inserted to avoid having a patient use the bathroom. The patient should have a low bed so that if the patient falls, the risk of injury may be lessened.

The assistive personnel (AP) informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place the care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.

. Answer: 4, 1, 3, 2, 5. The first priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assessing the patient. Check the distal pulse to verify circulation to the extremity and then obtain a manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms.

Clinical judgment is complex when promoting safety because ...

.. it requires understanding a patient's perspective of safety as well as the risks posed by any physical conditions

To obtain objective data on the peripheral circulatory and lymph...

...first assess the arms, noting the skin color, temperature, texture, and turgor. Assess for edema or clubbing and capillary refill. Palpate the radial and brachial pulses, noting rate, rhythm, vessel wall elasticity, and pulse force. Next assess the legs noting color, hair distribution, venous pattern, size, color changes, and skin lesions or ulcers. Palpate the temperature of the feet and legs, the inguinal nodes, and femoral, popliteal, posterior tibial, and dorsalis pedis pulses.

You complete a fall risk assessment on your assigned patient, who is 45 years old and has a history of cocaine use and liver failure. His laboratory results show an elevated prothrombin time. You determine that the patient is at high risk for falling. Which of the following measures are targeted to his fall risk status? (Select all that apply.) 1. Using skid-proof footwear 2. Scheduling any oral medications at least 2 hours before bedtime 3. Placing a low bed in room 4. Placing the nurse call system within patient's reach 5. Using a bed exit alarm 6. Providing patient with a protective head helmet when in chair or walking

.Answer: 2, 3, 5, 6. Use of skid-proof footwear and placement of nurse call light are basic Universal Fall Precautions for all patients. A patient at high risk may benefit from scheduling oral medications 2 hours before bedtime, providing the patient a low bed, using a bed exit alarm, and offering the patient a protective head helmet. This particular patient has a risk of bleeding following injury.

The general survey is a study of ...

.the whole person, covering the general health state and any obvious physical characteristics. It covers four areas: physical appearance, body structure, mobility, and behavior. Changes in any area may indicate illness

Which of the following factors control a person's blood pressure? (Select all that apply.) 1. Cardiac output 2. Age 3. Emotions 4. Vascular resistance 5. Viscosity

1,4,5, Factors that control blood pressure include cardiac output, vascular resistance, volume, viscosity, and elasticity of arterial walls. Blood pressure (BP) varies, but is not controlled by age, or emotions but rather represent social determinants that impact BP.

Because a hospitalized elderly female client, who ambulates with a walker, is receiving diuretics which results in frequent trips to the bathroom at night, the nurse should perform which of the following? 1.Leave the bathroom light on. 2.Withhold the client's diuretic medication. 3.Provide a bedside commode. 4.Keep the side rails up.

1.Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of falling when rushing to the bathroom. 2.The nurse cannot withhold a client's medication without consultation with the physician. 3.Correct. A bedside commode decreases the number of steps required to reach the goal. Rails up would increase the risks of falls as well as falling from a greater distance

The client is unresponsive and requires total care. Prior to providing oral care, the nurse should assess for which of the following? 1.Presence of pain 2.Condition of the skin 3.Gag reflex 4.Range of motion

1.More appropriate prior to bathing the client. 2.More appropriate prior to bathing the client. 3.Correct. The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. 4.More appropriate prior to bathing the client.

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

1.Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. 2.Option 2 is important to do as certain meds can increase a risk of a fall (e.g., tranquilizers, analgesics). 3.Option 3 would help the nurse assess if a client is at risk for a fall. 4.Correct. Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting up if the bed is at an appropriate height. The nurse would discuss this with the primary care provider. While it may be a priority, placing the bed in the lowest position would be a higher priority in the hospital setting.

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

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

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

1.Option 1 is true; however, it is not be as high a priority as preventing suicide. 2.Option 2 is true; however, it is not be as high a priority as preventing suicide. 3.Correct. Suicide and homicide are two leading causes of death among teenagers, and adolescent males commit suicide at a higher rate than adolescent females. 4.Option 4 is not true. A driver's education course is certainly encouraged; however, completing a course does not ensure safe practice.

Which NANDA nursing diagnosis is most applicable for toddlers? 1.Risk for Suffocation 2.Risk for Injury 3.Risk for Poisoning 4.Risk for Disuse Syndrome

1.The risk for suffocation could happen but is more likely with a newborn or infant, which is the reason parents are taught not to prop the bottle, to cut food in small pieces, and to use toys with no small detachable pieces. 2.Option 2 is too vague to address risks associated with a specific group of clients. 3.Correct. Remember that toddlers are active, like to explore, and are unable to use discretion about what they place in their mouths and as a result are at risk for poisoning (e.g., lead poisoning, toxic substances under the sink or in a drawer). 4.Option 4 is more applicable to the elder who is on total bed rest.

The nurse is observing another nurse performing perineal care for a client. Which of the following actions indicates that further teaching is required? 1.Uses a clean portion of the washcloth for each stroke. 2.Wipes from the pubis to the rectum. 3.Uses clean gloves. 4.Does not retract the foreskin.

1.This is appropriate. 2.This is appropriate. 3.This is appropriate. 4.Correct. It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth.

Match the fall prevention intervention (#) with the scientific rationale (Letter) ___1. Prioritize nurse call system responses to patients at high risk. ___2. Place patient in a wheelchair with wedge cushion. ___3. Establish elimination schedule with bedside commode. ___4. Use a low bed for patient. ___5. Provide a hip protector. ___6. Place nonskid floor mat on floor next to bed. A. Maintains comfort and makes exit difficult B. Makes it difficult for patients with lower extremity weakness to stand C. Reduces slipping when walking D. Reduces fall impact E. Ensures rapid response for help F. Reduces chance of patient trying to get out of bed on own

10. Answer: 1E, 2A, 3F, 4B, 5D, 6C.

What intercostal space corresponds with tricuspid valve auscultation?

4th or 5th intercostal space along the sternum

Which intercostal space marks the location where the nurse would auscultate the point of maximal impulse (PMI)?

5th

_________ pain is short-term and self-limiting, often follows a predictable track, and dissipates after the injury heals has a self-protective purpose; it warns of actual or threatened tissue damage.

Acute pain

Which of the following is considered when preparing to examine an older adult? a. Base the pace of the examination on the patient's needs and abilities. b. Avoid physical touch to avoid making the older adult uncomfortable. c. Be aware that loss will result in poor coping mechanisms. d.Confusion is a normal, expected finding in an older adult

A The pace of the examination should be adjusted to match the possible slowed pace of the aging person. Use physical touch (if it is not a cultural contraindication) to offset the disadvantages of diminishing vision and hearing. Be aware that loss is inevitable, and adaptation to loss affects health status. Confusion with a sudden onset may signify a disease state and is not a normal process of aging.

An older adult verbalizes to the nurse that he/she is having pain in his/her left wrist. Which of the following would be the most appropriate response by the nurse? a. "Tell me more about the pain." b. "It's nothing to worry about." c. "Occasional pain is a normal part of getting older." d. "We try to avoid prescribing pain medicine to older adults because they often become addicted."

A Whenever anyone reports pain, the nurse needs to complete a thorough pain assessment. Pain is common among older adults, but it is not a normal process of aging. Pain indicates pathology or injury and should always be assessed. Remember, pain is what the patient says it is. Fear of addiction is a common reason for underreporting of pain. While older adults may be more sensitive to medications, their pain should still be treated reasonably.

Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs? a. Roll toward the left side b. Roll toward the right side c. Trendelenburg position d. Recumbent position

A After auscultation in the supine position, the nurse should have the patient roll onto the left side; the examiner should listen at the apex with the bell for the presence of any diastolic filling sounds (i.e., S3 or S4) or murmurs that may be heard only in this position. The examiner should have the patient sit up and lean forward; the examiner should auscultate at the base with the diaphragm for a soft, high-pitched, early diastolic murmur of aortic or pulmonic regurgitation.

The nurse is completing a general survey for an older adult and notices the patient demonstrates a wider gait with short, uneven steps. Which of the following would be the most important action of the nurse? a. Document this as normal findings. b. Notify the physician immediately. c. Refer the patient to a geriatric health care specialist. d. Ask another nurse to assess the patient.

A An older adult with a wider gait with short, uneven steps is a normal finding. There is no need to immediately notify the physician since these are normal findings for an older adult. There is no need to refer the patient to a geriatric health care specialist since these are normal findings. Unless the nurse is a novice and this is the first time, they are assessing an older adult, there is no need for a second opinion.

Deep palpation is used to.. a. identify abdominal contents. b. evaluate surface characteristics. c. elicit deep tendon reflexes. d. determine the density of a structure.

A Deep palpation is used to identify abdominal contents. Light palpation is used to evaluate surface characteristics. Percussion with a reflex hammer is used to elicit deep tendon reflexes. Percussion is used to determine the density (air, fluid, or solid) of a structure by a characteristic note.

In young children, the thymus gland a. produces T lymphocytes. b. is small and begins to atrophy. c. is not important in immune function. d. produces B lymphocytes.

A In young children, the thymus gland is important in developing the T lymphocytes of the immune system. The thymus is large in the fetus and young children and atrophies after puberty. The thymus has no function in adults. The thymus gland does not produce B lymphocytes.

Palpable inguinal lymph nodes are a. normal if small (less than 1 cm), movable, and nontender. b. abnormal in adults but common in children and infants. c. normal if fixed and tender. d. abnormal and indicate the presence of malignant disease.

A Inguinal lymph nodes may be palpable. This is a normal finding if the nodes are small (1 cm or less), movable, and nontender. Lymph nodes may be relatively large in children, and the superficial ones often are palpable even when the child is healthy. Enlarged, tender, or fixed inguinal lymph nodes are an abnormal finding.

The jugular venous pressure is an indirect reflection of the a. heart's efficiency as a pump. b. cardiac cycle. c. conduction effectiveness. d. synchronization of mechanical activity.

A Jugular venous pressure reflects the heart's ability to pump blood. If the pressure is elevated, heart failure is suspected.

The nurse has completed a peripheral vascular assessment. Which of the following findings would be documented as expected findings? a. Radial pulses 2+ with regular rate and rhythm bilaterally. b. Right ankle 1+ edema with no perceptible swelling of the leg. c. Feet pale and cool to touch. c. Capillary refill <5 seconds.

A Radial pulses 2+ indicates normal force/amplitude and should have a regular rate and rhythm in both the right and left arms. Mild pitting edema is 1+. Unilateral edema in the ankles without swelling in the rest of the leg is not a normal finding. Feet should be pink or appropriate for race with capillary refill

The tympanic membrane thermometer (TMT) a. provides an accurate measurement of core body temperature. b. senses the infrared emissions of the cerebral cortex. c. is not used in unconscious patients. d. accurately measures temperature in 20 to 30 seconds.

A The TMT accurately measures core body temperature. The TMT senses the infrared emissions of the tympanic membrane; the tympanic membrane shares the same vascular supply that perfuses the hypothalamus. The TMT is used with unconscious patients or patients in the emergency department, recovery areas, and labor and delivery units. The temperature is displayed in 2 to 3 seconds.

Which technique would the nurse use to noninvasively assess arterial oxygen saturation? a. Pulse oximeter b. Respiratory rate c. Blood pressure d. Arterial blood gas

A The pulse oximeter is a noninvasive method to assess SpO2. Respiratory rate is only a measure of the rate of a person's breathing, not SpO2. Blood pressure is an assessment of the force of blood pushing against the side of the vessel, not SpO2. Arterial blood gas is an invasive measure to assess oxygen saturation.

Inspection is...

close, careful observation of the individual as a whole and then of each body system. Inspection requires good lighting, adequate exposure, and at times, the use of certain instruments, such as an otoscope or penlight.

What occurs during transduction (the first phase of nociceptive pain)? a. Pain signals move from the site of origin to the spinal cord. b. The pain impulse moves from the spinal cord to the brain. c. The brain interprets the pain signal. d. Chemical mediators are neutralized to decrease the perception of pain.

A Transduction is the first phase of nociceptive pain. During this phase, injured tissue releases chemicals that propagate the pain message; an action potential moves along an afferent fiber to the spinal cord. During transmission (the second phase), the pain impulse moves from the level of the spinal cord to the brain. The third phase is perception; the person has conscious awareness of a painful sensation. In phase four, modulation, the neurons from the brainstem release neurotransmitters that block the pain impulse.

The student nurse demonstrates correct technique in using the stethoscope to auscultate heart sounds when they do which of the following? a. Makes sure earpieces fit snugly and are pointed to their nose. b. Uses the bell to detect higher pitched sounds. c. Performs assessment while the patient is watching television. d. Auscultates in only 4 locations.

A When auscultating, the earpieces of the stethoscope should fit snugly in the examiner's ear canal, and they should be aimed forward (toward nose) to avoid air leak. The diaphragm of the stethoscope is used for higher pitched sounds and the bell for lower pitched sounds. It's important to minimize noise in order to be able to appropriately assess sounds with the stethoscope. Heart sounds should be assessed for in 5 locations using a rough Z pattern from the base of the hear across and down and over to the apex.

Which of the following assessments should be included as part of the body structure portion of the general survey? a. Stature, nutrition, and symmetry b. Sexual development, skin color, and overall appearance c. Gait and range of motion d. Facial expression, speech pattern, and dress

A When completing the body structure assessment portion of the general survey, the nurse should assess stature, nutrition, symmetry, posture, position, and for physical deformities. Sexual development, skin color, and overall appearance are included in physical appearance portion of the general survey assessment. Gait and range of motion are included as part of the mobility portion of the general survey assessment. Facial expression, speech pattern, dress, mood and affect, and personal hygiene should be included in the behavior portion of the general survey assessment.

To examine a toddler, the nurse should... a. allow the child to sit on the parent's lap. b. remove the child's clothing at the beginning of the examination. c. ask the child to decide whether parents or siblings should be present. d. perform the assessment from head to toes.

A a toddler should be sitting up on the parent's lap for the examination. An infant will not object to having clothing removed; a toddler does not like to take off his or her clothing. A school-age child has a sense of modesty; to maintain privacy, ask a child who is 11 or 12 years old to decide whether parents or siblings should be present. The sequence of the examination for a toddler should start with nonthreatening areas first; save distressing procedures such as assessment of the head, ears, nose, or throat for last.

Amplitude is a. the intensity (soft or loud) of sound. b. the length of time the note lingers. c. the number of vibrations per second. d. the subjective difference in a sound's distinctive overtones.

A amplitude is the intensity of sound. Duration is the length of time the note lingers. Pitch is the number of vibrations per second (high or low). Quality is the subjective difference owing to a sound's distinctive overtones.

Which of the following statements regarding cultural/racial differences in the treatment of pain is true? a. White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms. b. Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals. c. Pain modulation is more highly developed in black and Hispanic individuals. d. Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals.

A Various studies describe how black and Hispanic patients are often prescribed less analgesic therapy than white patients, although most of these differences are small. No evidence supports any of the other statements.

A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants

Answer: 3. Constipation is a common opioid-related side effect, and patients do not become tolerant to the medication

___________ Precautions focus on diseases that are transmitted by large droplets expelled into the air and by being within 3 feet of a patient, requiring use of a surgical mask when within 3 feet of the patient, proper hand hygiene, and dedicated personal protective equipment.

Airborne

The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who had a stroke. Which intervention(s) would be appropriate for the assistive personnel to accomplish during the bath? (Select all that apply.) 1. Checking distal pulses 2. Providing range-of-motion (ROM) exercises to extremities 3. Determining type of treatment for Stage 1 pressure injury 4. Changing the dressing over an intravenous site 5. Providing special skin care as indicated by nurse

Answer 2, 5. Providing ROM exercises may be delegated to assistive personnel. The nursing assistive personal can also give special skin care as instructed by the nurse. Checking distal pulses, determining the type of treatment for stage 1 pressure injury, and changing a dressing over an intravenous site all require a nurse's assessment and clinical decision making and should not be delegated to assistive personnel.

A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 4.5 kg (10 lb). She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her vital signs at the start of treatment are HR 112, BP 138/82, RR 22, tympanic temperature 37.9°C (100.2°F), and oxygen saturation 94%. Which of the vital signs taken 4 hours later reflect a positive outcome of the treatment interventions? (Select all that apply.) 1. Temperature: 37°C (98.6°F) 2. Radial pulse: 98 3. Respiratory rate: 18 4. Oxygen saturation: 96% 5. Blood pressure: 134/78

Answer: 1, 2, 3, 4. Radial pulse has dropped as the patient's temperature has also dropped to fall within the expected range. The respiratory rate has decreased with the lower temperature, and oxygen saturation has increased with the improved respiratory rate

You are caring for a patient in an intensive care unit (ICU) who has pulled out his own IV line. You have tried restraint alternatives. Which of the following would you assess to determine appropriateness or reason to physically restrain the patient? (Select all that apply.) 1. Health care provider's order 2. Patient's current behavior 3. Current medications 4. Health literacy 5. Presence of fever 6. Serum electrolytes 7. Age

Answer: 1, 2, 3, 5, 6. A health care provider's order is required and contains time limits for restraints. A patient's behavior can change rapidly. But if current behavior reflects confusion, disorientation, agitation, restlessness, combativeness, or inability to follow directions, physical restraints may be appropriate to prevent further removal of the patient's IV line. Current medications, if they affect cognition, should be considered. A change in medications might prevent restraint application. Presence of fever or electrolyte level can reflect metabolic problems that cause confusion or changes in consciousness. Health literacy and age are not factors for indication of physical restraints.

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses' part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. Decreasing a patient's environmental stimuli to decrease nausea

Answer: 1, 2, 3. Nausea is not typically associated with transmission of infection, and loose stools are a common side effect with antimicrobials. All the other interventions break the cycle of infection transmission.

The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel (AP). What cultural information does the nurse need to provide to the AP? (Select all that apply.) 1. Specific hygiene products 2. Timing of hygiene care 3. Socioeconomic status 4. The need for gender congruent caregiver 5. Religious practices

Answer: 1, 2, 4, 5. Cultural beliefs often influence patients' hygiene practices. Some cultural practices encourage specific hygiene products; in some cultures patient's bathe before prayers; often cultures require gender congruent caregiver, and a patient's religious practices may specify certain hygiene practices, especially during religious holidays.

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. Routine environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

Answer: 1, 2, 4. Proper cleaning and disinfection are processes that occur prior to sterilization. Routine environmental cleaning is an example of medical asepsis, which helps break the chain of infection. Cleaning is always done from least contaminated to most contaminated to decrease the risk of further infection and contamination.

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over the skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

Answer: 1, 2, 5. Apply the ice with firm pressure to the skin, which is covered with a lightweight cloth. Then use a slow, steady circular massage over the area. Apply cold within a 6-inch circular area near the pain site or on the opposite side of the body corresponding to the pain site. Limit application to 5 minutes or when the patient feels numbness. Application near the actual site of pain tends to work best, and it can be applied several times each hour to help reduce pain

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

Answer: 1, 2, 5. Chickenpox is an airborne organism that can travel great distances, so it is important that the air breathed by the nurse is filtered and that hands and clothes are covered, as required for Airborne Precautions.

Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months pregnant 3. A patient admitted with hypothermia 4. Postoperative patient waking from general anesthesia 5. Three-pack-per-day smoker with pneumonia

Answer: 1, 2, 5. The patient with rib fractures is unlikely to breathe deeply, and a large fetus restricts diaphragmatic movement; both result in decreased ventilatory volume and increased respiratory rate. Pneumonia decreases gas exchange surface area; thus tachypnea occurs to increase minute ventilation. Hypothermia and general anesthesia depress respiratory rates.

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure? (Select all that apply.) 1. Oxygen saturation 2. Heart rate 3. Respirations 4. Gag reflex 5. Response to painful stimulus

Answer: 1, 3, 4. Check a patient's respirations and oxygen saturation (optional) and whether there is a gag reflex present to determine risk for aspiration and to establish a baseline for the patient's condition.

The nurse is observing the patient for general appearance and behavior. What assessments might indicate that the patient is in pain? (Select all that apply). The patient: 1. is slumped in the bed. 2. responds to questions by making eye contact. 3. is short of breath and breathing rapidly. 4. protects and splints the left arm. 5. is alert and oriented.

Answer: 1, 3, 4. Sometimes obvious signs or symptoms indicate pain (grimacing, splinting painful area), difficulty breathing (shortness of breath, sternal retractions), or anxiety. Set priorities and examine the related physical areas first. Observe whether the patient has a slumped, erect, or bent posture, which reflects mood or pain.

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie bottom and then top mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

Answer: 1, 3, 5, 4, 2. Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator.

The licensed practical nurse (LPN) provides you with the shift handoff vital signs on four of your patients. Based on your knowledge of the pathophysiology of each patient's illness, use clinical judgment to prioritize, in order, the follow-up patient assessments to be made. 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 85% 2. 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3°C (99.1°F), HR 84 4. 77-year-old woman with left mastectomy 36 hours ago, temperature 38.3°C (101°F), pulse 110, RR 22, BP 148/62

Answer: 1, 4, 2, 3. (1) SpO2 85% is a critical value and requires immediate attention. (4) Elevated temperature may indicate a potential wound infection or postoperative dehydration. (2) Patient is postoperative for repair of fractured arm; do pain assessment. Elevated BP can be the result of pain. (3) This patient's vital signs do not require immediate follow-up assessments by the nurse.

Which of the following are normal findings you should find during a physical exam? (Select all that apply.) 1. Jugular vein flattens when a patient sits up. 2. A swooshing sound is normally heard when auscultating a carotid artery. 3. Upon palpation, a lymph node is normally tender. 4. Normal sitting posture involves some degree of rounding of the shoulders. 5. Normally there is no bulging within the intercostal spaces during breathing.

Answer: 1, 4, 5. During a physical examination you will normally find the jugular vein will flatten when a patient sits up, with no sounds over the carotid artery when auscultated. Normal findings also include nontender lymph nodes, a normal sitting posture involving some degree of rounding of the shoulders, and no bulging within the intercostal spaces during breathing.

A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72. He immediately repeated the measurement, and the value was 158/80. His normal BP value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/72? (Select all that apply.) 1. Cuff too small on the device 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements

Answer: 1, 4, 5. Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Clothing under blood pressure cuff can alter accurate fit of cuff and impede auscultation. Arm above heart level and slow inflation result in false low readings.

The nurse is teaching a patient how to perform a testicular selfexamination. Which statement made by the patient indicates a need for further teaching? 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15. " 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers.

Answer: 1. The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless.

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. Cranial Nerves Cranial Nerve Function ___1. XII Hypoglossal ___2. V Trigeminal ___3. VI Adducens ___4. IV Trochlear ___5. X Vagus a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue

Answer: 1e, 2a, 3b, 4d, 5c

A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order. 1. Have AP obtain a blood pressure. 2. Request that the patient lie on the clinical stretcher. 3. Assess the patient's apical pulse for a full minute. 4. Prepare to administer cardiac-stimulating medications as ordered. 5. Obtain oxygen saturation (SpO2).

Answer: 2, 1, 3, 5, 4. The first priority is patient safety. Getting the patient to lie on a stretcher prevents falls. Directing the AP to obtain BP relates to the patient's symptom of dizziness while the nurse assesses apical pulse. If the BP is abnormal, the nurse should recheck the value. Obtain oxygen saturation after essential vital signs. The patient may require medications to increase heart rate.

. The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit saturated and trans fats, sodium, red meats, sweets, and sugar-sweetened beverages. 5. Review strategies to encourage the patient to quit smoking.

Answer: 2, 3, 4, 5. Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in sodium and fats are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower sodium and fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

Answer: 2, 3. Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing such as gowns, masks, eyewear, and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer 1-inch border not considered sterile. Surgical asepsis requires the application of sterile (not clean) gloves.

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) 1. Prone position 2. Modified left lateral recumbent position 3. Semi-Fowler's position with head to side 4. Trendelenburg position 5. Supine position

Answer: 2, 3. Place the unconscious patient in semi-Fowler's position with head to the side or use the modified left lateral recumbent position to help avoid aspiration while performing oral care. The supine and Trendelenburg positions would make it easier for a patient to aspirate. The prone position would be unsuitable for accessing the oral cavity.

.The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) 1. Cut nails frequently. 2. Assess skin for redness, abrasions, and open areas daily. 3. Soak feet in water at least 10 minutes before nail care. 4. Apply lotion to feet daily. 5. Clean between toes after bathing.

Answer: 2, 4, 5. Because of a patient's risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes mellitus without a health care provider's order because this may create skin breakdown and open sores, leading to skin breakdown or infection

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the nonpharmacological therapy? (Select all that apply.) 1. Turn TENS on before patient feels discomfort. 2. TENS works peripherally and centrally on nerve receptors. 3. TENS does not require a health care provider order. 4. Remove any skin preparations before attaching TENS electrodes. 5. Placing electrodes directly over or near the pain site works best.

Answer: 2, 4, 5. TENS units act on both the central and peripheral nervous systems. The peripheral effect occurs through activation of the neuroreceptors at or near the source of pain; therefore, the electrodes should be placed near the site. A TENS unit requires a health care provider's order that identifies the site for the TENS electrode placement. Remove any hair or skin preparations before attaching the electrodes. Then place the electrodes directly over or near the pain site. Turn the transmitter on to the ordered level when the patient feels pain.

During a home health visit a nurse observes a patient preparing lunch. Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation.

Answer: 2, 4, 5. The Centers for Disease Control and Prevention (CDC) recommends washing hands thoroughly before food preparation, and washing cooking surfaces often. Keep raw meat, poultry, seafood, and their juices away from other foods, and use separate cutting boards for each. Rinse fruits and vegetables thoroughly, and always cook food to the proper temperature. Refrigerate leftovers promptly. A single cutting board can cause cross-contamination. Even if packages show that vegetables have been prewashed, thoroughly wash them after opening a package.

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

Answer: 2, 4. An MDRO is a single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available.

A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. 1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. 2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. 3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. 4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. 5. Remove partial plate or dentures if present. 6. Gently brush tongue but avoid stimulating gag reflex.

Answer: 2, 5, 1, 3, 6, 4.

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but the nurse recognizes that this is a normal response to isolation. Which is the nurse's best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

Answer: 3. By providing a rationale for the isolation, the patient can better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when the patient is alone in the room.

During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately. 2. Repeat the measurements on both arms using a stethoscope. 3. Ask the patient whether she has taken her blood pressure medications recently. 4. Obtain blood pressure measurements on lower extremities. 5. Review the patient's record for her baseline vital signs

Answer: 2, 5. The systolic BP measurements are significantly different and may reflect some vascular abnormalities. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider without further assessment. Eventually the nurse should assess medication adherence; however, it is unlikely the differences are caused by medications. An inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements

Which of the following signs or symptoms in a patient who is opioid naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 12 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

Answer: 2. Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.

The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse? 1. Vesicular breath sounds in the lung bases 2. Temperature 38.5o C (101.4o F) 3. Incision pain rating of 6 out of 10 4. Blood glucose of 164 mg/dL

Answer: 2. Temperature is a sign of infection. The temperature of the patient is outside the normal range and indicative of low-grade fever. The nurse should be concerned that the patient is developing an infection; the most likely location to assess would be the incision. Vesicular breath sounds are normal in the bases of the lungs. The pain rating is moderate and can be treated with pain medications. Although the glucose is elevated as expected in a postoperative patient, it is not in a critical value range for a postoperative patient.

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient had been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for the past year to manage her arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine 50 mg IVP, q3h, prn. 4. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

Answer: 2. The patient can be expected to have acute pain related to the G-tube insertion; in addition, she has a history of chronic pain. Her pain should be treated with ATC medication to match the timing of her pain.

A nurse enters the hospital room of a patient who had a total knee replacement the day before and is sitting in a chair. The nurse is preparing to return the patient to bed. Which of the following pose potential safety risks? (Select all that apply.) 1. A current safety inspection sticker is on the IV fluid pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

Answer: 3, 4, 5. All electrical equipment should be inspected routinely and have current safety inspection stickers. The patient has had knee surgery, so the presence of a walker is needed for him to ambulate. Safety risks include the absence of a gait belt; one should always be available for a patient who will need assistance in ambulation. The bed position is incorrect; it should be in low position. The position of the bedside table does not allow the patient to reach personal or care items easily.

Which of the following factors directly impairs salivary gland secretion? (Select all that apply.) 1. Use of cough drops 2. Immunosuppression 3. Radiation therapy 4. Dehydration 5. Presence of oral airway

Answer: 3, 4. Radiation therapy reduces salivary flow. Dehydration impairs salivary secretion in the mouth. Cough drops increase sugar or acid content in the mouth, causing caries. Immunosuppression causes inflammation and bleeding of the gums. An oral airway irritates oral mucosa.

Place the following steps in the correct order for administration of patient-controlled analgesia: 1. Insert drug cartridge into infusion device and prime tubing. 2. Wipe injection port of maintenance IV line vigorously with antiseptic swab for 15 seconds and allow to dry. 3. Demonstrate to patient how to push medication demand button. 4. Secure connection and anchor PCA tubing with tape. 5. Instruct patient to notify a nurse for possible side effects or changes in the severity or location of pain. 6. Insert needleless adapter into injection port nearest patient. 7. Apply clean gloves. Check infuser and patient-control module for accurate labeling or evidence of leaking. 8. Program computerized PCA pump as ordered to deliver prescribed medication dose and lockout interval. 9. Attach needleless adapter to tubing adapter of patient-controlled module.

Answer: 3, 5, 7, 1, 9, 2, 6, 4, 8. Instruct patient before final pump preparation.

A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

Answer: 3, 5. To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of 12

Answer: 3. In healthy adults the normal respiratory rate varies from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects.

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

Answer: 3. The Food and Drug Administration (FDA) recommends a maximum daily dose of 4 g of acetaminophen.

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern

Answer: 3. The temperature was elevated above the acceptable range at 0400, returned to normal, and then was elevated again

While planning morning care, which of the following patients would have the highest priority to receive a bath first? 1. A patient who just returned to the nursing unit from a diagnostic test 2. A patient with a fever who just finished a dose of intravenous antibiotics. 3. A patient who is experiencing frequent incontinent diarrheal stools and urine 4. A patient who has been awake all night because of pain 8/10

Answer: 3. Urine and fecal material contain substances that can injure a patient's skin and increase the risk for pressure injury and skin damage. Prompt and frequent perineal hygiene is a priority in incontinent patients.

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 45."

Answer: 4. American Cancer Society guidelines state that for people of average risk, beginning at the age of 45, an annual fecal occult blood test is recommended. Flexible sigmoidoscopy is recommended every 5 years in this population. A colonoscopy is used every 10 years if recommended by the health care provider.

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention when the nurse asks questions, and mumbles when speaking. 3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. 4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient

Answer: 4. Patients who are most likely to enact violence include those who have an increased volume of speech, are irritable, demonstrate prolonged or intense glaring, mumble, use abusive language toward the nurse, and pace around the waiting area or bed.

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems that will require thorough bathing and skin care? 1. A 44-year-old female patient who has had removal of a breast lesion and is in pain and unwilling to ambulate postoperatively. 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration. 3. A 60-year-old female patient who experienced a stroke with rightsided paralysis and has an orthopedic brace applied to the left leg 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and stool

Answer: 4. The 70-year-old patient has reduced circulation, which decreases sensation, and he may be unaware of any pressure or skin irritation. In addition, because he has dementia, he may not perceive any skin irritation. These factors and the presence of urine and fecal material on his skin increase his risk for skin problems. The 44-year-old female patient needs an analgesic prior to ambulation. The 56-year-old patient is at risk for dry, fragile skin. The 60-year-old patient has reduced sensation and mobility and thus is unaware of skin problems or pressure areas.

A patient has been admitted from the emergency department (ED) with a primary problem of abdominal pain. Diagnostic tests performed in the ED are pending. The nurse focuses an examination on the abdomen and uses the following techniques. Which technique is correct? 1. Perform auscultation first. 2. Have patient place folded arms under the head. 3. Palpate the patient's painful area first. 4. Observe the contour of the abdomen while asking the patient to take a deep breath and hold it.

Answer: 4. When performing an abdominal exam, perform inspection first, followed by auscultation. Have patient relax with arms at the side to relax the abdomen. Palpate the patient's painful area last

7. Match the intervention for promoting child safety with the correct developmental stage (A: School-age B: Preschool) . 1. Teach children proper bicycle and skateboard safety. 2. Teach children how to cross streets and walk in parking lots. 3. Teach children proper techniques for specific sports. 4. Teach children not to operate electric toothbrushes while unsupervised. 5. Teach children not to talk to or go with a stranger. 6. Teach children not to eat items found in the grass.

Answer: A: 1, 2, 3; B: 4, 5, 6.

Categorize the following as either acute or chronic pain A. Has a protective effect B. Lasts more than 3 to 6 months C. Usually has identifiable cause D. Dramatically affects quality of life E. Viewed as a disease F. Eventually resolves with or without treatment

Answer: Acute pain: A, C, F; Chronic pain: B, D, E. Acute pain is protective, usually has an identifiable cause, and is of short duration. It eventually resolves, with or without treatment, after an injured area heals. Acute pain seriously threatens a patient's recovery by hampering the ability to become active and involved in self-care, and motivating a patient toward self-care can be hindered until the pain is managed successfully. Chronic pain has a dramatic effect on a person's quality of life. It is not protective. It typically is an ongoing or recurrent pain that lasts more than 3 to 6 months. Chronic pain does not always have an identifiable cause. It is viewed as a disease.

to obtain a complete assessment of the patient's hygiene needs assess their...

Assess a patient's skin, feet and nails, oral mucosa, hair, and eyes and ears

Which of the following is a normal range for a patient's temperature measured using an oral thermometer? a. 36.2°C to 38.2°C b. 36.5°C to 37.8°C c. 37.5°C to 39.2°C d. 34.0°C to 34.9°C

B

Vascular insufficiency and reduced mobility, cognition, and sensation increase a patient's risk for impaired .....

skin integrity

Which of the following actions by the student nurse is indication that they do not know the correct method for assessing the carotid artery? a. The patient's neck is in a neutral position. b. They firmly press the bell of the stethoscope over the carotid artery. c. Asks patient to take a breath, exhale, and hold briefly while auscultating the carotid artery. d. Lightly palpates the left carotid artery, releases, and then palpates the right carotid artery.

B The student nurse who is firmly pressing the bell of the stethoscope over the carotid artery is performing incorrect procedure that could compress the artery and compromise circulation. In order to correctly assess the carotid arteries, the patient's neck should be in a neutral position; one side should be palpated at a time; and asking the patient to take a breath, exhale, and hold briefly assists so that breathing does not mask or mimic a carotid artery bruit.

A common error in blood pressure measurement is a. taking the blood pressure in an arm that is at the level of the heart. b. waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm. c. deflating the cuff about 2 mm Hg per heartbeat. d. using a blood pressure cuff whose bladder length is 80% of the arm circumference.

B Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a falsely high diastolic pressure due to venous congestion in the forearm. The patient's arm should be positioned at the level of the heart when obtaining a blood pressure measurement. The cuff should be deflated at a rate of 2 mm Hg per heartbeat. The blood pressure cuff bladder length should be about 80% of the arm circumference

A bruit heard while auscultating the carotid artery of a 65-year-old patient is caused by a. decreased velocity of blood flow through the carotid artery. b. turbulent blood flow through the carotid artery. c. rapid blood flow through the carotid artery. d. increased viscosity of blood.

B A carotid bruit is a blowing, swishing sound indicating blood flow turbulence. A bruit indicates atherosclerotic narrowing of the vessel.

An adult patient's pulse is 46 beats per minute. The term used to describe this rate is a. tachycardia. b. bradycardia. c. weak and thready. d. sinus dysrhythmia.

B A heart rate of less than 50 beats per minute in an adult is bradycardia. A heart rate of greater than 90 beats per minute in an adult is tachycardia. Weak and thready describes the force of the pulse reflecting a decreased stroke volume. Sinus dysrhythmia is a pulse that is irregular; the heart rate varies with the respiratory cycle.

Claudication is caused by a. venous insufficiency. b. arterial insufficiency c. varicose veins. d. stasis ulcerations.

B Claudication is caused by arterial insufficiency. Varicose veins are venous in origin. Stasis ulcerations are venous in origin.

What is the source of deep somatic pain? a. Skin and subcutaneous tissues b. Bones and joints c. Pancreas d. Intestine

B Deep somatic pain comes from the blood vessels, joints, tendons, muscles, and bones. Cutaneous pain is derived from skin surface and subcutaneous tissues. Visceral pain originates from the larger interior organs such as the pancreas. Visceral pain originates from the larger interior organs such as the intestine.

Which of the following cardiac alterations occurs during pregnancy? a. An increase in cardiac output and blood pressure b. An increase in cardiac volume and a decrease in blood pressure c. An increased heart rate and increased blood pressure d. An increased stroke volume and decreased cardiac output

B During pregnancy the blood volume increases by 40%; this creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 20 beats per minute. The arterial blood pressure decreases in pregnancy as a result of peripheral vasodilation.

Endogenous obesity is a. due to inadequate secretion of cortisol by the adrenal glands. b. caused by excess adrenocorticotropin (ACTH) production by the pituitary gland. c. characterized by evenly distributed excess body fat. d. a result of excessive secretion of growth hormone in adulthood.

B Endogenous obesity is caused by either the administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary. ACTH stimulates the adrenal cortex to secrete excess cortisol and causes Cushing syndrome, which is characterized by weight gain and edema with central trunk and cervical obesity. Excessive catabolism causes muscle wasting with thin arms and legs. Body fat is evenly distributed in exogenous obesity because of excessive caloric intake. Acromegaly is caused by an excessive secretion of growth hormone in adulthood.

The nurse is completing an assessment of a nonverbal patient who had an appendectomy the previous day. The patient is restless, holding their hand over his abdomen, sweating, and vital signs are heart rate 100 bpm, respirations 20, blood pressure 135/90. Which of the following would be the most appropriate action by the nurse? a. Chart vital signs and assessment and determine normal findings. b. Ask the patient to nod "yes" or "no" and ask them if they are experiencing pain. c. Teach the patient the importance about getting out of bed and walking after surgery. d. Offer to turn on healing music.

B Even though the patient is nonverbal, they may be able to answer yes/no questions by nodding his or her head. While these could be signs of other concerns, the nurse should always be concerned about pain in a postoperative patient. All of the noted vital signs are elevated, and the patient's behaviors are common for person's experiencing moderate-to-intense levels of pain. It is important to teach the patient about the importance of walking after surgery to prevent postoperative complications. However, these behaviors and the elevated vital signs should raise the nurse's level of concern that the patient is experiencing pain or another postoperative issue. Healing music is a helpful nonpharmacologic pain treatment method. However, the patient is exhibiting behaviors consistent with moderate-to-intense pain, and it is more appropriate for the nurse to provide pharmacologic methods to assist with decreasing pain

The nurse documents the following findings for the behavioral portion of the general survey assessment, "patient demonstrates flat affect, lack of eye contact, hair not brushed, and strong body odor". The nurse should be concerned that the patient is displaying signs/symptoms of? a. Dysarthria b. Depression c. Seizures d. Bulimia

B Flat affect, lack of eye contact, unkempt appearance (hair not brushed), and smelling of body odor are common warning signs that the patient may be depressed. Dysarthria is unclear articulation of speech commonly associated with a stroke or a speech disorder. A person with a seizure disorder may have altered affect or eye contact but may not demonstrate an unkempt appearance. A person with bulimia may have altered mood, affect, or facial expression, but typically not have altered dress or personal hygiene

Neuropathic pain implies an abnormal a. degree of pain interpretation. b. processing of the pain message. c. transmission of pain signals. d. modulation of pain signals.

B Neuropathic pain results from abnormal processing of the pain message. Neuropathic pain does not adhere to the typical and predictable phases inherent in nociceptive pain.

Physical appearance includes statements that compare appearance with a. mood and affect. b. stated age. c. gait. d. nutrition.

B Physical appearance includes statements that compare appearance with age, sex, level of consciousness, skin color, and facial features. Behavior is compared with mood and affect. Mobility is compared with gait. Body structure is compared with nutrition.

The first heart sound (S1) is produced by the a. closure of the semilunar valves. b. closure of the AV valves. c. opening of the semilunar valves. d. opening of the AV valves.

B S1 occurs with closure of the atrioventricular valves. The second heart sound (S2) occurs with closure of the semilunar valves. Normally opening of the semilunar valves is silent, but in aortic or pulmonic stenosis, an ejection click may be heard. An ejection click occurs early in systole at the start of ejection because it results from opening of the semilunar valves. A third heart sound (S3) can be heard when the ventricles are resistant to filling during the early rapid filling phase. S3 is heard when the AV valves open and atrial blood first pours into the ventricles.

The Doppler technique a. is used to assess the apical pulse. b. amplifies Korotkoff sounds during blood pressure measurement. c. provides an easy and accurate measurement of the diastolic pressure. d. measures arterial oxygenation saturation.

B The Doppler technique may be used to locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. A stethoscope is used to assess an apical pulse. The systolic blood pressure is more easily identified with the Doppler technique than the diastolic pressure. A pulse oximeter measures arterial oxygenation saturation.

The dorsa of the hands are used to determine... a. vibration. b.temperature. c. position of an organ. d. fine tactile discrimination.

B The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for vibration. A grasping action of the fingers and thumb is the best way to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination.

The ability of the heart to contract independently of any signals or stimulation is due to a. depolarization. b. automaticity. c. conduction. d. repolarization.

B The heart can contract by itself, independent of any signals or stimulation from the body; this property is termed automaticity. Depolarization is the reversal of the resting potential in excitable cardiac muscle cell membranes when stimulated. Conduction is the process by which an electrical impulse is transmitted through the heart. Repolarization is the process by which the membrane potential of a cardiac muscle cell is restored to the cell's resting potential.

Which of the following is the most reliable indicator for chronic pain? a. Magnetic resonance imaging (MRI) results b. Patient self-report c. Tissue enzyme levels d. Blood drug levels

B The most important and reliable indicator for chronic pain is the patient's self-report. Chronic pain is transmitted on a cellular level, and current technology such as MRI cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and current technology such as tissue enzyme levels cannot reliably detect this process. Chronic pain is transmitted on a cellular level, and blood drug levels cannot reliably detect this process.

Fine tactile discrimination is best achieved with the.. a. opposition of the fingers and thumb. b. fingertips. c. back of the hands and fingers. d. base of the fingers.

B the grasping action of the fingers and thumb is used to detect the position, shape, and consistency of an organ or mass. The fingertips are best for fine tactile discrimination such as skin texture, swelling, pulsation, and presence of lumps. The dorsa (back) of hands and fingers are best for determining temperature because the skin is thinner than on the palms. The base of the fingers or ulnar surface of the hand is best for detecting vibration.

Which of the following has been found to influence pain sensitivity in women? a. Age b. Hormonal changes c. Parity d. Weight

B Gender differences are influenced by societal expectation, hormones, and genetic makeup. Hormonal changes (estrogen modulation) are found to have strong influences on pain sensitivity for women. Age has not been found to influence pain sensitivity in women. Parity has not been found to influence pain sensitivity in women. Weight has not been found to influence pain sensitivity in women.

The examiner should use handwashing instead of an alcohol-based hand rub a. if the patient has an infection with Mycobacterium tuberculosis. b. if the patient has an infection with Clostridium difficile. c. if the patient has an infection with hepatitis B virus. d. if the patient is HIV positive.

B The examiner should use the mechanical action of soap-and-water handwashing when hands are visibly soiled and when patients are infected with spore-forming organisms (e.g., C. difficile or Bacillus anthracis). An alcohol-based hand rub would be effective against M. tuberculosis. An alcohol-based hand rub would be effective against hepatitis B virus. An alcohol-based hand rub would be effective against HIV.

When performing percussion, the examiner.. a.strikes the flank area with the palm of the hand. b.strikes the stationary finger at the distal interphalangeal joint. c. strikes the stationary finger at the proximal interphalangeal joint. d. taps fingertips over bony processes.

B To perform percussion, the examiner strikes the stationary finger at the distal interphalangeal joint (just behind the nail bed).

Pain signals are carried to the central nervous system by way of a. perception. b. afferent fibers. c. modulation. d. referred pain.

B Nociceptors carry the pain signal to the central nervous system by two primary sensory (or afferent) fibers. Perception indicates the conscious awareness of a painful sensation. Modulation inhibits the pain message producing an analgesic effect. Referred pain is pain felt at a particular site that originates from another location.

A nurse's role in managing environmental hazards is to...

educate patients about the common hazards in the home and at work, teaching them how to prevent injury and emphasizing the hazards to which patients are the most vulnerable.

________ pain is a transient spike in pain level in an otherwise controlled pain syndrome or as the result of incident or episodic pain.

Breakthrough

An adult with a body mass index (BMI) less than 18.5 kg/m2 is considered which of the following? a. Obese b. Normal weight c. Underweight d. Overweight

C A person with a body mass index (BMI) less than 18.5 kg/m2 is classified as underweight. Classification of obesity is a body mass index (BMI) of 30 to 39.9 kg/m2. Classification of normal weight is a body mass index (BMI) of 18.5 to 24.9 kg/m2. Classification of overweight is a body mass index (BMI) of 25 to 29.9 kg/m2

A water-hammer or Corrigan pulse is associated with a. hyperkinetic states. b. decreased cardiac output. c. aortic valve regurgitation. d. conduction disturbance.

C A water-hammer (Corrigan) pulse occurs in aortic valve regurgitation. A full, bounding pulse is associated with hyperkinetic states (exercise, anxiety, fever). A weak, thready pulse occurs with decreased cardiac output. Pulsus bigeminus occurs with conduction disturbances.

What type of pain is short and self-limiting and dissipates after the injury heals? a. Chronic b. Persistent c. Acute d. Breakthrough

C Acute pain is short-term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals. Chronic pain lasts 6 months or longer; the pain persists after the predicted trajectory. Persistent pain is another term for chronic pain. Breakthrough pain starts again or escalates before the next scheduled analgesic dose.

A patient has severe bilateral lower extremity edema. The most likely cause is a. an infection of the right great toe. b. Raynaud phenomenon. c. heart failure. d. an aortic aneurysm.

C Bilateral lower extremity edema is a result of a generalized disorder such as heart failure. An infection of only one extremity would lead to unilateral edema. Raynaud phenomenon does not result in bilateral lower extremity edema. Aneurysms do not cause bilateral lower extremity edema.

The general survey consists of four distinct areas. These areas include a.mental status, speech, behavior, and mood and affect. b.gait, range of motion, mental status, and behavior. c. physical appearance, body structure, mobility, and behavior. d. level of consciousness, personal hygiene, mental status, and physical condition.

C The general survey is a study of the whole person, covering the general health state and any obvious physical characteristics. The four areas of the general survey are physical appearance, body structure, mobility, and behavior. A general survey does not include assessment of mental status and physical condition.

When auscultating the heart of a newborn within 24 hours after birth, the examiner hears a continuous sound that mimics the sound of a machine. This finding most likely indicates a. the presence of congenital heart disease. b. a normal sound because of the thinner chest wall of the newborn. c. an expected sound caused by non closure of the ductus arteriosus. d. pathology only when accompanied by an increased heart rate.

C The murmur of a patent ductus arteriosus is a continuous machinery murmur, which disappears by 2 to 3 days.

The nurse is completing a general survey assessing the level of consciousness of a person. Which of the following findings are expected in this assessment? a. Patient appears drowsy and is having difficulty answering questions. b. No signs of acute distress are present. c. Patient is alert and oriented to person, place, time, and situation. d. Facial features symmetric with movement

C The normal/expected findings for level of consciousness includes alert and oriented to person, place, time, and situation along with patient attends to and appropriately responds to questions. A patient who is drowsy and having difficulty answering questions is demonstrating decreased level of consciousness and should be assessed further. No signs of acute distress are the expected findings when the nurse assesses overall appearance. Facial features symmetric are expected findings when completing a general survey assessing physical appearance but are not specifically associated with movement.

An ophthalmoscopic examination is an examination of the... a. inner ear. b. pharynx. c. internal structures of the eye. d. nasal turbinates.

C An ophthalmoscope is used for a funduscopic examination, which is an examination of the internal structures of the eye. An otoscope is used to visualize the ear canal and tympanic membrane. A flashlight or penlight and tongue depressor are used to examine the pharynx. An otoscope may also be used with a short, broad speculum to view the nasal turbinates and nares.

Arteriosclerosis refers to a. a variation from the heart's normal rhythm. b. a sac formed by dilation in the arterial wall. c. thickening and loss of elasticity of the arterial walls. d. deposition of fatty plaques along the intima of the arteries.

C Arteriosclerosis is the thickening and loss of elasticity of the arterial walls. A dysrhythmia is a variation from the heart's normal rhythm. An aneurysm is a sac formed by dilation in the artery wall. Atherosclerosis is the deposition of fatty plaques on the intima of the arteries.

To perform an accurate assessment of respirations, the examiner should a. inform the person of the procedure and count for 1 minute. b. count for 15 seconds while keeping fingers on the pulse and then multiply by four. c. count for 30 seconds after completing a pulse assessment and multiply by two. d. assess respirations for a full 2 minutes if an abnormality is suspected.

C Respirations should be counted for 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. Patients have conscious control over respirations; the examiner should not mention that respirations will be counted. Avoid counting respirations for 15 seconds because the results can vary +4 or -4 with such a small number. Respirations should be counted for 1 minute if abnormalities are suspected. Awarded 1.0 points out of 1.0 possible points.

Which of the following guidelines may be used to identify which heart sound is S1? a. S1 is louder than S2 at the base of the heart. b. S1 coincides with the A wave of the jugular venous pulse wave. c. S1 coincides with the carotid artery pulse. d. S1 coincides with the Q wave of the QRS electrocardiogram complex.

C S1 coincides with the carotid artery pulse. S1 is loudest at the apex of the heart. S1 coincides with the C wave of the jugular venous pulse wave. S1 coincides with the R wave (the upstroke of the QRS complex)

_________ pain continues for 6 months or longer. It results from abnormal processing by pain fibers from peripheral or central sites and does not stop when the injury heals. The level of pain intensity does not reflect the physical findings. can be malignant (cancer-related) or nonmalignant.

Chronic (persistent)

Lymph nodes are

small oval clumps of lymphatic tissue located at intervals along the vessels that filter fluid before it is returned to the bloodstream and remove harmful organisms

In the aging adult, arteriosclerosis may be present where the peripheral blood vessels.....

grow rigid. This causes a rise in systolic blood pressure.

You use basic medical aseptic techniques such as ______ with all patients to break the chain of infection.

handwashing and use of barrier precautions

tertiary prevention

minimizes the effects of disease or disability

Two types of risk

modifiable and unmodifiable

________ pain is derived from the skin and subcutaneous tissues

Cutaneous pain

transmission of pain

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

The nurse records that the patient's pulse is 3+ or full and bounding. Which of the following could be the cause? a. Dehydration b. Shock c. Bleeding d. Anxiety

D A full, bounding pulse (3+) reflects an increased stroke volume, as with anxiety and exercise. A weak, thready pulse may reflect a decreased stroke volume, as with dehydration. A weak, thready pulse may reflect a decreased stroke volume, as with shock. A weak, thready pulse reflects a decreased stroke volume, as with bleeding.

At the end of the examination, the examiner should... a. complete documentation before leaving the examination room. b. have findings confirmed by another provider. c. compare objective and subjective data for discrepancies. d. eview the findings with the patient.

D At the end of the examination, the examiner should summarize the findings and share necessary information with the patient. The examiner may take short notes during the examination; complete documentation should occur after leaving the examination room. The examiner should have findings confirmed only if the finding is abnormal and requires confirmation from another examiner. Subjective and objective data should be compared throughout the history and physical examination.

In pulsus paradoxus a. the rhythm is irregular; every other beat is premature. b. there is a deficiency of arterial blood to a body part. c. the rhythm is regular, but the force of the pulse varies with alternating beats. d. beats have weaker amplitude with respiratory inspiration and stronger amplitude with expiration.

D In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration. The rhythm is irregular and coupled in pulsus bigeminus; every other beat comes early or premature. A weak, thready pulse may result in a deficiency of arterial blood to a body part. The rhythm is regular in pulsus alternans, but the force varies with alternating beats of large and small amplitudes.Awarded 0.0 points out of 1.0 possible points.

Lymphedema is a. the indentation left after the examiner depresses the skin over swollen edematous tissue. b. a thickening and loss of elasticity of the arterial walls. c. an inflammation of the vein associated with thrombus formation. d. the swelling of an extremity caused by an obstructed lymph channel.

D Lymphedema is swelling of the limb caused by surgical removal of lymph nodes or damage to lymph nodes and vessels. Pretibial edema (pitting) occurs if an indentation is left after the examiner depresses skin over the tibia or the medial malleolus for 5 seconds. Arteriosclerosis is the thickening and loss of elasticity of the arterial walls. In deep vein thrombosis, a deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema.

Which of the following respiratory rates recorded for an infant without chronic illness would require further interventions and assessment by the nurse? a. 27 b. 30 c. 35 d. 55

D The nurse would need to complete further assessments and notify the physician for a respiratory rate of 55 breaths per minute. A respiratory rate greater than 50 would indicate tachypnea in an infant from 2 months to 12 months of age.

One of the leg's deep veins is the a. great saphenous. b. small saphenous. c. tibial. d. popliteal.

D The femoral and popliteal veins are the deep veins in the leg. The superficial veins are the great and small saphenous veins. The superficial veins are the great and small saphenous veins. The anterior tibial veins extend downward from the popliteal veins.

______ _______ pain comes from sources such as blood vessels, joints, tendons, muscles, and bone

Deep somatic

Three mechanisms keep blood moving toward the heart in the venous system... •

First, blood moves from the low-pressure system of the veins through the contraction of skeletal muscles that milk the blood back toward the heart. • Second, blood moves because of the pressure gradient caused by breathing. • And third, blood moves because intraluminal valves keep it flowing in one direction

The lymphatic system has three major functions: •

First, it conserves fluid and plasma proteins that leak out of capillaries. • Second, it is a major part of the immune system that defends the body against disease. • And third, it absorbs lipids from the intestinal tract.

This initiative identifies leading health indicators that are high priority health issues in the United States

Healthy People

Which of the following would be most appropriate when weighing an infant? a. Weigh the mother then have her hold the infant and subtract the mother's weight from the result. b. It's okay to weigh the infant fully dressed. c. The infant should be weighed undressed on a platform-type scale. d. If the infant can sit up, he/she can be weighed on a standard upright scale

Infants should be weighed undressed on a platform-type scale. A digital scale is preferred as they are usually more accurate. Using the process of weighing the mother then subtracting her weight after weighing her holding the infant, is an inaccurate procedure. Weight measurements of infants and children must be accurate to appropriate assess their growth patterns. In order to obtain the most accurate weight measurement of an infant, they should be weighed without clothes or diaper. It is inappropriate to weigh an infant using an upright scale. A platform-type scale placed on a counter is the safest and most accurate way to measure an infant's weight.

_____________ pain does not adhere to typical and predictable phases. It is pain due to a lesion or disease in the somatosensory system and implies an abnormal processing of the pain message due to an injury of the nerve fibers. It is sustained on a neurochemical level. This pain is very difficult to assess and treat because it is perceived long after the site of injury heals and thus turns into a chronic condition

Neuropathic pain

______ pain typically is predictable and time limited based on the extent of the injury. __________ pain is protective and can serve as a warning signal.

Nociceptive pain

Routes of temperature measurement

Oral, Axillary, Tympanic, Temporal artery, Rectal

Primary Prevention

Reduces the incidence of disease

_______ pain is felt at a particular site but originates from another location

Referred

_________ pain originates from musculoskeletal tissues or the body surface

Somatic

__________. _________ are applied in all patient care activities to prevent patients and health care workers from transmitting infection even in the absence of disease.

Standard Precautions

Use _____ _______ for all patients. Use____ _____ _____ for patients with documented or suspected transmissible infections.

Standard Precautions, transmission-based precautions

To obtain objective data about the circulatory system focus on the .....

neck vessels first, palpating each carotid artery separately, and auscultating each artery for a bruit; inspect the jugular venous pulse, and estimate the jugular venous pressure as needed.

___________ asepsis,such as sterile gloving, is a more stringent technique than ___________ asepsis.

Surgical Medical

This type of pain provides a protective physiological series of events that allows individuals to become aware of events that may cause tissue damage

nociceptive

Pain develops by ________ and _________- processing.

nociceptive, neuropathic

____________--based precautions, including airborne, droplet, contact, and protective environment, are used in addition to Standard Precautions for patients with highly transmissible pathogens.

Transmission

_________ pain originates from larger internal organs, such as the stomach, intestines, gallbladder, and pancreas.

Visceral

The lymph nodes that are inspected and palpated are

cervical, axillary, epitrochlear, and inguinal.

Significant individual and environmental factors create barriers to pain management. These factors include....

a lack of knowledge or misconceptions about pain and appropriate pain management in patients, caregivers and health care providers; cultural beliefs; lack of pain-management protocols; and poor access to care

An assessment of psychosocial factors that influence patient safety must include...

a review of a patient's health literacy, cultural background, and perception of health and safety.

Health Promotion Activities (Definition)

activities that help maintain or enhance health

Health care-associated infections lead to ..

adverse patient events and signifcantly higher health care costs that are often not reimbursed.

Hygiene needs, preferences, and the ability to participate in care change as people ......

age

Conduct a fall risk assessment in a hospital by using a validated tool containing major risk categories such as...

age, fall history, elimination habits, high-risk medications, mobility, and cognition. At a minimum, conduct the assessment on admission, following a change in a patient's condition, after a fall, and when the patient is transferred to a new health care setting.

Physical appearance includes an assessment of the person's ....

age, sex, level of consciousness, skin color, facial features, and overall appearance.

Several factors affect blood pressure, including ...

age, sex, race, diurnal rhythm, weight, exercise, emotions, and stress.

Cues for acute pain include...

an identifiable cause, a sudden onset, and a short duration.

Excess abdominal fat is ....

an important independent risk factor for disease, over and above that of BMI. Waist circumference measurement should be taken with BMI.

To obtain subjective data, ask questions that investigate ...

chest pain, dyspnea, or orthopnea; cough; fatigue, cyanosis, or pallor; edema; nocturia; and past or family history of cardiac disease.

Hand hygiene using ________ or _________ is the most effective basic technique in preventing and controlling infection transmission. Hands must remain in contact with antimicrobial agent long enough to clean hand surfaces.

antiseptic hand rub or soap and water

Vital signs can be delegated to assistive personnel when the patient's condition is stable; however, the skill of ________ pulse measurement cannot be delegated.

apical

The cardiac impulse that originates in the sinoatrial node spreads through the atria and to the ______ node, where it is delayed.

atrioventricular

The first heart sound (or S1) results from closure of the __________ valves.

atrioventricular

For a child, also observe interactions with the accompanying adult. Unexpected behavior on the part of the adult or child may be clues to...

child abuse, mental illness, or a developmental disability or disorder.

The thymus

behind the sternum in the mediastinum, develops T lymphocytes in the immune system in children but atrophies after puberty.

Assessment of a child's vital signs requires you to consider that the ___________ or ________ pulse is the best site for assessing an infant's or a young child's pulse, and when measuring respirations, infants tend to breathe less regularly

brachial , apical

A pulse lower than 50 beats/minute is _______ , whereas a pulse higher than 95 beats/minute is _______

bradycardia, tachycardia.

Patients should be encouraged to perform regular self-screening examinations for _____, _____, and _______ cancers.

breast, testicular, and skin

Peripheral artery disease (PAD) is caused by ....

cigarette smoking, diabetes, obesity, elevated levels of total cholesterol, and hypertension.

The rhythmic movement of blood through the heart is the ...

cardiac cycle,

The blood pressure level is determined by five factors:

cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and vessel wall elasticity.

The _________ __________ is located in the groove between the trachea and the sternomastoid muscle. Its pulse closely coincides with ventricular systole.

carotid artery

• Vascular structures in the neck include the ....

carotid artery and jugular veins

Proper application of personal protective equipment protects the patient and health care worker from transmission of pathogens. When entering isolation, apply a _______ first, followed by a _________ , then __________ and, finally, _______

cover gown, surgical mask or respirator, eyewear or face shield, clean gloves

Consideration of a patient's _________ may affect whether you make adaptations in the physical assessment and mode of communication while assessing in the context of a patient's health beliefs and practices and nutritional practices.

cultural background

It is important to learn a patient's routines and willingness to make changes in the environment, because ....

decisions on ways to change the environment require the patient's full participation.

Body temperature will _______ using measures that increase radiation, evaporation, convection, and conduction of heat.

decrease

Adjust the examination position, preparation, and sequence based on the patient's ....

developmental needs

the cardiac cycle has two phases: ______ when the ventricles relax and fill with blood, and __________ when the heart contracts and pumps blood into the pulmonary and systemic arteries.

diastole . systole,

in infants. The _________ ________ lets any remaining blood being directed to the lungs to be shunted into the aorta.

ductus arteriosus

• Proper handling and management of urinary catheters and drainage sets prevents infection by .....

eliminating a potential portal of entry for microorganisms.

Fever increases metabolism, which requires additional _____ and ______-

energy, Oxygen

During the examination...

explain each step and how the patient can cooperate. Proceed systematically and offer brief teaching, as appropriate.

Behavior considers ....

facial expression, mood and affect, speech and speech pattern, dress, and personal hygiene.

Diabetes mellitus and peripheral vascular diseases increase the patient's risk for.....

foot and nail problems.

Before birth, the ______ ________ allows oxygenated blood from the placenta to be shunted to the left side of the heart and out to the general circulation

foramen ovale

Nociceptive pain develops when

functioning and intact nerve fibers in the peripheral and central nervous systems are stimulated. It starts outside the nervous system from actual or potential tissue damage. Nociception occurs in four phases

Mobility is concerned with ....

gait, range of motion, and the presence of involuntary movement.

The major risk factors for heart disease and stroke are .....

high blood pressure, smoking, high cholesterol levels, and physical inactivity.

Acceptable vital signs fall within a normal range, with infant and children values_________ for pulse and respirations and _______ in blood pressure, compared with adults

higher, lower

Observe _______ measures to prevent the spread of infection.

infection control

Physical examination requires the sequential use of four assessment techniques:

inspection, palpation, percussion, and auscultation.

Body mass index (BMI)....

is a practical marker of healthy weight for height and an indicator of obesity or malnutrition.

The ________ ___________ give information about filling pressures and volume changes in the right side of the heart.

jugular veins

Chronic pain is....

not protective, may not have an identifiable cause, and has a dramatic effect on a person's quality of life; it varies in intensity, and usually lasts longer than 3 to 6 months, beyond the expected or predicted healing time.

Keep in mind that adolescents are self-conscious and introspective, thus when examining the genitalia, do it ....

last and quickly

A patient's developmental stage can create threats to safety because of ....

lifestyle choices, cognitive and mobility status, sensory impairments, and safety awareness.

Auscultation is ..

listening to sounds produced by the body, usually using a stethoscope. The heart, blood vessels, lungs, and abdomen are commonly auscultated areas.• Use the stethoscope's diaphragm for high-pitched sounds, such as breath, bowel, and normal heart sounds. Use the stethoscope's bell for soft, low pitched sounds, such as extra heart sounds or murmurs. • To ensure accurate auscultation, eliminate confusing artifacts, for example, by making sure the room is quiet and warm and not listening through clothing.

A Doppler may be used to ...

locate peripheral pulse sites or for blood pressure measurement when sounds are difficult to hear with a stethoscope alone

The lymphatic system is the same in children as in adults except that...

lymph nodes in children tend to be relatively large

Patients with actual or potential risks to safety require you to ...

make clinical judgments necessary in selecting the patient centered interventions that prevent and minimize the specific threats to safety.

Reduce patient anxiety by beginning with familiar, nonthreatening actions, such as ....

measuring height, weight, and vital signs. After the person puts on a patient gown, return to the room and clean your hands in his or her presence.

Multiple factors influence a patient's susceptibility to infection; patients may have one or more of these factors. Careful analysis of data and cues allow you to recognize patient risks such as ...

poor nutrition, stress, chronic disease, and treatments that compromise the immune response.

After examining the neck vessels, examine the ___________ Use inspection and palpation to assess the apical impulse and detect any heave or thrill.

precordium.

Transmission of infection can occur if the six elements of the infection chain are ...

present and uninterrupted.

Secondary prevention

prevents the spread of disease when it does occur

modulation of pain

process by which the sensation of pain is inhibited or modified

Transduction of Pain

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

Multimodal analgesia

provides for safe analgesic administration because it combines drugs with at least two different mechanisms of action to optimize pain control, which allows for lower-thanusual doses of each medication. Thus, an individualized multimodal regimen lowers the risk of side effects while providing pain relief that is as good as or even better than could be obtained if each of the medications were administered alone.

The vascular response to acute inflammation includes ...

rapid vasodilation, allowing more blood to be delivered near the location of the injury. The increase in local blood flow causes the redness and localized warmth at the site of inflammation, and the body releases chemical mediators that increase the permeability of small blood vessels, which leads to edema of interstitial spaces. The cellular response results in an increase in WBCs to the site of inflammation. If the inflammation becomes systemic, cellular responses result in increased WBCs in the bloodstream.

When palpating a peripheral pulse, assess three qualities:

rate, rhythm, and force.

Normal body flora and body system defenses help the body resist infection by ...

reducing the number of pathogenic organisms.

Proper storage and refrigeration of food prevents a _________ from developing in food.

reservoir of infection

Document _______ and _______ when measuring temperature, blood pressure, pulse, and oxygen saturation.

route, site

A patient in the community may seek _____ for specific health conditions that are often dependent on age or health risks, such as breast cancer(mammogram age 55 years and older), colorectal cancer (age 45 years and older), ear disorders (periodic tests at all ages), and obesity (all ages).

screening

The second heart sound (or S2) results from closure of the _______ valves

semilunar

Risk factors for venous disease include ...

standing, sitting, or bed rest because of the absence of the milking action of walking. Other risk factors are hypercoagulation, vein wall trauma, varicose veins, obesity, pregnancy, and genetic predisposition.

Body structure addresses ...

stature, nutrition, symmetry, posture, position, body build or contour, and any obvious deformities.

Veins are called capacitance vessels because they can ...

stretch and hold more blood when blood volume increases. This compensatory mechanism reduces preload on the heart.

Through the health history interview, you gather _______ data about a patient's condition and ______ data from observations of a patient's behavior and overall presentation. These data allow you to focus a physical examination appropriately

subjective, subjective

Position patients and make_______ available to reduce the risk for aspiration when providing oral care to unconscious patients.

suction

Orthostatic vital signs are taken when the patient is in various positions:

supine, sitting, and standing.

Signs of localized infection are more targeted and include ___ whereas the signs and symptoms of systemic inflammation are more generalized and include _____

swelling, redness, pain, and restriction of movement in the affected body part, fever, fatigue, nausea/vomiting, malaise, and lymph nodes that are enlarged, swollen, and tender.

Percussion is...

tapping the patient's skin with short, sharp strokes to assess underlying structures. This technique is used to assess the location, size, and density of an organ, detect a fairly superficial abnormal mass, or elicit a deep tendon reflex. • To perform percussion, hyperextend the middle finger and place its distal joint and tip firmly against the person's skin. Then use the middle finger of your dominant hand to strike the stationary finger at a right angle. Deliver two even, staccato blows, using a quick wrist action. • Each percussion sound has four components. Amplitude is the sound's intensity, which may be loud or soft. Pitch or frequency describes the number of vibrations per second. Quality (or timbre) is the subjective difference due to a sound's distinctive overtones. Duration is the length of time the note lingers.

Blood pressure can be taken in the thigh if

the blood pressure measured in the arm is excessively high.

Pain is a highly complex and subjective experience that originates from...

the central or peripheral nervous system or both.

Pulse pressure is...

the difference between the systolic and diastolic pressures and reflects the stroke volume.

When a patient is in a physical restraint, assess ...

the placement of the restraint, and note skin integrity, pulses, skin temperature and color, and sensation of the restrained body part.

Mean arterial pressure is ..

the pressure forcing blood into the tissues, averaged over the cardiac cycle.

The cardiac output equals

the stroke volume (or blood volume in each systole) times the rate (or beats per minute).

Palpation is ...

the use of touch to assess texture, temperature, moisture, and organ location and size. This technique also helps identify swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, and tenderness or pain. The fingertips are best for fine tactile discrimination. Grasping with the fingers and thumb is ideal for detecting position, shape, and consistency of an organ or mass. The backs of the hands and fingers are good for determining temperature. The base of the fingers or ulnar surface of the hand is best for assessing vibration.The fingertips are best for fine tactile discrimination. Grasping with the fingers and thumb is ideal for detecting position, shape, and consistency of an organ or mass. The backs of the hands and fingers are good for determining temperature. The base of the fingers or ulnar surface of the hand is best for assessing vibration. Light palpation detects surface characteristics and accustoms the person to being touched. Deep palpation assesses an organ or mass deeper in a body cavity. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs.

A fourth heart sound (or S4), due to ...

the vibration of noncompliant ventricles when the atria contract and push blood into them

A third heart sound (or S3), due to...

the vibration of ventricles that resist early, rapid filling;

The single most important step to decrease microorganism transmission is ...

thorough handwashing or using an alcohol-based hand rub. Perform hand hygiene before and after physical contact with each patient, after contact with body fluids or contaminated equipment, and after removing gloves.

After the AV node, the impulse spreads

to the bundle of His, the right and left bundle branches, and then to the ventricles.

The palatine, adenoid, and lingual _________s are located at the entrance to the respiratory and gastrointestinal tracts. They respond to local inflammation.

tonsils

4 phases of Nociceptive pain

transduction, transmission, perception, modulation

Before applying restraints, review the medical record for ...

underlying cause(s) of agitation and cognitive impairment, assess whether the patient has a history of dementia or depression, and review medications and current laboratory values.

Common environmental hazards to safety include...

vehicle accidents, poisonings, conditions causing falls, and fire hazards.

Preload is the ...

venous return that builds during diastole.