Fundamentals of Nursing Final Exam

The registered nurse is evaluating the statements of a student nurse after teaching about cultural assessment models. Which statement by the student nurse needs correction?

"Cultural assessment models are used to stereotype a particular group of patients."

Which recommendation will the nurse give to support the attachment process between the newborn and the mother?

"Hold your baby immediately after birth."

A parent of a 2-year-old child tells the nurse, "I am worried that my child is not eating properly and is not gaining weight." Which advice would the nurse give to the parent?

"Provide nutritious finger foods to your child."

Which instruction is beneficial for a patient who receives medication through the buccal mucosa?

"You should place the medication against the mucous membrane of the cheek."

After cardiac surgery, a patient is prescribed nothing by mouth (NPO). Which sequence of diet progression would the nurse follow? Arrange the steps in order.

1. Clear liquid 2. Full liquid 3. Pureed diet 4. Mechanical soft 5. Low-residue diet

The nurse is teaching a group of health care team members in a hospital setting about the interventions and guidelines related to fire. Which order of steps listed by a team member indicates effective learning?

1. Rescue and remove all patients in immediate dangerf 2. Activate the alarm 3. Confine the fire by closing doors and windows 4. Extinguish the firs with an appropriate extinguisher

Place the chain of infection in the correct order.

1. Reservoir 2. Port of exit 3. Mode of transmission 4. Port of entry 5. Susceptible host

Which injection is given to a patient receiving a tuberculin screening test?

Intradermal

Which information about oropharyngeal suctioning is true?

Is used to treat a patient who is able to cough effectively

Which rationale describes the benefit of passive relaxation therapy over progressive relaxation therapy in a patient who is bedridden and debilitated?

Is useful for patients who have no energy for muscle contraction

The nurse provides education for a patient's family member about bathing techniques. The family member asks, "Why do I need to use long strokes on the extremities, moving from distal to proximal areas?" Which explanation does the nurse give?

It promotes venous return

Health care professionals have an increased risk of musculoskeletal injuries, because their occupation involves lifting and transferring patients. How can the nurse reduce the risk of musculoskeletal injuries when lifting any person or object?

Keep trunk erect and bend the knees

A patient is experiencing a seizure during acute hospitalization. Which measure facilitates breathing and reduces the risk of musculoskeletal injury? Select all that apply.

Loosen the patient gown; Hold the limbs loosely; Place something soft under the head

What is the major preventive action that a nurse should know to inhibit catheter-associated infections? Select all that apply.

Maintain a closed urinary drainage system; Keep urinary drainage bags below the level of the bladder; Prevent urine backflow from the tubing and bag into the bladder

After reviewing medical records, the nurse identifies that the patients with which condition are more susceptible to infections? Select all that apply.

Malnutrition; Cancer; Diabetes; Critical illness

How would the nurse complete the discharge teaching for a patient with limited english proficiency who is to be discharge on a new medication?

Obtain an interpreter to facilitate communication of medication information

A patient is avoiding discussion of her cervical cancer diagnosis and postoperative care. How would the nurse plan to provide discharge teaching for this patient?

Provide only the information the patient needs to go home

Which intervention does the nurse perform to protect older adults in acute care settings? Select all that apply.

Providing bedrails for safety; Keeping the environment free from clutter; Explaining and demonstrating how to use the nurse call system; Responding quickly to nurse call systems and bed/chair alarms

Which behavior is suggestive of altered self-concept in a patient? Select all that apply.

Slumped posture; Overly apologetic; Hesitant speech; Avoidance of eye contact

Which risk factor for cerebrovascular disease is considered modifiable? Select all that apply.

Smoking five times a day; Sedentary lifestyle; High sodium and saturated fat in diet

When preparing a sterile work surface, what is the rationale for the nurse opening the outermost flap away from the body, keeping the arm outstretched and away from the sterile field?

To avoid contamination of the sterile field

The nurse instructs a patient to rinse his or her mouth with water after using a corticosteroid inhaler. Which statement describes the rational for this instruction?

To prevent a fungal infection

Which explanation would the nurse give when a patient with tuberculosis (TB) asks why isolation in a special kind of room is necessary? Select all that apply.

To prevent the spread of the disease to other people; To provide negative-pressure airflow

What is the goal of culturally congruent care?

To provide care to fit a patient's own values, beliefs, and traditions

A patient just gave birth to a beautiful baby. The mother says, "It's like a miracle. I don't have words to explain this feeling. My baby is perfect, like something out of this world. Thank you, God." Which feeling did the patient express?

Transcendence

Which is the major route of transmission for pathogens identified in the health care setting?

Unwashed hands of the health care worker

A patient with postural hypotension is hospitalized. Which safety measure would the nurse implement during ambulation?

Use of gait belt

The nurse provides education for a nursing student about factors that influence the process of bowel elimination. Which statement by the student indicates the need for further teaching?

"A fluid intake of 1.5 L per day for women is recommended to maintain normal bowel elimination."

The registered nurse is teaching a nursing student about procedure-related accidents. Which statement made by the nursing student indicates a need for further teaching?

"Accidents are mainly caused by the misuse of equipment."

Which patient response indicated the need for further teaching related to imagery therapy?

"All images can be used for all patients."

Which statement made by the nurse indicates assessment of learning resources for patient education?

"I need to determine the availability of teaching tools."

Which statement made by the nursing student indicates effective learning regarding the handling of sterile instruments?

"I will apply sterile gloves to handle sterile forceps."

Which statement by a patient with end-stage cancer indicates the need for spiritual intervention?

"I would like to ask my pastor about a final blessing."

Which statement made by the nurse indicates a correct understanding of physical examination positioning?

"While assessing a patient's heart, I'll ask the patient to assume the lateral recumbent position."

Place the statements from a patient-centered interview in the correct order.

1. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 2. "Tell me what brought you to the hospital." 3. "You say you've lost weight. Tell me how much weight you have lost in the last month." 4. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor, correct?" 5. "I have no further questions. Thank you for your patience."

Arrange the steps chronologically that would be followed by the nurse while performing open gloving.

1. Perform hand hygiene 2. Remove the outer glove package wrapper 3. Grasp the inner package and lay it on a clean surface above waist level 4. Open the package and identify the right and left gloves 5. Grasp the glove for the dominant hand touching only the inside surface of the cuff 6. Slip the fingers underneath the cuff of the second glove 7. Interlock the fingers of the gloved hands and hold them away from the body above waist level

Arrange the needs starting from most basic to the highest according to Maslow's hierarchy of needs.

1. Physiological 2. Safety and security 3. Love and belonging 4. Self-esteem 5. Self-actualization

Which site is frequently recommended for administering heparin injections?

Abdomen

Which type of documentation is based on the concept that all standards for normal assessment finding or for routine care activities are met unless otherwise documented?

Charting by exception

The nurse notes that the patient's indwelling catheter bag has been empty for 4 hours. Which action is priority?

Check for kinks in the tubing

A patient with multiple fractures has casts that make it difficult to move voluntarily. Which measure would the nurse take to decrease the risk of developing pressure injuries in this patient? Select all that apply.

Check the skin around the casts regularly for any signs of deteriorated skin condition; Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient; Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements

Which action does the nurse take to prevent skin breakdown in a drowsy patient who is incontinent of stools?

Checking frequently for soiling

Which task related to the use of patient restraints can be delegated to assistive personnel (AP)?

Checking on a restraint

Which assessment finding would the nurse report to the health care provider for a patient who is prescribed aspiration precautions? Select all that apply.

Choking; Gagging; Coughing; Difficulty swallowing

Which nursing action is inappropriate when checking for gastric residual volume (GRV) before each enteral feeding?

Discarding gastric contents

Which action will the nurse take for a patient who agrees with the nurse that expected outcomes were met?

Discontinue the care plan

Which action would the nurse perform during the evaluation phase of the nursing process?

Discusses the patient's connectedness with family after providing spiritual care

Which ego-defense mechanism may manifest as a patient with psychosis losing track of time and having disrupted normal though processes?

Dissociation

Which statement is true regarding respiratory changes because of immobility?

Entire lung lobe or whole lung collapse may be caused by immobility

Which equipment would the nurse have available when assessing the pH of gastric aspirate?

pH indicator strip

Which word does T represent in the SMART acronym as it relates to setting goals for the patient?

Timed

The nurse reviews the following documentation of an assessment of a 63-year-old female patient: "Patient has had abdominal pain for 6 days and has not had a bowel movement for 4 days. Normal bowel elimination pattern is every 2 to 3 days. No previous hospitalization. Abdomen distended. Patient verbalizes anxiety about upcoming test. Vital signs: Temperature 37°C, pulse 82 beats per minute and regular, blood pressure 128/72 mm Hg." Which data will the nurse note as a cluster? Select all that apply.

Abdominal distention; Change in bowel elimination pattern; Abdominal pain

While administering medications, a nurse realizes that she has given the wrong dose of medication to a patient. She completes an incident report and notifies the patient's health care provider. Which characteristic is the nurse demonstrating?

Accountability

Which action supports nurses in demonstrating accountability? Select all that apply.

Acquiring knowledge; Improving competencies; Acquiring technical skills

Which stage of behaviroal change is a patient exhibiting when they join a fitness club and attend aerobics class 3 nights a week?

Action

Which therapy involves the insertion of thin needles in a specific body region?

Acupuncture

In the FICA assessment tool for evaluating spirituality, what does the letter A stand for?

Address

Which nursing intervention helps to ensure that a patient receives 35% oxygen via Venturi mask as prescribed?

Adjust the barrel on the mask to the correct oxygen level

A patient with end-stage lung disease wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risks and benefits of the surgery to the family and discusses the patient's wishes. Which role is the nurse demonstrating for the patient?

Advocate

Which parameter would the nurse assess during the general survey? Select al that apply.

Age; Body odor; Signs of abuse; Race

The nurse is calculating the fall risk score of an 85-year-old patient using a standard fall assessment tool. Which factor contributes to the patient's overall fall risk? Select all that apply.

Age; Fall history; Medications

Which factor affects body temperature? Select all that apply.

Age; Stress; Hormonal changes

The nurse states that being self-directed and independent are essential for accomplishing goals. Which element of communication is the nurse describing?

Autonomy

The nurse is teaching a program on healthy nutrition at the senior community center. Which point would be included in the program for older adults? Select all that apply.

Avoid grapefruit and grapefruit juice, which impair drug absorption; For bone health, take a multivitamin that includes vitamin D; Cheese and eggs are good sources of protein

Which phrase best explains the term proprioception?

Awareness of the position of the body and its parts

A patient states that she gets anxious when she thinks about giving herself insulin. Which approach to intrapersonal communication would help in this situation?

Coach the patient to give herself positive messages about the ability to do this

When witnessing a patient giving informed consent prior to undergoing surgery, which action should the nurse perform? Select all that apply.

Confirm that the patient has understood the information about the surgery; Inform the health care provider if the patient refuses to undergo the surgery; Sign the consent form as a witness once the patient voluntarily gives consent

When the nurse shines a penlight into the patient's right eye, the left pupil constricts but no constriction of the right pupil occurs; when a distant object is brought closer to the patient, the left eye converges and it pupil constricts, but the right eye fails to constrict? Which finding would the nurse document? Select all that apply.

Consensual light reflex of the left eye is positive; Direct light reflex of the right eye is negative; Accommodation is present in the left eye

Which infection control practice would the nurse implement for a patient who is hospitalized for treatment of an infection with a multidrug-resistant organism?

Contact Precautions

Which type of transmission-based precaution requires a gown and gloves?

Contact precautions

The nurse identifies that which physiological change is considered to be normal for an older adult? Select all that apply.

Decreased saliva production; Loss of skin elasticity; Loss of visual acuity; Increased systolic blood pressure

Which condition does the nurse suspect in a patient whose assessment findings include memory deficit, disorientation, and reporting images that do not exist?

Delirium

A female patient requires an indwelling catheter. The patient should be placed in which body position?

Dorsal recumbent position

Which positioning of the patient would be appropriate while administering vaginal suppositories?

Dorsal recumbent position

The nurse provides postoperative care for a patient who underwent abdominal surgery. Which nursing action will help prevent constipation in this patient? Select all that apply.

Encouraging ambulation as early as possible; Increasing the amount of fluids in the patient's diet; Establishing a regular defecation schedule for the patient

Which intervention would the nurse perform to reduce the risk of thrombus formation in a bedridden patient? Select all that apply.

Ensure adequate fluid intake; Use elastic stockings on the legs; Perform leg, ankle, and foot exercises regularly

The nurse is caring for a patient who is at risk of falls because of an improper gait. Which measure would the nurse take to ensure patient safety? Select all that apply.

Ensure that the patient wears rubber-soled slippers; Encourage the patient to use crutches or walkers after ensuring correct use; Remove excess furniture from the path

During which step of the teaching process does the nurse determine the outcomes of teaching and measure a patient's level of achievement of learning objectives?

Evaluation

How would the nurse respond to a patient with an infection who states, "I am anxious and feeling depressed that I need to stay in this room with isolation precautions"?

Explain each item used for infection control and isolation procedures

Which nursing action would help an 8-year old admitted to the hospital after a bicycle injury adjust to the hospital stay?

Explain hospital routines such as mealtimes

Which observation by the nurse indicates positive outcomes in the patient who was previously in spiritual distress? Select all that apply.

Expressing increased hope of becoming healthy; Having a satisfactory relationship with. his partner; Being compliant with his medication regimen

The nurse finds that a patient has sudden weight gain, confusion, edema in the dependent areas, and crackles in the lungs upon auscultation. Which condition does the nurse suspect?

Extracellular fluid volume (ECV) excess

Which precaution would the nurse take to avoid environmental risks at a health care agency? Select all that apply.

Follow proper hand hygiene; Follow standard isolation procedures; Be aware of the location of material safety data sheets

Which approach would the nurse use with a hospitalized toddler?

Gain cooperation before attempting treatment

Which condition would the nurse suspect in a patient with decreased tendon reflexes?

Hypercalcemia

A patient reports intense thirst, decreased alertness, and has a serum sodium level of 170 mEq/L. Which condition would the nurse document in the patient's medical chart?

Hypernatremia

Which electrolyte balance would prompt the nurse to instruct the patient to consume dairy products?

Hypocalcemia

Which electrolyte disturbance is responsible for tetany and positive Chvostek's and Trousseau's signs?

Hypocalcemia

Which condition is common in patients with chronic diarrhea? Select all that apply.

Hypocalcemia; Hypernatremia; Hypomagnesemia

Which electrolyte imbalance will the nurse suspect in a patient with chronic diarrhea who demonstrates a positive Chvostek's sign? Select all that apply.

Hypocalcemia; Hypomagnesemia

Which electrolyte abnormality is least likely to be caused by the use of laxatives?

Hyponatremia

When assessing a patient's self-concept, the nurse would focus on which competent? Select all that apply.

Identity; Body image; Role performance

Which urinary elimination change is often observed as the period of immobility continues for a patient? Select all that apply.

Increased risk of renal calculi; Increased urine concentration; Increased risk of urinary tract infections

What are double-lumen catheters used for?

Indwelling catheterization

A patient with an abdominal wound from a motor vehicle accident comes into the emergency department with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. Which rationale explains this nursing action?

Infection prevention

Which action is an example of a dependent nursing intervention? Select all that apply.

Inserting a Foley catheter; Dressing a surgical incision wound; Administering an antidepressive drug

Upon evaluation of a patient with an elastic bandage on the arm, which observation would indicate impaired circulation? Select all that apply.

Pooling; Diminished pulses; Discoloration of the skin

When providing patient care, which trait is an obstacle to the nurse's use of critical thinking? Select all that apply.

Prejudice

When an older adult states, "Even though I turn up the volume on my television, I still can't seem to hear it." what condition would the nurse suspect?

Presbycusis

The nurse identifies that an older adult is experiencing which condition based on the patient's report of needing more ambient light for reading?

Presbyopia

Which age-group of children has imaginary playmates?

Preschoolers

A patient is undergoing treatment in a long-term care facility. Which type of immobility complication is likely to develop in the immobilized patient?

Pressure ulcers

Which level of prevention describes the nurse administering influenza vaccines to senior citizens at a health fair?

Primary

Which nursing action is appropriate when advancing the rate of a continuous tube feeding?

Programming the infusion pump at 10 to 40 mL/h for the intital feeding

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair?

Protein

Which characteristic of nursing goals and expected outcomes would the nurse consider when developing a care plan? Select all that apply.

Realistic; Attainable; Specific to patient

The nurse is caring for a Muslim patient who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month, in which Muslims fast during daylight for 28 days. The nurse understands that a good diet is important for the patient's wounds to heal. Which action would the nurse take when planning the patient's diet? Select all that apply.

Reschedule meals; Respect the cultural beliefs and assure the patient that medical needs will be taken care of

While assessing a patient with impaired mobility, the nurse prioritizes which type of related complication?

Respiratory

Which initial action would the nurse take when a patient's symptoms have changed from those that were recorded earlier?

Revise patient data by noting the change

When presenting education about the transmission of infection in the hospital setting, which disease would the nurse use as an example of when to implement Contact Precautions?

Scabies

A young child who is ill and the parent speak and understand a different language than the nurse. Which action would the nurse take to communicate with them?

Seek help with language interpretation and understanding cultural differences

Which question asked by the nurse while interviewing a patient presenting to the emergency department with a headache of 5 days' duration is an example of a closed-ended question? Select all that apply.

"Do you have pain now?"; "Is your headache sever?"; "Are you frightened that the diagnosis will be cancer?"

A group of adolescents approaches the nurse for advice regarding diet. They play football every day to prepare for an interstate sporting event scheduled for next month. Which dietary advice would the nurse give them?

"Drink water after exercise in hot climates."; "Take vitamin and mineral supplements."; "Eat iron-rich foods to prevent anemia."; "Increase carbohydrate intake."

Which response is the most appropriate by the nurse when asked by the patient about the use of therapeutic herbs?

"Herbs are not regulated, and some herbs can have health risks, especially if used with prescribed drugs."

Which statement made by the patient indicates that the patient's self-concept is improving after treatment? Select all that apply.

"I am pretty comfortable with my crutches."; "It is easier to administer insulin than I had imagined."; "Physical therapy is going well; I am walking further distances with each session."

The nurse explains how to provide eye care to a nursing student. Which statement made by the nursing student indicates effective learning?

"I should avoid chlorhexidine gluconate (CHG) solution for cleaning around the eyes."

Which statement made by the nursing student indicates effective learning regarding sterile procedures? Select all that apply.

"I should inform the patient to avoid touching the sterile supplies."; "If a patient is in pain, I should administer prescribed analgesics about a half-hour before the procedure begins."; "I should inform the patient to avoid sudden movements of any parts of the body covered by sterile drapes."

Which statement requires correction regarding legal guidelines of handwritten documentation?

"I should leave spaces with unknown information blank."

Which statement if made by the nursing student indicates a need for further teaching regarding examination of the carotid arteries?

"I should palpate the carotid artery vigorously."

After receiving instructions about pouring a sterile solution during a sterile procedure, which statement made by the nursing student indicates the need for further learning? Select all that apply.

"I should quickly pour the contents into the container."; "I should make sure that a receptacle for a solution is located far away from the sterile work surface edge."

Which statements by the nurse indicate effective planning for a teaching demonstration? Select all that apply.

"I will make sure all the equipment works."; "I will position the learner to provide a clear view of the skill being performed."; "I will encourage the patient to ask questions."

Which statement made by an adult patient demonstrates understanding of the nurse's healthy nutrition teaching?

"I will make sure that I eat a balanced diet and exercise regularly."

The nurse provides education for a nursing student about the require interventions while administering an enema. Which statement made by the student indicates effective understanding? Select all that apply.

"I'll place a waterproof pad under the patient's hips and buttocks."; "I'll cover the patient with a bath blanket, exposing only the rectal area and clearly visualizing the anus."; "If the patient has poor sphincter control, I'll position the patient on a bedpan in a comfortable dorsal recumbent position."

The nurse is teaching a parent about toddler care. Which instruction provided by the nurse indicates effective teaching?

"Immunize with all recommended vaccines."

An individual has accidentally been poisoned and loses consciousness. Which statement by the caregiver indicates an understanding of emergency care in this situation?

"It is never safe to induce vomiting in an unconscious victim."

The nurse is assessing the nutritional status of a 3-month-old baby. The mother informs the nurse that she feeds the baby cow's milk mixed with one spoon of honey. Which advice would the nurse offer to this mother? Select all that apply.

"Switch to formula milk rather than cow's milk."; "Stop giving honey to the baby."

Which statement by the nurse represents "background" when using the SBAR (Situation-Background-Assessment-Recommendation) technique?

"The patient has a history of congestive heart failure."

The registered nurse is teaching a nursing student about the advantages and disadvantages of selecting temperature measurement sites. Which statement by the nursing student indicates the need for further learning?

"The tympanic membrane site is difficult to access and requires major position changes."

Which statement by a nursing student regarding respiratory changes in immobile patients needs correction?

"There is increased cough productivity in immobile patients."

Which statement explains why middle-aged adults are referred to as the sandwich generation?

"They become responsible for their children and look after their parents too."

The nurse is preparing a 5-year-old patient for a wound dressing. Which statement by the nurse is likely to be misinterpreted by the child?

"This colored solution is not medicine; it's dye used to clean the wound."

A teenager tells the nurse, "For the past few weeks, I have been perspiring a lot, especially in the underarm area." How does the nurse respond?

"This is typical at your age; you could begin using an antiperspirant daily."

Which statement by the nurse would promote a positive perception in an older adult who states, "Now that I am retired, I don't feel like I contribute much to society."

"Your previous work experience still adds. a lot of value to the success of the company in which you worked."

While assessing the stength of pulse in a patient, the nurse finds the pulse to be diminished and barely palpable. Which rating would the nurse include in the medical report?

1

Which factor influences a patient's spirituality? Select all that apply.

Age; Gender; Culture; Religion; Education

Which condition is the consequence of using an oral airway that is too large?

Airway obstruction

Which stage is seen in general adaptation syndrome (GAS)? Select all that apply.

Alarm reaction; Resistance; Exhaustion

When discussing the tiers of transmission-based precautions at an education session, the nurse would state that Standard Precautions apply to which patient population?

All patients receiving care

Which action would the nurse take when preparing to assess a patient's abdomen, genitalia, and rectum?

Allow the patient to use the restroom

The nurse understands that an immobile patient is at high risk of thrombus formation. Which factor may contribute to this risk? Select all that apply.

Alteration or slowing of blood flow; Damage to the wall of the blood vessels; Alteration of the constituents in the blood

Which patient finding is the nurse likely to observe when assessing sleep patterns?

An infant taking several naps during the day

Which element is part of the chain of infection? Select all that apply.

An infectious agent; The source of pathogen growth; A susceptible host

Which individual is a member of a vulnerable population and at risk for health problems?

An older adult who is a homeless immigrant

Which condition might a patient with chronic kidney disease and decreased production of erythropoietin experience?

Anemia

The nurse is conduction a health awareness program on eating disorders. Which condition is an example of an eating disorder? Select all that apply.

Anorexia nervosa; Bulimia nervosa

Which site is preferred for subcutaneous injection? Select all that apply.

Anterior aspects of the thighs; Outer posterior aspect of the upper arms; Abdomen from below the coastal margins to the iliac crests

Which component helps maintain the body's fluid balance? Select all that apply.

Antidiuretic hormone (ADH); Atrial natriuretic peptides (ANPs); Renin-angiotensin-aldosterone system (RAAS)

Which technique would the nurse use when gloving during the suctioning procedure?

Applying clean gloves to both hands for oropharyngeal suctioning

Which intervention would the nurse follow while administering topical medications? Select all that apply.

Applying the topical medications with gloves and applicators; Applying each type of medication according to the directions of use; Documenting the location on the patient's body where the medication was placed

Which complication of dysphagia would the nurse be aware of? Select all that apply.

Aspiration pneumonia; Dehydration; Decreased nutrition status; Weight loss

A nurse accidentally gives a patient a medication at the wrong time. Which action would the nurse take first?

Assess the patient for adverse effects

The nurse is evaluating a patient who has an elastic bandage on the hand. The nurse palpates the extremity and assesses the patient's pulse, temperature, and capillary refill. Which explanation would provide the rational for the nurse's action?

Assessing for impaired circulation distal to the elastic bandage

The nurse is supervising assessment skills of nursing students. Which student action indicates a need for further instruction?

Assessing the carotid pulses simultaneously

Which step of the SOAP (subjective, objective, assessment, plan) format documentation reflects the nurse's interpretation of patient data?

Assessment

Which teaching tool is beneficial for patients with reading comprehension problems and visual deficits?

Audiovisual materials

Which technique is used by the nurse while performing a respiratory assessment, based on the image given?

Auscultation

A 50-year-old patient admitted with acute exacerbation of asthma is now clinically stable and is planned for discharge. The nurse teaches the patient about deep-breathing exercises to improve the patient's lung capacity. Which professional behavior is the nurse showing?

Autonomy

To enhance cultural awareness, which should the nursing students include in their self-examination?

Background, personal biases, and prejudices

Which factor would the nurse consider when communicating with adolescents?

Be alert for clues to their emotional state

Which strategy maintains good interpersonal communication? Select all that apply.

Be authentic; Take initiative in communicating; Respond appropriately to others

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this likely indicates a wound evisceration

When discussing cough etiquette during an education session, which information would the nurse include? Select all that apply.

Cover the nose and mouth with a tissue when coughing; Dispose of any contaminated tissue promptly; Perform hand hygiene after contact with respiratory secretions and contaminated objects; Place a surgical mask on the patient if it does not compromise respiratory function

Which precaution would the nurse take to prevent infections during injection administration? Select all that apply.

Cover the tip of the syringe with a cap; Clean the skin with an antiseptic swab; Avoid touching the needle with the contaminated area

Which action made by the patient indicates a need for correction regarding self-administering medication through a metered-dose inhaler using a spcer?

Covering the small exhalation slots with the lips

Which type of cultural competency recognizes biases, prejudices, and assumptions about other people?

Cultural awareness

The nurse is explaining the concept of being culturally competent to another nurse. Which is a component of cultural competence? Select all that apply.

Cultural awareness; Cultural knowledge; Cultural skills; Cultural encounters; Cultural desire

Which factor influences a patient's hygiene practices? Select all that apply.

Cultural beliefs; Personal values; Functional ability; Religious practices; Available resources

How often would the nurse change the feeding bag for a patient who is prescribed an intermittent enteral feeding?

Daily

The removal of devitalized tissue from a wound describes which process?

Debridement

Which site would the nurse choose when administering an intramuscular (IM) injection? Select all that apply.

Deltoid; Vastus lateralis; Ventrogluteal

Which method does the nurse use to teach insulin administration to a patient with newly diagnosed diabetes?

Demonstration

a 50-year-old male patient seen in the clinic has a flat affect. He tells the nurse that he has recently lost his job, and his wife of 26 years has asked for a divorce. Family history reveals that his father committed suicide at the age of 53. For which condition is the patient at high risk?

Depression

Which action would the nurse take to effectively educate a postsurgical patient? Select all that apply.

Determine the extent to which the patient can perform skills; Assess the patient's physical condition before teaching; If the patient is willing, involve the family member of the patient while teaching

Which intravenous fluid is appropriate for a patient who requires isotonic fluids to correct dehydration?

Dextrose 5% in water (D5W)

Which factor causing extracellular fluid volume (ECV) deficit would the nurse evaluate? Select all that apply.

Diarrhea; Vomiting; Nasogastric suctioning

Which factors represent the processes of respiration? Select all that apply.

Diffusion; Perfusion; Ventilation

Which point would be included in a teaching session for a group of high school student about health-promoting behaviors that improve sleep? Select all that apply.

Do not study in bed; Turn off cell phones at bedtime; Avoid drinking coffee or soda before bedtime

A patient with hypertension comes to the clinic for a checkup. On assessment, the nurse finds that the patient has experienced a weight loss of 5 pounds and has a poor nutrition status. Which physical sign is indicative of poor nutrition status? Select all that apply.

Dry scaly lips; Flaccid, wasted muscles; Spoon-shaped and brittle nails

Which clinical finding is likely to be seen in a patient who has suffered burns and has developed extracellular fluid volume (ECV) deficit? Select all that apply.

Hypotension; Cold, clammy skin; Dry mucous membranes

Which priority nursing action complies with The Joint Commission's standards and promotes patient safety when administering an enteral feeding by nasoenteric tube?

Identifying the patient using two identifiers

Which reason is appropriate for use of an enema? Select all that apply.

Immediate relief of constipation; Beginning a program of bowel training; Emptying the bowel before diagnostic tests or surgery

Which finding does the nurse anticipate while assessing a patient who has had limited mobility for the past month and is diagnosed with hemiplegia?

Increased calcium resorption

The nurse notes that a postoperative patient has a risk of infection. Which cue supports the diagnosis? Select all that apply.

Inflamed incision; Wound separation; Purulent drainage from the wound

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone and in bed. Which action by the nurse would be best in this situation? Select all that apply.

Inform the family of the risks associated with side-rail use; Discuss alternatives with the family that are appropriate for this patient; Ask the family to stay with the patient, if possible

Which stage of development according to Erikson involves teaching children impulse control and cooperative behaviors?

Initiative versus guilt

Which precaution would the nurse follow when administering a subcutaneous infection? Select all that apply.

Inject medication slowly; Pinch skin with the non dominant hand

A patient reports the loss of a small volume of urine while sneezing or coughing but no leakage of urine at night when sleeping. Which condition is the likely cause of this type of incontinence? Select all that apply.

Injury to the urinary sphincter; Weakness of the pelvic floor muscles

Which information would the nurse provide to the patient to ensure correct self-administration of insulin? Select all that apply.

Insulin is given as a subcutaneous injection; The insulin is absorbed more quickly when injected into the abdomen; The recommended sites of injection include the upper arm, thigh, abdomen, and buttocks

Which type of health care service is an example of tertiary care?

Intensive care

Which injection is preferred for allergy skin testing?

Intradermal injection

Which parenteral route of administration used the Z-track method?

Intramuscular route

Which route of administration is illustrated in this image?

Intramuscular route

The nurse explains to a patient that self-talk can improve self-awareness and help build a positive self-concept. To which level of communication does this refer?

Intrapersonal

A nursing student is learning about the standards of care for nursing. Which action would the student take to maintain high nursing standards? Select all that apply.

Learn about the Nurse Practice Act in the state; Follow updates of laws and policies practiced; Read current nursing literature in specified practice areas; Understand current legal issues affecting nursing practice

Which action is a principle of proper body mechanics when lifting or carrying objects?

Maintain a wide base of support.

Which action would the nurse take when preparing to perform a physical examination on an adult patient?

Maintain the appropriate room tempurature

The nurse recognizes which indication of a more positive self-concept in a patient who expereinced low self-esteem following a recent leg amputation? Select all that apply.

Making frequent eye contact during conversation; Verbalizing acceptance of a prosthetic leg; Maintaining adequate self-care; Interacting in a social setting; Discussing personal feelings about the loss of the leg

An older-adult patient has been prescribed a potentially toxic drug for treatment of arthritis. The patient and family have expressed concern about the drug. Which action by the nurse would demonstrate advocacy?

Provide information so the patient can make a treatment decision

The nurse uses a U-100 insulin syringe to inject insulin in the anterior and lateral parts of the thigh of the patient. Which nursing intervention would provide consistent absorption of the insulin?

Rotating the injections within the same body part

Which level of need according to Maslow is being addressed when the nurse discusses with the elderly couple about removing the throw rugs and low footstool and improving the lighting in the home>

Safety and security

Which laboratory value would the nurse assess for in a patient with muscle weakness who is taking furosemide?

Serum potassium

Which action will the nurse take during bedside hand-off at shift change?

Share information about the patient's condition

Which activity is classified as an instrumental activity of daily living (IADL)? Select all that apply.

Shopping; House cleaning; Preparing meals

Which position would be well tolerated by the patient with respiratory difficulties during a physical assessment of the anterior thorax and lungs?

Sitting

Which position is usually recommended when the nurse is assessing a patient's heart and lungs? Select all that apply.

Sitting; Dorsal recumbent; Supine

Which event that occurred during a sterile aseptic procedure indicates potential contamination? Select all that apply.

The sterile field was lower than the nure's waist; The package was slightly damp on the bottom; An instrument was out of the nurse's line of sight; The sterile syringe tip touched the nurse's clean glove

When evaluating the skill of open gloving, the nurse would correct which action by the nursing student?

The student sets the inner package of gloves on a clean, flat surface just below waist level

The nurse suspects which reason for a patient's acute onset of coughing during suctioning through an endotracheal tube?

The tip of the suction catheter is at the level of the carina

Which is true about the functional ability of most older adults? Select all that apply.

They are active; They are involved members of their communities; They remain functionally independent

Which statement is true regarding use of an abdominal binder after surgery? Select all that apply.

They protect incisions during movement; The binders are secured with Velcro strips; They are effective in providing comfort during coughing

Which patient would likely need teaching regarding dietary sodium restrictions?

A 65-year-old recently diagnosed with heart failure

Which instruction would the nurse give a patient who has altered urinary elimination about maintaining a healthy bladder?

"Avoid drinking tea, coffee, or chocolate drinks."

A patient is experiencing a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone. Which condition does the patient likely have?

Hypercalcemia

Which condition may cause functional incontinence?

Mobility difficulties

On admission, the nurse documents the following initial assessments. Which patient need would be the nurse's priority?

Pain related to oral ulcers

Which statement accurately describes body temperature measurement? Select all that apply.

Pulmonary artery catheters measure core temperature; Temperature values are affected by the measurement site

A patient has been advised to consume more complete proteins. Which food does the nurse suggest?

Soybeans

A postoperative patient is prescribed clear liquids. Which fluid would the nurse provide? Select all that apply.

Tea; Coffee; Carbonated beverages

By which age has the young adult usually completed physical growth?

20

Which patient is susceptible to having a barrel-shaped chest? Select all that apply.

A 45-year-old patient with emphysema; A60-year-old patient with tuberculosis; A 55-year-old patient with chronic obstructive pulmonary disease (COPD)

When caring for a patient 1 hour after a posterior chest tube insertion for treatment of a hemothorax, the nurse suspects a hemorrhage based on which assessment finding?

225 mL/h of bloody drainage

To place a patient in the semi-Fowler's position, the nurse would elevate the head of the bed to which angle?

30 to 45 degrees

Which pH range of urine is considered normal?

4.6 to 8

A mother hides a toy under a pillow while playing with her child and then observes that the child searches for the toy. At which age does the child acieve this developmental milestone?

8 months

Which patient is at greatest risk of developing multiple adverse effects of immobility?

80-year-old woman with a stroke

Which patient is at highest risk for spiritual disress related to grief?

A 30-year-old patient who underwent a mastectomy

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply.

Bedsore; Pressure sore; Pressure ulcer; Decubitus ulcer

A female patient living in the community as an immigrant travels out of the local area recently for work. She is married with two children and describes a history of domestic violence. She is the sole earner for her family and struggles to have enough money for food. Which patient factor makes her vulnerable? Select all that apply.

Being an immigrant; Having a history of domestic violence; Having an income that is not sufficient to meet her family's needs

Which physiologic symptom is observed in the nurse who has a sleep disorder because of working rotating shifts? Select all that apply.

Blurred vision; Decreased judgement; Slowed response time

Which information would the nurse include when teaching new parents about feeding their infants? Select all that apply.

Breast milk is recommended for the first year; Pureed vegetables can be gradually introduced after 6 months of age; Iron-fortified cereals can be introduced after 6 months of age

Which color would be sanguineous drainage on a patient's dressing?

Bright red

Which breath sound is heard only over the trachea in a healthy individual?

Bronchial

Which technique would the nurse use to assess the elasticity of the patient's skin?

By grasping the skin of the forearm with the fingertips and releasing it

The nurse provides education to a group of nursing students about the use of chlorhexidine gluconate (CHG) and includes which information?

CHG helps reduce the occurrence of health care-associated infections

A patient sustained a sever injury in a motor vehicle accident. The patient is unable to perform any movement. Which metabolic change would be found in the patient because of immobility? Select all that apply.

Calcium imbalance; Gastrointestinal disturbances; Alteration in the metabolism of protein

Which concern is common for persons who are between 35 and 64 years of age? Select all that apply.

Career-related changes; Caring for aging parents

Which factor must be assessed prior to the application of an abdominal binder? Select all that apply.

Effective coughing; Ability for deep breathing

Which system enables the ability to review patient education information provided to the patient during previous appointments?

Electronic health record

Which action performed for the patient is a nurse-initiated intervention? Select all that apply.

Elevating an edematous leg; Offering counseling for coping; Initiating early mobility protocols

Which benefit would the patient obtain from relaxation therapy? Select all that apply.

Elongation of muscle fibers; Decrease in respiratory rates; Reduction in the neural impulses sent to the brain

The nurse is caring for a bedridden patient. The nurse understands that immobility results in many metabolic changes. Which metabolic change may be found in this patient? Select all that apply.

Negative nitrogen balance; Decrease in the basal metabolic rate (BMR); Decreased appetite and slowing of peristalsis

Which type of report is given at the end of a shift so that the next nurse can follow the appropriate treatment plan and care for the patient?

Hand-off report

Which event in life can alter the self-concept of a person significantly? Select all that apply.

Having a child; Losing a child; Being promoted at work; Being diagnosed with a chronic illness

Which parameter increases in the body during general adaptation syndrome as a result of increased epinephrine? Select all that apply.

Heart rate; Blood glucose levels; Oxygen intake

Which reason would justify the use of restraints on a disoriented patient? Select all that apply.

Helps reduce the risk of patient injury from falls; Prevents the patient from removing intravenous (IV) infusions; Helps reduce the risk of injury to others by the patient

Which factor can be a risk for causing extracellular volume (ECV) deficit?

Hemorrhage

Chest tubes are used to treat which respiratory condition? Select all that apply.

Hemothorax; Pneumothorax

Which nursing action may contaminate the surface of a sterile item?

Holding the arm over the sterile field

Which nursing intervention would be beneficial when administering nasal drops to a patient with an ethmoid sinus infection? Select all that apply.

Holding the dropper 1 cm (1/2 inch) above the nares; Instructing the patient to breathe through the mouth; Tilting the patient's head back over the edge of the bed

Which nursing action needs correction regarding preparing an injection from a vial?

Holding the vial between the fingers of the dominant hand

A patient is diagnosed with end-stage renal disease. The patient tells the nurse, "I know I am going to be all right, and I will be healthy again. I believe in God, and He will make things right. My spouse and I have yet to tour the world." Which kind of spiritual belief does this patient exhibit?

Hope

Which position change will require the nurse to implement precautions to prevent orthostatic hypotension in a patient reporting dizziness, lightheadedness, and nausea?

Horizontal to vertical

The nurse observes the development of a pressure injury while providing care to a patient after hip replacement surgery. Which nursing intervention would have prevented the pressure injury?

Monitoring the surgical area for drainage

Which stage of the sleep cycle is decreased in the patient who has hypthyroidism?

N3

Which element would the nurse document after administering a medication to a patient? Select all that apply.

Name of medication; Dose of medication; Route of administration

Which datum will the nurse document as subjective when conducting an admission interview on a patient? Select all that apply.

Nausea; Light-headedness; Discomfort in the stomach

The nurse expects which additional assessment finding in a patient who is 10 days post-hysterectomy who reports purulent drainage at the incision site? Select all that apply.

Pain; Redness; Tenderness

Which technique is the nurse performing when using the sense of touch with the surface of the hand to collect clinical data about a patient's skin?

Palpation

Which patient is risk of fatigue?

Patient B

Which patient is suitable for oral medication administration

Patient C

A patient who was admitted to the hospital receives a red wristband for identification purposes. Which explanation is the significance of the wristband?

Patient allergies

The senior nurse is discussing with student nurses the serious reportable event included on the National Quality Forum (NQF) list. Which environmental event would be discussed? Select all that apply.

Patient death caused by burns from agency equipment; Patient death associated with falls; Patient death caused by electrocution

Which option is an appropriate goal for restorative care?

Patient will walk 200 feet without shortness of breath

The nurse is assessing four patients. Which patient does the nurse suspect to be at increased risk of pulmonary embolism because of immobility?

Patient with enlarged calf circumference

Which factor would the nurse consider before setting a goal that the patient will self-administer insulin injections? Select all that apply.

Patient's ability to meet the goal; Patient's cognitive function; Availability of the patient's support network to assist

Which information will the nurse elicit to help arrive at the probable cause when a patient is reporting severe abdominal pain in the right iliac region?

Some questions about the digestive system

Which intervention facilitates effective learning for older adults?

Speaking in a low tone of voice

Which statement is true regarding spiritualaity?

Spirituality has five overlapping constructs

The nurse would intervene when a nursing student takes which action when preparing a sterile field?

Stands close to the sterile field while opening the last flap

Which example will the nurse provide to explain situational factors that might cause stress when discussing the stress response with a patient? Select all that apply.

Sudden transfer of a job; Health-related problems in obese people; Caregiving responsibilities for a family member who has had a stroke

Which health risk in the adolescent age-group would the nurse address in a health promotion course? Select all that apply.

Suicide; Pregnancy; Sexually transmitted diseases

The nurse is feeding a patient with dysphagia. Which patient position should be avoided to reduce the risk of aspiration?

Supine

A patient presents with muscle twitching and cramping. On examination, the health care provider diagnoses the patient with calcium deficiency. Which dietary instruction would the nurse give to this patient? Select all that apply.

Supplement with vitamin D; Increase the intake of dairy products; Increase the intake of canned fish with bones

Which reason would a nurse have for applying a binder over an abdominal incision?

Supporting the wound

Which condition will the nurse suspect the health care provider to diagnose in a patient with a head injury whose sodium level is 109 mEq/L?

Syndrome of inappropriate antidiuretic hormone

Which approach is used to determine the outcome of patient teaching?

Teach-back

Which task delegated to a newly graduated nurse is the nurse's lowest priority?

Teaching self-hygiene home care

Which action would the nurse implement when feeding a patient who is prescribed aspiration precautions? Select all that apply.

Telling the patient to open the mouth; Encouraging the patient to feel the food in the mouth; Asking the patient to cough to clear the airway; Teaching the patient to raise the tongue to the roof of the mouth when eating

Which phase of the helping relationship is represented when the nurse recalls a funny shared experience with a patient shortly before the patient is transferred to another unit?

Termination

Which level of prevention describes a patient who experienced a myocardial infarction (hear attack) 4 weeks ago and is currently participating in daily cardiac rehabilitation exercise sessions?

Tertiary

Which information would the nurse provide in the discharge summary for a patient being discharged home? Select all that apply.

The contact information of the health care provider; The instructions for self-administration of medications; The signs and symptoms that the patient should report to the health care provider

Which instruction would the nurse include when teaching parents of infants about safety measures? Select all that apply.

The crib slats should not be more than 6 cm apart; The crib mattress should fir snugly; A federally approved car seat should be used for transporting the infant

The nurse assesses a patient's condition and suspects that the patient has footdrop. Which assessment finding supports the nurse's suspicion?

The foot is permanently fixed in plantar flexion

Which point would the nurse consider when administering enoxaparin? Select all that apply.

The injection should be given in the abdomen; The injection site should be pinched while the needle is being inserted

A patient dies after receiving care from the nurse. In what circumstance would the nurse be legally protected by Good Samaritan laws?

The nurse provides emergency care outside the hospital, performing a procedure for which the nurse has been trained.

Which statement about medication preparation and administration is correct?

The nurse who administers medication to the patient is responsible for any errors related to it

Which patient response indicated the patient has not mastered the integrity versus despair stage of Erikson's stage of psychosocial development? Select all that apply.

The patient feels she is a failure in her life; The individual states she regrets her life because she did not achieve her goals

The health care provider prescribes a clear liquid diet for a patient with gastritis. How would the nurse document the outcome of this prescription?

The patient had 2 cups of soup and denied discomfort

Which patient in a long-term care unit would be at high risk of developing pressure injuries? Select all that apply.

The patient with a spinal cord injury; A comatose patient; The patient with urinary incontinence: An immobile patient with excessive wound drainage

An adolescent has successfully mastered the stage of identity versus role confusion of Erikson's theory of psychosocial development. According to Erikson, which statement is accurate regarding how a person at this stage would behave?

The person is loyal towards others and his or her own ideals

Which factor may be contributing to the obesity of a middle-aged adult? Select all that apply.

Working in a sedentary job that is very stressful; Limited time to prepare meals and eating out four nights a week

Which technique would the nurse use to develop trust? Select all that apply.

Treat the patient with respect; Answer the patient honestly; Display consistent behavior when responding to patients

Which purpose does noninvaseive posititve pressure ventilation (NIPPV) serve? Select all that apply.

Treats obstructive sleep apnea; Improves alveolar ventilation; Maintains positive airway pressure

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage would be applied to this patient's pressure injury?

Unstageable

The nurse assesses an elderly patient admitted to the hospital after a fall. Which assessment finding would place the patient at risk of developing pressure injuries? Select all that apply.

Urinary incontinence; Immobilization because of a leg fracture; Impaired sensory perception

Which site is depicted in the image?

Vastus lateralis site

Which action describes an independent nursing intervention? Select all that apply.

Offering counseling for coping; Initiating early mobility protocols; Instructing patients on side effects of medications; Positioning patients to prevent pressure injury formation

The nurse walks by a patient's room and observes a caregiver changing the patient's gown after incontinence of urine. Which problem would the nurse address first?

The room door is open to the hallway

Which condition does the nurse suspect when a patient who has been on bed rest for several days attempts to walk with assistance and becomes dizzy and nauseated, with an elevation in his pulse rate from 85 beats per minute to 110 beats per minute?

Orthostatic hypotension

Under supervision of the registered nurse, a nursing student is caring for a patient from a different cultural background. Which action performed by the student nurse indicates the need for further teaching on transcultural nursing?

Offering generalized opinions during the assessment of the patient's worldview

Which group of patients is most at risk of severe injuries related to falls>

Older adults

Which statement describes evidence-based practice(EBP)?

Optimal patient care based on current research

Arrange the activities in the correct order for examination of the patient's abdomen.

1. Consent from the patient 2. Inspection of abdomen 3. Auscultation of abdomen 4. Palpation of abdomen

In which order does the nurse complete the steps of perineal care for a patient with an uncircumcised penis?

1. Place the patient in a supine position 2. Cover the thighs 3. Retract the foreskin 4. Clean the tip of the penis at the urethral meatus 5. Return the foreskin to its natural position 6. Clean the shaft of the penis and scrotum

The nurse is explaining and demonstrating the correct use of fire extinguishers at home to a group of adolescents. Which order of steps listed by an adolescent indicates effective learning?

1. Pull the pin to unlock the handle 2. Aim low at the base of the fire 3. Squeeze the handle 4. Sweep the unit from side to side

Place the following event in order of priority of nursing care, starting with the most important event.

1. The patient's vital signs change, showing a drop in blood pressure 2. The patient expresses concern about pain 3. The family comes to visit the patient 4. The charge nurse approaches the nurse and requests a report at end of shift

Which duty is the responsibility of the nurse as a patient educator? Select all that apply.

Explain concepts and facts about health to patients; Teach the patient to self-administer medications

Which patient does the nurse suspect to have an increased anteroposterior diameter of the chest>

A 50-year-old patient who has chronic lung disease

A patient has ingested poison and is found conscious and alert. Which action by the nurse is priority?

Calling the local poison control center or the national toll-free poison control center number

Which nursing action is a measure to reduce reservoirs of infection? Select all that apply.

Changing soiled dressings; Never raising a urinary drainage bag above the level of the site being drained unless it is clamped off; Dating bottles when opened and discarding them in 24 hours

Which action would the nurse perform to prepare a sterile field for a dressing change? Select all that apply.

Choose a clean, dry work surface above waist level; Remove bracelets and rings; Perform hand hygiene before handling equipment; Check the labels and condition of supply packaging and equipment

A 30-year-old patient has a recent diagnosis of osteoarthritis that has resulted in dependence upon an assistive device to ambulate, the need to move back into the home of a parent who will provide assistance, and an inability to perform job duties. The nurse identifies which factor as responsible for a change in the patient's self-concept? Select all that apply.

Chronic illness; Dependency on other; Physical impairment; Loss of job identity

Which factor is true regarding the development of pressure injuries? Select all that apply.

Chronic immobility can cause pressure injuries; Edema of the skin can cause pressure injuries; Dehydration of the body can cause pressure injuries

Which method would the nurse use to collect a urine specimen of a patient who has an indwelling catheter?

Clean the port with an alcohol swab, insert a sterile hub, and withdraw at least 3 to 5 mL of urine

Which factor can affect body image in a 15-year-old female patient? Select all that apply.

Cognitive and physical growth; Cultural and societal attitudes; Hormonal changes

Which intervention will the home care nurse include when developing a plan for managing activities of daily living (ADLs) in a patient with dementia? Select all that apply.

Collaborate with an occupational therapist; Consider the patient's sociocultural patterns when planning individual care; Include family caregivers in health care decisions; Make accommodations for sensory deficits

Which system is involved in providing built-in reminders and alerts for prescribing medications and diagnostic tests?

Computerized provider order entry system

While monitoring a postoperative patient, the nurse notes that the urine output has been 80 mL over 2 hours. Which action would the nurse to take?

Continue to monitor the patient

Which action is an example of the principle of patient-centered care that focused on respect for patient's values, preferences, and expressed needs? Select all that apply.

Engaging the patient in decision making about when to ambulate; Following the patient's normal routine of bathing in the evening rather than in the morning; Working with the family to bring in ethnic foods that the patient prefers

A patient with chronic stress reports sleep deprivation, chronic fatigue, and depression and has a blood pressure of 160/98 mm Hg and a heart rate of 78 beats per minute. Which factor will the nurse consider as the most probable reason for these symptoms?

Excessive wear and tear by hormones

Which strategy can the nurse implement when providing discharge instructions to an older adult with a hearing impairment? Select all that apply.

Face the patient; Present one concept at a time; Include the family caregivers in the teaching session

A single young adult interacts with a group of close friends from college and work. They celebrate birthdays and holidays together. In addition, they help one another through many stressors. Which term describes how the young adult views these individuals?

Family

Which complaint is common in patients with obstructive sleep apnea (OSA)?

Fatigue

Which manifestation would be observed in a patient with a serum calcium concentration of 12.2 mg/dL? Select all that apply.

Fatigue; Anorexia

Which physiologic implication would the nurse look for in a patient with obstructube sleep apnea (OSA)? Select all that apply.

Fatigue; Cardiac dysrhythmias; Excessive daytime sleepiness

When assessing a patient, the nurse suspects anorexia nervosa. Which behavioral finding may have led the nurse to this suspicion?

Fear of becoming fat despite being significantly underweight

Which element of the communication process is the patient displaying when frequently nodding and saying "I see" as the nurse explains the steps of a dressing change?

Feedback

Which nursing action addresses the most basic need according to Maslow's hierarchy of needs? Select all that apply.

Feeding the patient; Ensuring adequate fluid intake; Assisting with bladder elimination

Which action by the assistive personnel at bedtime requires the. nurse to intervene?

Giving a patient a cup of coffee

The nurse is assessing an Asian patient in a day care center. The nurse is developing a transcultural care plan for the patient who identifies both with his native culture and American culture. Which component should the nurse incorporate to provide culturally congruent care? Select all that apply.

Obtaining knowledge of the patient's health beliefs; Self-examining the nurse's own culture; Being open and accepting of cultural differences

The nurse is caring for a 50-year-old Hindu, Asian male patient with diabetes who is hospitalized after an incidence of high blood pressure. The nurse reviews the data and concludes that the patient's health care needs conflict with his health care practices. His cultural practices do not help him maintain normal blood pressure and manage his diabetes. How would the nurse implement culturally congruent care? Select all that apply.

Negotiate for a change in the patient's cultural practices; Preserve the patient's values relevant to maintaining his health; Modify the patient's lifestyle to develop a beneficial health care plan

In a public health clinic, the nurse notices bruises on the back and injuries to the genitalia and breasts of a female patient. The patient also appears apprehensive in the presence of her husband. Which action would the nurse take? Select all that apply.

Notify the relevant authorities; Discuss the findings with the woman when her husband is not around

Which food item suggested by the nurse contains significant amounts of fiber? Select all that apply.

Oats; Barley; Cornmeal

Which method of evaluating an elevated serum potassium level in a patient with renal failure is appropriate? Select all that apply.

Obtain serial serum potassium levels; Monitor the patient's electrocardiogram (ECG) strips

A postoperative patient refuses to eat and complains of a loss of appetite. Which intervention would the nurse perform o improve the patient's appetite?

Offer smaller and more frequent meals

Which teaching strategy will likely lead to effective learning in an older adult? Select all that apple.

Pausing frequently before providing any new information; Including the family caregiver in the teaching session; Using lay terms while providing medical information to the patient

Which statement indicates a correct understanding of sleep disorders?

Peptic ulcers predispose a person to wake up in the middle of the night

Which developmental theory focuses on the development of children's intellectual organization, specifically, how they think, reason, and perceive the world?

Piaget's theory of cognitive development

An 80-year-old patient demonstrates some confusion but no anxiety. The nursing assessment reveals that the patient is a fall risk because the patient continues to get out of bed without help despite frequent reminders. Which nursing intervention would be initiated to prevent falls for. this patient?

Place a bed alarm device on the bed

Which precaution would the nurse follow while performing surgical asepsis? Select all that apply.

Placing objects on the sterile field inside the 1-inch (2.5-cm) border; Holding sterile objects above waist level; Discarding objects immediately if the sterile package becomes wet; Opening sterile packages when a minimum number of people are walking into an area

Which complication is associated with invasive mechanical ventilation? Select all that apply.

Pneumothorax; Ventilator-associated pneumonia

The nurse is caring for a patient who recently had coronary bypass surgery. Which legal source of standards of care would the nurse use to deliver safe health care? Selects all that apply.

Policies and procedures of the employing hospital; State Nurse Practice Act; Regulations indentified in The Joint Commission's manual; The American Nurses Association (ANA) standards of nursing practice

Which action is correct by the nurse when performing a wound irrigation?

Positioning the patient's wound vertical to the collection basin

Which pulse site would the nurse assess for circulation of blood to the foot? Select all that apply.

Posterior tibial; Dorsalis pedis

Which measure would the nurse emphasize to prevent urinary tract infections in female? Select all that apply.

Proper handwashing; Wiping from front to back after voiding and defecation; Adequate fluid intake

Which action would be taken during the regular checkup of a healthy young adult patient?

Provide education regarding health promotion activities

Which measure would the nurse follow to maintain or enhance the self-concept of the postoperative patient during wound care? Select all that apply.

Providing privacy by draping the patient completely while exposing the dressing area; Maintaining hygiene by providing the patient a complete bath after the first day of surgery

Which type of wound drainage is shown in the image?

Purulent

The nurse provides care for an older adult during hospitalization and uses which technique to help the patient become more aware of time, place, and person?

Reality orientation

Which response by the nurse reflects critical thinking when provided to a patient with nausea and vomiting who asks to take a ginger supplement rather than the antiemetic medication that has been prescribed? Select all that apple.

Recognize that multiple solutions exist; Reflect on the nurse's own beliefs about alternative therapies; Examine the evidence-based information related to treatment of nausea and vomiting

When delivering patient care, which intervention does the nurse perform as part of the evaluation process?

Recognize unmet outcomes

Which actions meet legal guidelines for nursing documentation? Select all that apply.

Record facts; Correct all errors promptly; Chart only for yourself

Which is the probably route of administration advised for a patient prescribed a suppository form of medication? Select all that apply.

Rectal route; Vaginal route

Where would the nurse place a rectal suppository in an adult patient?

Rectal wall 10 cm into the rectum

The nurse applies an elastic bandage to a patient who has a sprained ankle. Which purpose would the bandage serve? Select all that apply.

Reduces edema; Provides support; Provides immobilization

Which option is an indication for a binder to be placed around a surgical patient with a new abdominal wound>

Reduction of stress on the abdominal incision

According to the circular transactional model, which element motivates a patient to communicate with the nurse?

Referent

Which evaluation of clinical judgments is being used when nurses meet after an unexpected death of a patient to discuss actions taken during the event and to identify what other treatments should have been performed?

Reflection

Which nursing intervention is the nurse least likely to provide to a patient diagnosed with stress urinary incontinence related to a weakened pelvic musculature?

Reinforcing teaching related to type 2 diabetes

A patient tells the nurse, "After my colostomy surgery, I don't know how I am going to live with a bag on my belly for the rest of my life." Which nursing action addresses the patient's self-concept and altered body image? Select all that apply.

Remaining sensitive to the patient's level of acceptance of any change; Discussing the availability of support groups for patients with colostomies

The nurse is delegating a task of measuring a patient's oxygen saturation (SpO2). Which instruction would be provided to the assistive personnel (AP)?

Report immediately if the SpO2 is below 95%

The nurse is attending to a patient who is immobilized because of a stroke. Which measure would the nurse take to prevent development of pressure ulcers in the patient? Select all that apply.

Reposition the patient every 1 to 2 hours; Place the patient in a 30-degree lateral position; Avoid pulling the patient when repositioning; Keep the patient well hydrated

A patient states, "My religion does not permit me to bathe today." Which action would the nurse take?

Request clarification of the patient's belief and adapt a plan for bathing accordingly

When there is a fire in the hospital, which action by the nurse is priority?

Rescuing patients in immediate danger

The nurse is caring for a patient who has been immobile for a month because of quadriplegia. Which risk would the nurse be prepared for? Select all that apply.

Risk of developing atelectasis; Risk of developing hypostatic pneumonia; Risk of ineffective coughing

A patient with which documented finding would be provided with a yellow wristband according to the American Hospital Association (AHA)?

Risk of falls

The nurse is teaching a parenting class to a group of pregnant adolescents. The nurse pretends to be the baby's father, and the adolescent mother asked to show how she would respond to the father. Which teaching approach did the nurse use?

Role play

Which right do patients have regarding medication administration? Select all that apply.

The right to know the name and purpose of medications; The right to refuse a medication regardless of the consequences

Which intervention would reduce the risk of pressure injury in immobilized patients? Select all that apply.

Using an objective, valid scale to assess patient's risk of pressure ulcer development; Using a device to relieve pressure when the patient is seated in a chair; Teaching the patient how to shift weight at regular intervals while sitting in a chair; Following this good rule: the higher the risk of skin breakdown, the shorter the interval between position changes

Which action of the nursing students needs correction regarding administration of eyedrops to a patient?

Using the eye medication for both the affected and unaffected eye of the patient

Which nursing measure is helpful in minimizing medication errors? Select all that apply.

Using two patient identifiers; Ensuring adequate rest for the nurse; Preparing medications for one patient at a time

When discussing modes of transmission for pathogens, which example would the nurse include? Select all that apply.

Vehicle; eating thawed meat that is partially cooked; Droplet; an infected person coughs or sneezes; Indirect; personal contact of susceptible host with contaminated inanimate object; Vector; internal transmission such as a parasitic condition between vector and mosquito; Airborne; germs that are suspended in the dust from a construction zone

Which closures are used to secure an abdominal binder?

Velcro strips

Which vitamin is fat-soluble and stored in the adipose tissue of the body? Select all that apply.

Vitamin A; Vitamin D; Vitamin E

Which measure would the nurse suggest to promote sleep in a patient? Select all that apply.

Void before going to sleep; Use extra blankets, if necessary; Wear soft, cotton nightclothes

The nurse provides teaching to a female patient about perineal care. Which method of washing the perineum indicates effective learning by the patient?

Washing from front to back using a clean washcloth

Which nursing intervention would be appropriate to reduce the risk of transmission of Mycobacterium tuberculosis? Select all that apply.

Wearing an N95 respirator; Wearing gloves while performing a physical examination of the patient

Which food item contains gluten and should be avoided in patients with celiac disease? Select all that apply.

Wheat; Rye; Barley

Which lifestyle factor would the nurse inform the patient about that might adversely affect sleep pattern? Select all that apply.

Working a rotating shift; Performing unaccustomed, heavy work; Participating in late-night social activities; Changing evening mealtime

Which nursing action best represents the role of collaboration with others for the patient's plan of car?

Works with colleagues and the patient's family to provide combined expertise in planning care

Which statement describes physical differences in younger and older adults?

Younger adults have less severe illnesses than older adult