Fundamentals of Success 3rd ed- final comprehensive
A practitioner orders the insertion of an indwelling urinary catheter (retention, Foley) as part of the patient's preoperative orders. Place the following steps of the procedure in the order in which they should be performed by the nurse. 1. _____ Don sterile gloves 2. _____ Open catheterization package 3. _____ Inflate and deflate catheter balloon 4. _____ Place a fenestrated drape over the patient's perineal area 5. _____ Maintain spread of labia while swiping directly over the urinary meatus 6. _____ Maintain spread of labia while swiping each labium with a separate cotton ball
-2, 1, 4, 3, 6, 5 2. The outside of the catheterization package is contaminated and should be opened with hands that have been washed with soap and water. 1. The inside of the catheterization package is sterile. Sterile gloves are on the top of the supplies included because all subsequent equipment in the package must remain sterile. 4. The nurse's sterile gloved hands then place the fenestrated drape over the patient's perineal area to continue with the establishment of a sterile field, 3. The integrity of the balloon (inability to inflate or deflate, presence of leaks) is established before insertion to prevent trauma to the patient. 6. Cleansing the labia moves from areas that are less likely to be contaminated than the urinary meatus as well as reduces the spread of microorganisms toward the urinary meatus. 5. Cleansing the urinary meatus last reduces the possibility of introducing microorganisms into the urinary meatus and bladder.
A patient states, "I like to have a bowel movement every morning." Which additional data collected by the nurse most supports a concern with perceived constipation? 1. Hard, dry stools are defecated daily 2. Laxatives are used excessively 3. Abdominal distention 4. Straining is required
2. The expectation of a daily bowel movement at the same time every day with the resulting overuse of laxatives, enemas, and/or suppositories support a concern with perceived constipation.
A charge nurse is delegating assignments to other members of the nursing team. Which actions should be implemented only by a Registered Nurse? Select all that apply. 1. _____ Taking the pulse of a patient with a dysrhythmia 2. _____ Teaching a patient how to change a colostomy bag 3. _____ Applying a condom catheter on a patient who is incontinent 4. _____ Changing the linen on an occupied bed for a comatose patient 5. _____ Transferring a patient from a bed to a chair with a mechanical lift
1, 2 1. A task of this complexity requires the knowledge and judgment of a Registered Nurse. If the caregiver is unable to assess the patient's condition adequately, this task has great potential for harm. In addition, it requires problem solving that may call for innovation in the form of an individually designed plan of care to address the presence of a dysrhythmia. 2. Patient teaching is a complex task. It requires knowledge of principles, such as identifying readiness to learn, progressing from simple to complex information, using motivational theory, and evaluating outcomes. Also, it requires knowledge of principles related to colostomy care such as: the bag opening must be at least 1 / 8 of an inch larger than the stoma, a pale stoma may indicate ischemia, and what to include in an assessment of the characteristics of intestinal output.
A patient consistently eats only 25% of every meal. What should the nurse do to encourage the dietary intake of this patient? 1. Help the patient to select preferred foods 2. Teach the patient to avoid fluids and foods that cause flatus 3. Encourage the patient to engage in light exercise before meals 4. Persuade the patient to drink between-meal supplements twice daily
1. A person's cultural, religious, educational, economic, and experiential background influences eating behaviors and food preferences. When familiar, preferred foods are available and personally selected, patients may feel that the care is individualized and that they are in more control, resulting in eating a greater percentage of the meal.
A patient develops diarrhea after receiving several intermittent tube feedings. What should the nurse consider is the cause of the diarrhea? 1. A high osmolarity of the feeding 2. An inadequate volume of the feeding 3. Failure to test for a residual before the feeding 4. Lying in the high-Fowler position during the feeding
1. A tube feeding formula usually is hypertonic, which exerts an osmotic force that pulls fluid into the stomach and intestine, resulting in intestinal cramping and diarrhea.
Which concept related to general growth and development should be considered by the nurse when caring for patients? 1. Individuals experience growth and development at their own pace 2. Each task must be achieved before moving on to the next task 3. Family members provide safe and supportive environments 4. Once a task is achieved regression is minimal
1. Although there is a predictable sequence to growth and development, there are individual differences in the rate and pace in which developmental milestones are achieved. Therefore, achievement of milestones is measured in ranges of time to allow for individual differences.
A patient sustains soft tissue injuries from a motor vehicle collision. Which intervention may be helpful in limiting the stress of both edema and bleeding into tissue? 1. Applying a cold compress 2. Exerting direct pressure 3. Performing effleurage 4. Providing massage
1. Cold lowers the temperature of skin and underlying tissue, which causes vasoconstriction, reducing blood flow to the area. This controls bleeding and slows the passage of fluid from the intravascular to the interstitial compartment, which limits edema.
A nurse is caring for a patient with prolonged diarrhea. For which common problem associated with prolonged diarrhea should the nurse assess the patient? 1. Skin breakdown 2. Deficient self-care 3. Sexual dysfunction 4. Disturbed body image
1. Diarrhea is related directly to a risk for damage to epidermal and dermal tissue. The gastric and intestinal enzymes present in feces are acids capable of eroding the skin.
A nurse working in a nursing home routinely administers digoxin (Lanoxin) 0.125 mg by mouth to a patient every morning. Which patient response should alert the nurse to withhold the drug? 1. Diplopia 2. Tachypnea 3. Hypertension 4. Hyperthermia
1. Digoxin (Lanoxin) can cause sensory changes, such as diplopia (double vision), halos, colored vision, blind spots, and flashing lights. If any of these symptoms of toxicity occur, the medication should be withheld and a serum digoxin level assessed to determine if the drug is exceeding its therapeutic range of 0.5 to 2 ng/mL.
What should the nurse do when providing a back massage for a patient? 1. Use continuous light gliding strokes with fingertips when finishing 2. Concentrate deep circular motions over the scapulae and sacrum 3. Knead firmly and quickly over the shoulders and the entire back 4. Massage gently over the bony prominences of the vertebrae
1. Effleurage involves long, smooth strokes sliding over the skin that have a relaxing, sedative effect. When performed slowly with light pressure at the end of a back massage, it is called "feathering off."
A practitioner orders antiembolism hose for a patient. Which is the most important action the nurse should teach the patient? 1. Monitor the heels and toes for blanchable erythema every 8 hours 2. Put them on after the legs have been dependent for 5 minutes 3. Apply body lotion before putting them on 4. Remove and reapply them once a day
1. Elastic stockings provide external pressure on the patient's legs to prevent pooling of blood in the veins while not interfering with arterial circulation. Inspecting the skin three times a day is adequate.
A patient has a temperature of 102°F and complains of feeling cold. Which additional response should the nurse expect during this onset stage of fever? 1. Shivering 2. Diaphoresis 3. Dehydration 4. Flushed skin
1. Feeling cold, chills, and shivering are adaptations associated with the onset (chill, initiation) stage of a fever. During this stage the body responds to pyrogens by conserving heat to raise body temperature and reset the body's thermostat.
Which early response indicates to the nurse that the patient is experiencing hypoxia? 1. Increased heart rate 2. Difficulty breathing 3. Bradypnea 4. Pallor
1. Hypoxia is insufficient oxygen anywhere in the body. To compensate for this lack of oxygen, the heart increases its rate to improve cardiac output, thereby increasing oxygen to all body cells.
A nurse places a patient who had abdominal surgery in the semi-Fowler position. What is the rationale for this nursing intervention? 1. Supports ventilation 2. Facilitates the passing of flatus 3. Encourages urinary elimination 4. Promotes drainage in the portable wound drainage system
1. In the semi-Fowler position the abdominal organs drop by gravity, which permits maximum thoracic excursion. In addition, slight flexion of the hips reduces abdominal muscle tension, which limits pressure on the suture line and facilitates diaphragmatic (abdominal) breathing.
A nurse in the postanesthesia care unit is assessing several patients in pain. Patients in which age group should the nurse anticipate will be most sensitive to pain? 1. Infants 2. Adolescents 3. Older adults 4. Pregnant women
1. Infants react to pain in an intense way including physical resistance and lack of cooperation. Separation of an infant from the usual comforting contact with parents contributes to separation anxiety, which in turn lowers pain tolerance, which intensifies the pain experience. Infants express pain by irritability, rolling of the head, flexing the extremities, overreacting to common stimuli, an inability to be comforted by holding and rocking, and physical responses indicating stimulation of the sympathetic nervous system.
Which question by the nurse best assesses a patient's pain tolerance? 1. "At what point on a scale of 1 to 10 do you feel that you must have pain medication?" 2. "What activities help distract you so that you don't feel the need for medication?" 3. "How intense on a scale of 1 to 10 is the pain that you feel right now?" 4. "Do you take pain medication frequently?"
1. Pain tolerance is the maximum amount and duration of pain that a person is willing to tolerate. It is influenced by psychosociocultural factors and usually increases with age.
A patient has a history of chronic pain because of arthritis but dislikes taking large doses of analgesics. What concept unique to unrelieved chronic pain should the nurse consider when caring for this patient? 1. Generally, pain is better tolerated as the duration of exposure increases 2. Pain minimally interferes with activities of daily living 3. Usually, pain is related to the current pathology 4. Pain rarely affects the immune response
1. Persistent chronic pain becomes an unchanging part of life. As the duration of exposure increases, the individual may learn cognitive and behavioral strategies to cope with the pain.
A nurse transfers a patient from a bed to a wheelchair. What is the most important nursing intervention after placing the patient in the wheelchair? 1. Ensure the patient's popliteal areas are not touching the seat edge 2. Attach the patient's transfer belt to clips on the wheelchair 3. Support the patient's back with a pillow 4. Put the patient's feet flat on the floor
1. Pressure on the popliteal areas can cause damage to nerves and interferes with circulation and must be avoided.
Which level need in Maslow's Hierarchy of Needs is most supported when the nurse places the patient's get-well cards where the patient can see them? 1. Love and belonging 2. Safety and security 3. Physiological 4. Self-estee
1. Taping a patient's get-well cards to the wall where the patient can see them supports the patient's need to feel loved and appreciated and meets loveand belonging needs according to Maslow's Hierarchy of Needs.
What should the nurse do first when the vent of a patient's double-lumen nasogastric tube for decompression becomes obstructed? 1. Instill 10 mL of air into the vent lumen 2. Place the patient in the high-Fowler position 3. Position the vent below the level of the stomach 4. Withdraw 30 mL of gastric contents from the drainage lumen
1. The only way to reestablish patency of the air vent lumen of a double-lumen nasogastric tube is to instill air into the lumen. The injected air will push the secretions blocking the lumen back into the stomach where the fluid can be removed by the drainage lumen. Keeping the end of the air vent lumen higher than the stomach prevents reflux of gastric contents into the air vent lumen.
A nurse is giving a patient a bed bath. What should the nurse do to increase circulation? 1. Wash the extremities with firm strokes toward the heart 2. Soak the feet in warm water for at least 20 minutes 3. Expose just the areas that are being washed 4. Ensure that the water is 120°F to 125°F
1. The pressure of firm strokes on the skin moving from distal to proximal areas increases venous return. When venous return increases, cardiac output increases.
A patient prefers and excessively maintains the supine position. For what potential problem associated with this position should the nurse assess the patient? 1. Pressure on the heels 2. Pressure on the trochanters 3. Internal rotation of the hips 4. Flexion contracture of the knees
1. The supine position is a back-lying position that results in pressure on the heels (calcaneus), which have minimal tissue between the bone and skin, making them vulnerable to the development of pressure ulcers.
A nurse going off duty is making rounds with the nurse coming on duty and provides a report on each patient in the district. Which information given by the nurse is most meaningful? 1. The patient was given an antiemetic and reports resolution of the nausea 2. The patient's family members just visited and the patient appears happy 3. The patient seems less anxious than earlier in the day +4. The patient's blood pressure is now stable
1. This information includes a nursing intervention and an evaluation of the outcome, which is the most specific and complete of all the options.
A nurse wants to influence a patient's beliefs so that new behaviors can be incorporated into the patient's lifestyle. Within which learning domain does the nurse need to direct teaching? 1. Affective 2. Cognitive 3. Physiological 4. Psychomotor
1. This is an example of learning in the affective domain. In the affective domain, learning is concerned with feelings, emotions, values, beliefs, and attitudes.
A patient with terminal cancer says to the nurse, "I've been fairly religious, but sometimes I wonder if the things I did were acceptable to God." What is the best response by the nurse? 1. "Not knowing what the future brings can be a frightening thought." 2. "God will appreciate that you went to religious services." 3. "If you were good, you have nothing to fear." 4. "In life, all we have to do is try to be good."
1. This recognizes the patient's feelings.
Which should the nurse use to best provide oral care to an unconscious patient? 1. Gauze-wrapped tongue blades with a saline solution 2. Half-strength mouthwash and saline 3. Packaged glycerin swabs 4. Nonfoaming toothpaste
1. Unconscious patients often bite down when something is placed in the mouth. Therefore, a padded tongue blade should be placed between the upper and lower teeth to help keep the mouth open during oral care. Other padded tongue blades, wetted with a small amount of saline, should be used to clean the oral cavity. This technique does not require flushing the oral cavity with fluid, which may compromise the airway.
Which nursing action is specifically related to the principle, the greater the base of support, the more stable the body? 1. Using a walker when ambulating 2. Locking the wheels of a wheelchair 3. Holding objects close to the body when walking 4. Keeping the back straight when lifting an object
1. Walkers surround a person on three sides and provide four points of contact with the floor. This wide base provides the best support available for assisted ambulation.
A practitioner orders a vest restraint for a patient in a wheelchair. What should the nurse do to prevent the most serious complication associated with the use of a vest restraint? 1. Remove the vest every 2 hours for range of motion 2. Ensure the V opening is positioned in the front 3. Check the circulation every 30 minutes 4. Inspect the skin every 2 hours
2. The V opening of a jacket restraint should be in the front of the patient to prevent pressure against the neck, particularly the trachea. The rounded side of the restraint goes across the patient's back.
A nurse must administer a sedative to a patient before surgery. What should the nurse do first? 1. Verify that the preoperative checklist is completed 2. Check that the surgical consent is signed 3. Ensure an intravenous line is in place 4. Assess vital signs
2. The consent for surgery must be signed before preoperative medications are administered because they depress the central nervous system, impairing problem solving and decision making.
Which word best describes the concept of one's adaptive capacity? 1. Treatment 2. Flexible 3. Threat 4. Illnes
2. A major component of adaptive capacity is the ability to be flexible in all realms of human dimension, as a person seeks to regain homeostasis or balance. Adaptive capacity refers to the quality and quantity of personal resources one can draw on to regain balance after one is threatened.
Which nursing action is most appropriate in relation to the concept, "Bacteria and enzymes in stool are irritating to the skin"? 1. Wearing a pair of sterile gloves when collecting a patient's stool for culture and sensitivity 2. Applying a moisture barrier to the perianal area of incontinent patients 3. Encouraging a patient to drink a cup of cranberry juice daily 4. Toileting a confused patient before each meal
2. A skin barrier protects the skin from the digestive enzymes in feces.
A nurse identifies that an adult patient is exhibiting antisocial behavior. According to Erikson, the negative resolution of which stage of development is most commonly associated with antisocial behavior? 1. Preschool age 2. Adolescence 3. School age 4. Infancy
2. Adolescents (age 12 to 20 years— Identity versus Role Confusion) strive to develop a personal identity and autonomy. This is a turbulent time as the adolescent internalizes the dramatic physical changes and the psychological stressors of new social conflicts. It is common for adolescents to experience mood swings, make decisions without having all the facts, challenge authority, and assert the self. However, these behaviors are left behind when the developmental tasks of adolescence are positively resolved. Negative resolution results in assertive, rebellious, and antisocial behavior.
Which mechanism is designed to facilitate tracking a patient's progress as a costcontainment strategy in managed care? 1. Primary nursing 2. Critical pathways 3. Functional method 4. Quality management
2. Critical pathways are a case management system that identifies specific protocols and timetables for care and treatment by various disciplines designed to achieve expected patient outcomes within a specific time frame. The purpose is to discharge patients sooner, thereby reducing the cost of health care.
A nurse identifies a patient's perception of health. What can the nurse do as a result of obtaining this information? 1. Identify the patient's needs based on Maslow's Hierarchy of Basic Human Needs 2. Provide more meaningful assistance to help the patient regain a state of health 3. Help the patient prevent the occurrence of human responses to disease 4. Choose a place for the patient along the health-illness continuum
2. Health perception reflects a person's knowledge, behavior, and attitudes regarding illness, disease prevention, health promotion, and what constitutes a healthy lifestyle. An assessment of these factors captures the uniqueness of each individual and provides essential data that must be considered before needs are identified and a plan formulated.
A nurse decides to give a partial bath to a patient instead of a complete bath. When the nurse made this decision, the nurse was working: 1. Dependently 2. Independently 3. Collaboratively 4. Interdependently
2. Providing hygiene, an activity of daily living, is within the scope of nursing practice.
A nurse is teaching a group of nursing assistants about the administration of enemas. Which enema solution that works by irritating the intestinal mucosa should be included in the teaching? 1. Oil 2. Soap 3. Tap water 4. Normal saline
2. Soap irritates the intestinal mucosa and thus stimulates the circular and longitudinal muscles of the intestinal wall, which respond with wave-like movements (peristalsis) that propel intestinal contents toward the anus.
A nurse is administering medication to a patient in a geriatric facility. The nurse anticipates the risk of drug toxicity in this older adult primarily because of a decrease in the patient's: 1. Serum calcium level 2. Glomerular filtration 3. Red blood cell count 4. Frequency of voiding
2. The glomerular filtration rate is reduced by as much as 46% at 90 years of age. In addition, decreased cardiac output can reduce the amount of blood flow to the kidneys by as much as 50%. When the glomerular filtration rate declines, the time necessary for half of a drug to be excreted increases by as much as 40%, which places the older adult at risk for drug toxicity.
A home health-care nurse is helping a patient negotiate the health-care system within the community. Which word best reflects this role of the nurse? 1. Leader 2. Resource 3. Surrogate 4. Counselor
2. The health-care delivery system in the United States is complex and can be confusing at a time when patients have the least energy to explore and negotiate intervention options. When functioning as a resource person, the nurse identifies resources, provides information, and makes referrals.
A patient is admitted to the emergency department after sustaining a crushing injury at work. Which characteristic of blood pressure should alert the nurse to impending shock? 1. Rising diastolic 2. Decreasing systolic 3. Korotkoff's sounds 4. Widening pulse pressure
2. The initial stage of shock begins when baroreceptors in the aortic arch and the carotid sinus detect a drop in the mean arterial pressure. The systolic pressure is the pressure in the arteries during ventricular contraction.
Health teaching regarding a kitchen fire should include what to do if grease in a frying pan catches on fire. The nurse teaches that in this situation people should first call 911. What should people be taught to do next? 1. Pour water in the pan 2. Put the lid on the pan 3. Close the door to the kitchen 4. Use a class A fire extinguisher
2. The lid of the frying pan deprives the fire of oxygen. Without oxygen to support combustion the fire will go out.
What is the most important purpose of the orientation phase of the assessment interview? 1. Collect data 2. Build rapport 3. Identify problems 4. Establish priorities
2. The orientation phase (also called the introductory or pre-helping phase) of a therapeutic relationship sets the tone for the rest of the relationship. A rapport develops when the patient recognizes that the nurse is willing and able to help and can be trusted.
A nurse is caring for a patient using an incentive spirometer. What behavior observed by the nurse indicates that further teaching is necessary? 1. Inhales slowly and deeply using the spirometer 2. Tilts the incentive spirometer while breathing in 3. Raises the inspiratory goal on the spirometer once a day 4. Takes several regular breaths and then uses the spirometer again
2. The patient is using the incentive spirometer incorrectly and needs further teaching. An incentive spirometer must be held in an upright position. A tilted flow-oriented device requires less effort to reach the desired inspiratory volume. A tilted volume-oriented device will not function correctly.
Which patient should the nurse identify will benefit the most from soaking the feet as part of a bath? 1. Has a preference for taking showers 2. Has lower extremity arterial disease 3. Is ambulating with paper slippers 4. Is on bedrest
2. The warm water used to soak the feet promotes vasodilation, which improves circulation to the most distal portions of the feet. Soaking the feet loosens dirt and limits scrubbing, which prevent trauma to the skin. Soaking the feet should be done for just several minutes because prolonged soaking removes natural skin oils, which dries the skin and makes it prone to cracking.
*omit we don't use this anymore* What action should the nurse use to landmark the left dorsogluteal site for an intramuscular injection? 1. Locate the lower edge of the acromion and the midpoint of the lateral aspect of the arm 2. Identify the line from the posterior superior iliac spine to the greater trochanter 3. Place the heel of the left hand on the greater trochanter 4. Palpate the anterior lateral aspect of the thigh
2. These anatomical landmarks help to identify the dorsogluteal site. This site contains the well-developed gluteus muscles, particularly the gluteus maximus, in the buttocks
A practitioner orders peak and trough levels for a patient receiving an antibiotic. What time should the nurse obtain a blood sample to determine a trough level when the antibiotic was administered at 12:00 noon? 1. 11:00 AM 2. 11:30 AM 3. 12:30 PM 4. 1:00 PM
2. Thirty minutes before or closer to the next scheduled dose is the most appropriate time for a trough blood level to be obtained. The serum level of the drug will be at its lowest.
A patient is admitted to the hospital with a medical diagnosis of diverticulitis. What is the best question the nurse should ask when obtaining an admission history from this patient? 1. "Have you ever had any previous episodes of diverticulitis?" 2. "What led up to your coming to the hospital today?" 3. "How long have you had diverticulitis?" 4. "What did you eat yesterday?"
2. This invites the patient to expand on and develop a topic of importance that relates to the current problem.
A patient appears agitated and states, "I'm not sure that I want to go through with this surgery." Which response by the nurse uses the technique of paraphrasing? 1. "Are you saying that you want to postpone the surgery?" 2. "You are undecided about having this surgery?" 3. "You seem upset about this surgery." 4. "Tell me more about your concerns."
2. This is an example of paraphrasing, which restates the content of the patient's message in similar words.
Which is the most important nursing intervention to help prevent falls from physical hazards in a hospital? 1. Using an over-bed table 2. Ensuring adequate lighting 3. Storing belongings in a safe place 4. Positioning the telephone within easy reach
2. This provides for the safety of patients, staff, and visitors within a hospital. Inadequate lighting causes shadows, a dark environment, and the potential for misinterpreting stimuli (illusions) and is a major cause of accidents in the hospital setting.
A nurse is assisting a patient who has cognitive deficits with a bed bath. What is most important for the nurse to do? 1. Check the patient every few minutes 2. Encourage attention to each task of bathing 3. Arrange the basin within the center of the patient's visual field 4. Explain in detail everything that will be done during the bath before beginning
2. When progressing through each aspect of the bath give simple, direct statements to limit the amount of incoming stimuli at one time. This will promote comprehension and self-care.
A nurse is planning to apply a transdermal patch to a patient. What action should the nurse implement? 1. Use the same area each time to limit skin irritation and excoriation 2. Rub the area to promote comfort and vasodilation before applying the patch 3. Shave the area to facilitate adherence of the patch and medication absorption 4. Remove the old patch an hour after applying the new patch to ensure a therapeutic blood level of the drug
3. A hairless site will ensure that there is effective contact with the skin.
A nurse is assisting a patient with dysphagia to eat. What should the nurse encourage the patient to do? 1. Tilt the head backward when swallowing 2. Drink fluids when eating bites of solid food 3. Reduce environmental stimuli to a minimum 4. Keep food in the front of the mouth when chewing
3. A patient with dysphagia should concentrate on the acts of chewing and swallowing. Environmental stimuli can be distracting and can result in inadequate chewing or premature swallowing, which in turn can result in choking and aspiration.
A nurse is administering a lozenge to a patient's buccal area of the mouth. What should the nurse do? 1. Ensure the medication is dissolved under the tongue 2. Instruct the patient to take occasional sips of water 3. Alternate the cheeks from one dose to another 4. Administer the lozenge an hour before meals
3. Alternating cheeks will limit irritation to the mucous membranes in the buccal area.
A patient sustained a brain injury resulting in neurological deficits after falling off a ladder at work. Which setting is most appropriate for assisting this patient to learn how to live with neurological limitations? 1. Hospice program 2. Acute care setting 3. Extended-care facility 4. Assisted-living residence
3. An extended-care facility is an inpatient setting where people live while receiving subacute medical, nursing, and rehabilitative care. Extended-care facilities that should meet the needs of this individual include intermediatecare facilities, nursing homes that provide subacute care/skilled nursing care, or rehabilitation centers.
A nurse is caring for a patient who is practicing Orthodox Judaism. What should the nurse consider about dietary regulations when assisting the patient to plan meals? 1. Coffee and tea are restricted during Passover 2. Dairy products and eggs are forbidden after sundown on Fridays 3. Dairy foods should not be ingested at the same meal as meats and meat products 4. Shellfish is permitted but must be prepared according to biblical religious rituals
3. Dairy products and meat/poultry are never served at the same meal or on the same set of dishes. Dairy products are not permitted within 1 to 6 hours after eating meat/poultry. Meat/poultry cannot be eaten for 30 minutes after consuming dairy products. Historically, this was practiced so that one food did not contaminate the other.
A practitioner prescribes 1 g of an antibiotic to be administered via the intramuscular route twice a day. Which nursing action reflects the planning step of the Nursing Process? 1. Identifying body landmarks before giving the injection 2. Sending a copy of the written order to the hospital pharmacy 3. Determining that the medication should be given at 8:00 AM and 8:00 PM 4. Verifying the patient's allergies in the chart and on the patient's allergy band
3. Determining when medications should be administered requires planning and, therefore, is part of the planning step of the nursing process.
A nurse is administering oral medications to several patients. It is important that the nurse anticipate that oral medications are absorbed more quickly when they are given: 1. With water 2. In the morning 3. On an empty stomach 4. When the patient is resting
3. Food can delay the dissolution and absorption of many drugs; therefore, most oral medications should be administered on an empty stomach. Oral medications should be administered with food only when indicated by the manufacturer's directions.
A nurse is providing dietary teaching for a patient who is a vegan. What food combination that is a substitute for a complete protein should the nurse include in the dietary teaching? 1. Yogurt and fruit 2. Bread and cheese 3. Legumes and rice 4. Peanut butter and jelly
3. Grains and legumes lack different amino acids. When these foods are combined, they substitute for a complete protein. Complete proteins supply all eight essential amino acids. Essential amino acids are those that cannot be manufactured by the human body and must be obtained from food sources.
A patient who has a transdermal analgesic patch for cancer experiences breakthrough pain with activity. What is most important for the nurse to do? 1. Encourage the avoidance of moving around 2. Seek a dose increase in the long-acting opioid 3. Administer the prescribed shorter-acting opioid 4. Obtain a prescription for an antianxiety medication
3. Intermittent episodes of pain that occur despite continued use of an analgesic (breakthrough pain) can be managed by administering an immediate-release analgesic to reduce pain (rescue dosing). This reduces pain during an unanticipated pain episode without unnecessarily raising the dosage of the long-acting analgesic.
In which situation is a nurse required to complete an incident report? 1. Nurse left work early without reporting to the supervisor 2. Visitor ambulated a patient who should have been on bed rest 3. Patient did not receive a medication prescribed by a practitioner 4. Patient refused to go to physical therapy as ordered by a practitioner
3. Not receiving a prescribed medication may have the potential to cause harm. Therefore, an incident or adverse occurrence report should be completed to document the incident to add to the data so that similar situations can be prevented in the future.
A nurse instills medicated drops into the ear of an adult. What should the nurse do to ensure that the medication flows toward the eardrum? 1. Pull the pinna of the ear backward and downward 2. Insert the drops into the center of the auditory canal 3. Press the tragus of the ear several times after insertion 4. Roll the patient from the side-lying to the supine position
3. Pressing gently on the tragus facilitates the flow of medication toward the eardrum.
A nurse is caring for a patient with a pressure ulcer. Which type of stressor is a pressure ulcer? 1. Microbiological 2. Developmental 3. Physiological 4. Physical
3. Pressure is a physical stressor that stimulates responses that cause an ulcer. Once an ulcer is present, the ulcer becomes a secondary stressor and is considered physiological in nature.
A patient in pain tells the nurse, "It feels like something is on fire." Which characteristic of pain is associated with this statement? 1. Location 2. Intensity 3. Quality 4. Pattern
3. Quality refers to the description of the pain sensation. A pain assessment is facilitated by the use of the mnemonic COLDERR (Character, Onset, Location, Duration, Exacerbation, Relief, Radiation) and the use of a pain scale (e.g., numerical scale, Wong-Baker FACES Rating Scale).
A patient has a diagnosis of osteoporosis. What nutrient should the nurse encourage this patient to eat? 1. Rice 2. Celery 3. Sardines 4. Tomatoes
3. Sardines are an excellent source of dietary calcium. Three ounces of sardines contains approximately 371 mg of calcium.
A nurse is assessing the skin of an older adult. Which response is of the greatest concern? 1. Flat, brown-colored spots on the skin 2. Thin, translucent skin 3. Tenting of the skin 4. Dry, flaky skin
3. Tenting occurs when the skin of a dehydrated person remains in a peak or tent position after the skin is pinched together. This is a sign of a fluid volume deficit. Care must be taken when assessing an older person because some degree of tenting may occur, even when hydrated, because of the decrease in skin elasticity and decrease in tissue fluid associated with aging; however, in the hydrated patient tenting will slowly resolve.
What is most important for the nurse to do when assisting a female patient with care of the hair? 1. Use rubbing alcohol to remove tangles 2. Ensure that the patient's hair is left dry, not wet 3. Ask the patient what should be done with her hair 4. Comb hair from the proximal to distal end of the hair shaft
3. The appearance of one's hair is an extension of self-image. Therefore, the patient's personal preferences should be considered before grooming the hair.
A nurse evaluates that teaching about the care of dry skin is effective when the older adult says, "I should: 1. Bathe daily with a moisturizing soap." 2. Wear clothes made of woolen fabrics." 3. Increase the amount of water that I drink." 4. Use baby powder rather than lotion on my skin."
3. The percentage of body water dramatically decreases with age, and older adults have altered thirst mechanisms that place them at risk for inadequate fluid intake and dehydration. In addition, the skin of older adults is drier because of a decreased ability to sweat and a decreased production of sebum.
A nurse discovers that a patient is taking natural herbal remedies. What action is most important for the nurse to do? 1. Learn about the supplements 2. Think of the supplements as drugs 3. Communicate the supplement use to the practitioner 4. Include the details about supplement use in the health history
3. The practitioner should be notified immediately because the herb may interact with prescribed medications or therapies.
A patient with type 2 diabetes is experiencing blurred vision, generalized weakness, and fatigue. The nurse receives a report from the nurse on the previous shift and obtains additional information from the patient's clinical record. Which should the nurse conclude that the patient is experiencing? 1. Brain attack 2. Kidney failure 3. Hyperglycemic event 4. Hypertensive episode CHART Laboratory Results: BUN: 18 mg/dL Creatinine: 1.2 mg/dL Hemoglobin A1c: 8.0% Serum glucose: 350 mg/dL I&O Record (past 24 hours): Intake: 2400 mL Output: 4200 mL Nursing Progress Note: 10:00 AM—patient reports "being thirsty and urinating a lot" and has lost 20 pounds over the past 2 months; has poor skin turgor and dry mucous membranes.
3. The serum glucose value of 350 mg/dL is excessive and indicates a hyperglycemic event; the acceptable range is 80 to 120 mg/dL.A hemoglobin A1c greater than 6% to 7% indicates inadequate glucose control over the past 90 to 120 days.
A practitioner prescribes a vaginal suppository for a patient. What should the nurse do when administering this medication? 1. Irrigate the vagina with normal saline before inserting the suppository 2. Place the patient in the left-lateral position for the procedure 3. Advance the suppository along the posterior vaginal wall 4. Insert the suppository while wearing sterile gloves
3. This facilitates the placement of the vaginal suppository just outside the cervical os so that when it melts it will eventually disperse through the entire vaginal canal.
What is the most important consequence of the use of Diagnostic Related Groups (DRGs) on the health-care system? 1. Increased quality of medical care 2. Increased reliability of research statistics 3. Decreased acuity of hospitalized patients 4. Decreased length of an average hospital stay
4. The DRGs, pretreatment diagnoses reimbursement categories, were designed to decrease the average length of a hospital stay, which in turn reduces costs.
While in a restaurant, a pregnant woman exhibits a total airway obstruction because of a bolus of food. How should the nurse modify the thrusts of the abdominal thrust (Heimlich) maneuver for this person? 1. Perform them when the woman is in the supine, rather than standing, position 2. Use pinkie finger side of the fist, rather than the thumb side, against the woman's body 3. Compress against the middle of the woman's sternum, rather than between the umbilicus and xiphoid process 4. Initiate the procedure after the woman becomes unconscious, and discontinue the thrusts after six tries if unsuccessful
3. This is the appropriate modification of the abdominal thrust (Heimlich) maneuver for a pregnant woman. This provides thoracic compression while preventing pressure against the uterus that can result in trauma to the woman or the fetus.
A nurse must perform a procedure and is unsure of the exact steps of the procedure. What should the nurse do first? 1. Call the staff education department for educational assistance 2. Refer to a fundamentals of nursing skills textbook 3. Check the nursing policy and procedure manual 4. Refuse to do the nursing procedure
3. This is the first resource the nurse should use when unsure of the steps in a nursing procedure. A review of the procedure in the Procedure Manual may refresh the memory or support the confidence of the nurse so that it is safe to proceed.
The most important concept that nurses must consider to make accurate assessments is that nonverbal behavior: 1. Is controlled by the conscious mind 2. Carries less weight than what the patient says 3. Does not have the same meaning for everyone 4. Is generally a poor reflection of what the patient is feeling
3. Transculturally, nonverbal communication varies widely. For example, gestures, facial expressions, eye contact, and touch may reflect opposite messages among cultures and among individuals within a culture.
Which response by a patient in the postanesthesia care unit is the priority concern for the nurse? 1. Pain 2. Nausea 3. Reduced level of consciousness 4. Excessive loss of fluid through indwelling drains
3. With an altered level of consciousness the pharyngeal, laryngeal, and gag reflexes may be impaired. The inability to cough or swallow can result in aspiration of oral secretions. When considering the ABCs of nursing intervention, the airway has priority.
A nurse is assessing several patients who had surgery the previous day. Which sudden patient response should the nurse identify as a life-threatening event? 1. Slightly elevated temperature 2. Wound dehiscence 3. Edema of the legs 4. Chest pain
4. An acute onset of chest pain within 24 hours of surgery may indicate myocardial infarction in response to the stress of surgery. Also, it can be caused by a pulmonary embolus, although this is more likely to occur between the 7th and 10th postoperative days. Both of these complications are life threatening
A newly admitted patient is exhibiting anxiety associated with being hospitalized. What is most important for the nurse to do to help reduce the patient's anxiety? 1. Teach relaxation techniques 2. Validate the anxious feelings 3. Minimize environmental stimuli 4. Explain procedures to the patient
4. Anxiety is a response to an unknown threat to the self or self-esteem. Therefore, explaining what, how, why, when, and where of every procedure to the patient will reduce anxiety by minimizing the unknown.
An older adult asks the nurse, "Now that I am getting older I want to make sure I get enough vitamin A to keep my eyes healthy. What food can I eat?" Which fruit should the nurse explain is an excellent source of vitamin A? 1.Grapefruit 2.Tangerine 3.Banana 4.Apricot
4. Apricots are an excellent source of vitamin A. Three medium-sized apricots contain 867 µgRE (retinol equivalents) of vitamin A.
An obese patient asks the nurse, "What should I do to help myself lose weight?" How should the nurse respond considering the best behavior modification strategy for controlling food intake? 1. "Ask family members not to bring tempting food into the house." 2. "Post piggy pictures on the refrigerator." 3. "Avoid snacks between meals." 4. "Maintain a daily food diary."
4. Behavior modification strategies are most successful when the person has an internal locus of control and is actively involved in self-care. Research demonstrates that self-monitoring of food intake is the single most helpful strategy in weight reduction.
A nurse assesses a patient and concludes that the patient is cachectic. For which skin integrity problem should the nurse determine that this patient is at the highest risk? 1. Altered tissue perfusion 2. Perineal excoriation 3. Reduced sensation 4. Pressure ulcers
4. Cachexia involves weight loss, muscle atrophy, and decreased subcutaneous tissue, which results in a reduction in the padding between skin and bones, thus increasing the risk of pressure ulcer development.
A patient who is secretly smoking in bed falls asleep and the cigarette ignites the patient's gown. What should the nurse do first after discovering the fire? 1. Close the door 2. Activate the fire alarm 3. Roll the patient from side to side 4. Smother the flames with a blanket
4. Smothering the flames with a blanket deprives the fire of oxygen. Without oxygen to support combustion, the fire will go out. Rescuing the patient is the first step of fire safety.
When interviewing the wife of a patient, which statement about her husband supports the presence of sleep apnea? 1. "He falls asleep sometimes when he drives, so now I do all the driving." 2. "He has nightmares that are so scary that he wakes me up because he is afraid." 3. "He kicks and thrashes so much that the bed linen is upside down by morning." 4. "He snores and gasps all night long and wakes me up, and then I can't get back to sleep.
4. Episodes of sleep apnea begin with loud snoring followed by silence, during which the person struggles to breathe against a blocked airway. Decreasing oxygen levels cause the person to awaken abruptly with a loud snort.
A nurse is teaching a family member how to perform range-of-motion exercises of the hand. Which motion occurs when the angle is reduced between the palm of the hand and forearm? 1. Hyperextension 2. Opposition 3. Abduction 4. Flexion
4. Flexion of the wrist, a condyloid joint, occurs when the fingers of the hand move toward the inner aspect of the forearm.
What is the most effective nursing intervention to promote sleep that is appropriate for a patient in any situation? 1. Providing a back rub 2. Playing relaxing music 3. Offering a glass of warm milk 4. Following a routine at bedtime
4. Following routines provides consistency and comfort in an unfamiliar environment. Bedtime rituals meet basic physiological needs and usually include physically and emotionally relaxing behaviors.
A nurse causes harm to a hospitalized patient because of improper use of medical equipment. What is this tort specifically called? 1. Battery 2. Assault 3. Negligence 4. Malpractice
4. Malpractice is misconduct, an act of commission or omission, performed in professional practice that results in harm to another.
A nurse is planning care for a patient in the spiritual realm. Which age group generally is more involved with expanding and refining spiritual beliefs? 1. Adolescents 2. Older adults 3. Young adults 4. Middle-aged adults
4. Middle-aged adults tend to engage in refining and expanding spiritual beliefs through questioning. Middle-aged adults are reported to have greater faith, more reliance on personal spiritual strength, and be less inflexible in spiritual beliefs. Middle-aged adults integrate other viewpoints about faith, which introduces tension while working toward resolution of spiritual beliefs. This stage is called Conjunctive Faith by James Fowler.
A nurse is planning care to support a patient's ability to sleep. Which factor from among the options presented most commonly interferes with the sleep of hospitalized patients? 1. Napping during the day 2. Disrupted bedtime rituals 3. Medication administration 4. Difficulty finding a comfortable position
4. Patients frequently find hospital beds unfamiliar and uncomfortable. In addition, therapeutic regimens restrict movement or require patients to assume sleeping positions other than their preference. Studies support the fact that finding a comfortable position is the most common factor that interferes with sleep as reported by hospitalized patients.
Which nursing technique will result in an accurate measurement when obtaining a patient's blood pressure? 1. Wrapping the lower edge of the cuff over the antecubital space 2. Positioning the sphygmomanometer above the level of the heart 3. Pumping the cuff about 60 mm Hg above the point where the brachial pulse is lost 4. Releasing the valve on the cuff so that the pressure decreases at the rate of 2 to 3 mm Hg per second
4. Releasing the valve slowly ensures that all five Korotkoff's sounds are heard accurately. Deflating the cuff too rapidly can result in a falsely low systolic reading, and deflating the cuff too slowly can result in a falsely high diastolic reading.
A patient who self-administers an aerosol medication by a metered-dose inhaler complains of "the nasty taste of the medication." What should the nurse encourage the patient to do? 1. Suck on a hard candy after the procedure 2. Shake the cartridge longer before using it 3. Perform oral hygiene before inhalation of medication 4. Attach an aerosol chamber to the metered-dose cartridge
4. The aerosolized medication enters the aerosol chamber where the larger droplets fall to the bottom of the chamber. The smaller droplets are inhaled deep into the lungs rather than falling on the patient's tongue.
A nurse is bathing a patient. Which nursing action best supports a principle associated with medical asepsis? 1. Wearing sterile gloves when washing the perineum 2. Having the patient void before beginning the bed bath 3. Replacing the top covers with a clean flannel bath blanket 4. Washing from the inner canthus to the outer canthus of the eye
4. The eye should always be washed from the inner to the outer canthus to prevent secretions from entering the lacrimal ducts, which may result in an infection.
A group of nurses on a unit are personally and professionally mature and motivated. Which leadership style should the nurse manager employ when working with this group? 1. Directive 2. Autocratic 3. Democratic 4. Laissez-faire
4. The laissez-faire leadership style is appropriate for a group of individuals who have an internal locus of control and desire autonomy and independence. Individuals who are professionally mature and motivated more often have an internal locus of control.
A practitioner orders a clear liquid diet for a patient who had abdominal surgery 3 days ago. What does the nurse conclude is the primary reason why a clear liquid diet was ordered for this patient? 1. Relieves abdominal distention 2. Stimulates digestive enzymes 3. Prevents postoperative ileus 4. Is easily digested
4. The molecules in clear liquids are less complex and easier to ingest, tolerate, and digest than those in a full-liquid diet or food.
A nurse is predicting the success of a teaching program regarding the learning of a skill. Which factor is most relevant? 1. Cognitive ability of the learner 2. Amount of reinforcement 3. Extent of family support 4. Interest of the learner
4. The motivation of the learner to acquire new attitudes, information, or skills is the most important component for successful learning; motivation exists when the learner recognizes the future benefits of learning.
A nurse on a postpartum unit is teaching a class for new mothers about umbilical cord care. The nurse identifies that one mother does not become involved with the discussion and is withdrawn. What is the best action by the nurse to help this new mother learn about umbilical cord care? 1. Give the patient written material about cord care 2. Invite the patient to the next class about cord care 3. Bring an audiovisual cassette into the patient's room 4. Provide informal individual instruction for the patient
4. The nurse identified that the patient was quiet and withdrawn in the group class. Individual instruction provides the nurse the opportunity to explore the patient's concerns and address the patient's individual needs in privacy.
A nurse is caring for a patient recovering from general anesthesia. For which most serious complication of intubation should the nurse assess the patient? 1. Stomatitis 2. Atelectasis 3. Sore throat 4. Laryngeal spasm
4. This is a potentially life-threatening complication because it prevents the exchange of gases between the lungs and the atmosphere. Laryngeal spasm can result from irritation caused by the presence of the intubation tube in the glottis (space between the vocal cords) during surgery.
A patient is using the call bell numerous times an hour and requesting assistance with activities that the patient is capable of achieving independently. What should the nurse do to best help this patient? 1. Set limits verbally 2. Alternate care with another nurse 3. Point out the behavior to the patient 4. Attempt to see the situation from the patient's perspective
4. This is an example of empathy, which is understanding a patient's emotional point of view. An empathic response communicates that the nurse is listening and cares.
A male patient is told by his practitioner that he has metastatic lung cancer and he is seriously ill. After the practitioner leaves the room, the patient has a severe episode of coughing and shortness of breath and says, "This is just a cold, I'll be fine once I get over it." What is the best response by the nurse? 1. "The practitioner talked to you about having a serious illness." 2. "The practitioner had some bad news for you today." 3. "This is not a cold; it's lung cancer." 4. "Tell me more about your illness."
4. This provides an opportunity to discuss the illness; eventually a developing awareness will occur and the patient will move on to other coping mechanisms.
A practitioner orders a 2-g sodium diet for a patient. Which fluid should the nurse teach this patient to avoid? 1. Kool-Aid 2. Club soda 3. Lemonade 4. Diet root beer
4. Twelve fluid ounces of diet root beer contains approximately 170 mg of sodium and should be avoided on a 2-g sodium diet.
A nurse must obtain a urine specimen from a patient with a urinary retention catheter (Foley). What should the nurse do first? 1. Cleanse the exit tube at the bottom of the drainage bag with an alcohol swab 2. Clamp the tubing immediately distal to the collection port 3. Position the patient in a semi-Fowler position 4. Don a pair of clean glove
4. Wearing personal protective equipment, such as clean gloves, is a medical asepsis practice. The catheter is close to the perineal area that may be contaminated, and the gloves protect the nurse from the patient's body fluids.
A practitioner prescribes 500 mg of an antibiotic to be administered IVPB every 6 hours for a patient with a systemic infection. The vial dispensed by the hospital pharmacist contains 1 g of the prescribed antibiotic in powder form. The instructions on the vial state: "Instill 9.6 mL to yield 10 mL." How many milliliters of the antibiotic should the nurse add to the IVPB bag? Record your answer using a whole number. Answer in mL.
Answer: 5 mL
omit The nurse is performing an assessment of a patient. Indicate on the figure of the body where the nurse should place the stethoscope to assess for the presence of borborygmi?
OMIT THIS QUESTION