HEALTH ASSESSMENT TTL's Day 6-10

D. Neurologic disorder Asymmetry can be a sign of a neurologic disorder, such as paralysis or a malignancy. Fatigue, stress, and infection are not manifested by facial asymmetry.

During an examination of facial features, the nurse observes that the patient exhibits asymmetry of the mouth. What problem may asymmetric facial features indicate? A. Infectious process B. Stress disorder C. Fatigue D. Neurologic disorder

D. Use principles of trauma-informed care and respect the patient's personal space. The nurse should ensure personal safety while attempting to calm the patient verbally. Threatening the patient, restraining the patient, and offering an ultimatum can result in further escalation of hostile behaviors. The patient may be at risk for self-harm and should not be left alone.

During the interview, the patient becomes hostile and argumentative. What is the appropriate nursing action? A. Offer the patient an ultimatum to change behaviors immediately and set limits on patient behaviors. B. Call security to assist with restraining the patient and advise the patient the interview is over. C. Leave the patient in the room alone while going to ask someone for assistance in calming him or her. D. Use principles of trauma-informed care and respect the patient's personal space.

D. Family members correctly perform the steps for transferring their mother from bed to chair. Rationale: A return demonstration is the most effective way to determine if family members are adequately prepared. A video may reinforce understanding of the procedure, but it does not allow for determination of adequate preparation. Having family members state or write the correct steps also does not allow for proper evaluation of preparation.

Family members are being taught how to transfer their mother safely from the bed to a chair. Which action indicates that the family has been adequately prepared for the task? A. Family members repeat the steps for transferring their mother safely from bed to chair. B. Family members write down the steps in order for transferring their mother from bed to chair. C. Family members watch a video demonstrating proper transfers. D. Family members correctly perform the steps for transferring their mother from bed to chair.

B. Less than or equal to 18 Patients are at risk for skin breakdown/development of pressure injuries with a Braden score of 18 or less. The other numbers are not the risk cutoff scores for the Braden scale.

Pressure injury prevention measures should be implemented for a patient with which Braden score? A. Less than or equal to 16 B. Less than or equal to 18 C. Less than or equal to 20 D. Less than or equal to 24

C. Biofilm build-up Soaking dentures removes stains and prevents the buildup of biofilm and bacteria. It will not prevent denture cracking, jaw malformation, or sleep apnea.

Soaking the patient's metal-tipped dentures overnight helps to prevent which situation? A. Denture cracking B. Jaw malformation C. Biofilm build-up D. Sleep apnea

A. Assess the patient for a medical condition, including intoxication. Neurologic symptoms should be addressed immediately; a physiologic process could alter the mental status assessment, so the nurse should assess the patient for a medical condition. The nurse should contact the practitioner personally and not leave a message when the patient exhibits neurologic changes. Although the family can be helpful by offering collateral information, the family is not an appropriate alternative at this time. The patient needs further assessment.

. During the mental status evaluation, the nurse observes that the patient's gait is uncoordinated and speech is slurred. What should the nurse do next? A. Assess the patient for a medical condition, including intoxication. B. Postpone the assessment. C. Leave a message for the practitioner, describing the symptoms. D. Let the patient rest and interview the family instead.

A. "Getting out of bed maintains your strength." Getting out of bed to the chair and physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions. Getting out of bed will not necessarily improve blood pressure or lower blood glucose. Getting out of bed may improve appetite not decrease it.

6. The nurse is ready to sit the patient up at the side of the bed. The patient states they are tired and want to stay in bed all day. Which is the best response from the nurse? A. "Getting out of bed maintains your strength." B. "Getting out of bed will improve your blood pressure." C. "Getting out of bed will decrease your appetite." D. "Getting out of bed will lower your blood glucose."

A. Actively engage the child's family in the explanation of any procedures. Actively involving the child's family in the explanation of any procedures helps to ease the child's fears. The health care team member must wear the respirator mask at all times when in the child's room to prevent disease transmission. A TB respirator mask on the child would not prevent expulsion of droplet nuclei; additionally, applying a fitted mask to a child would be very frightening for the child. Although the child may be tired, the child is most likely crying because of fear related to the unfamiliar environment, masks, and procedures.

A 5-year-old child cries every time a health care team member enters the TB isolation room. Which action should be taken in this situation? A. Actively engage the child's family in the explanation of any procedures. B. Remove the mask for a short period so the child can see the health care team member's face. C. Apply the respirator mask to the child so that the health care team member does not need to wear the mask. D. Explain to the child's family that the child is probably tired from his or her stay.

B. Incorporate play into ROM exercises to encourage the child's participation Active and active-assisted ROM exercises for a child who is immobilized help prevent muscular atrophy and joint contractures; a child should be encouraged to participate as much as possible, and play is an effective way to obtain his or her participation. Passive ROM does not maintain muscle mass. A child is equally at risk for contractures. The child may not ambulate for many days, which increases the risk of contractures; a child who is immobilized must receive some type of exercise to prevent excessive muscle atrophy and joint contractures.

A 6-year-old patient is immobile because of a leg fracture. To maintain joint mobility in the unaffected joints, what should the nurse do? A. Perform passive ROM on joints to maintain muscle mass B. Incorporate play into ROM exercises to encourage the child's participation C. Allow the child to choose the level of activity because children are not at risk for contractures D. Wait until the child can ambulate and attend physical therapy sessions

A. "Protective eyewear should be worn by the person performing the sterile procedure to protect him or her from splattered blood." The person performing a sterile procedure should wear protective eyewear if there is a chance that blood may splatter. The protective eyewear prevents the splattered blood from coming into contact with the family member's eyes and skin. The patient does not need to wear protective eyewear to avoid being contaminated by his or her own blood. A cap is not sufficient protection against splattered blood for the person performing the procedure or the patient. A cap is worn to prevent the hair or dander of the person performing the procedure from contaminating a sterile field.

A 63-year-old patient is being discharged from the hospital. Which statement by the nurse is correct when teaching the patient and family member about using PPE while performing a procedure at home with the potential for blood splatter? A. "Protective eyewear should be worn by the person performing the sterile procedure to protect him or her from splattered blood." B. "Protective eyewear should be worn by the patient to protect him or her from splattered blood." C. "A cap should be worn by the person performing the sterile procedure to protect him or her from splattered blood." D. "A cap should be worn by the patient to protect him or her from splattered blood."

C. On the patient's right side. If the patient demonstrates weakness or paralysis on one side of the body, place the chair on his or her strong side which is the right side. The chair should not go on the left side which is his or her weak side or in front of the patient. The chair should be at a comfortable angle to the bed but on the patient's strong side.

A family is being instructed on how to get a patient with left-sided paralysis out of bed. The family should be instructed to place the chair in which position? A. In front of the patient. B. On the patient's left side. C. On the patient's right side. D. Place the chair at a comfortable angle to the bed.

A. Patients with cancer Patients with cancer may have strong, abnormal taste and smell senses because of their medications, so checking for food aversions before and during meals is important. Older adults and patients with neurologic impairment may have altered senses of taste and smell but may not develop aversions to foods as readily as cancer patients. Children may not desire certain foods, but they do not typically develop food aversions related to medications.

A graduate nurse is assigned to work on a medical-surgical unit. The orienting nurse informs the graduate that assessing for food aversions associated with medications before and during meals is essential for certain populations. Which population particularly requires assessment for food aversions? A. Patients with cancer B. Children C. Older adults D. Patients with neurologic impairment

C. Perform the steps to sit the patient safely up. A return demonstration is the most effective way to determine if family members are adequately prepared. A video may reinforce understanding of the procedure, but it does not allow the nurse to evaluate whether the family members are adequately prepared. Having family members state or write the correct steps does not allow the nurse to evaluate whether they are adequately prepared.

A nurse demonstrated to family members how to sit the patient safely up in bed. The nurse knows that the family has been adequately prepared when they take which action? A. Watch a video demonstrating proper transfer techniques. B. Repeat to the nurse the steps for sitting the patient safely in the bed. C. Perform the steps to sit the patient safely up. D. Write down the steps for sitting the patient safely in the bed in the order they should perform them

B. "Contact, droplet, airborne, standard precautions, and special PPE precautions are required to protect health care personnel. "Contact, droplet, airborne, standard precautions, and special PPE precautions are required to protect health care personnel caring for a patient suspected of or diagnosed with Ebola. Although the Ebola virus is not airborne, the CDC has recommended using both Tier 1 (standard precautions) and all components of Tier 2 (contact, droplet, and airborne) precautions as well as special PPE precautions as a safety measure to protect health care personnel because of the highly contagious nature of the virus. Not implementing all of the required precautions places health care personnel at risk.

A nurse is preparing to admit a patient diagnosed with or suspected of Ebola. Which of the following statements regarding the isolation plan demonstrates that the nurse has a good understanding of the Ebola virus? A. "Contact, droplet, airborne, and standard precautions are required to protect health care personnel." B. "Contact, droplet, airborne, standard precautions, and special PPE precautions are required to protect health care personnel." C. "Contact, airborne, standard precautions, and special PPE precautions are required to protect health care personnel." D. "Contact, droplet, standard precautions, and special PPE precautions are required to protect health care personnel."

D. "A PAPR is required when caring for a patient with Ebola." The CDC's updated guidelines instruct health care personnel to wear either a PAPR or an N95 respirator. Both the N95 and the PAPR provide equal protection, and staff members should choose the one they are most comfortable wearing. Supervision of both the donning and doffing processes is an essential component to ensure the safety of health care personnel. The trained observer uses a standardized checklist to guide health care personnel and observes each step of the process. A key step in the donning process is for the trained observer to ensure that no skin is exposed. Improper donning can result in exposed areas of skin, which increases the staff member's risk of coming in contact with the Ebola virus. The incubation period (time interval from infection with the virus to onset of symptoms) is within 21 days. Humans are not infectious until they develop symptoms. First symptoms are the sudden onset of fever, fatigue, muscle pain, headache, and sore throat.

A nurse is preparing to enter the room of a patient diagnosed with Ebola. Which of the following statements indicates the nurse needs more education? A. "The donning and doffing of PPE requires supervision by a trained observer." B. "The principle of ensuring no skin is exposed before entering the room of a patient with Ebola provides protection for the health care giver." C. "Strict monitoring is required for 21 days after an exposure to the Ebola virus." D. "A PAPR is required when caring for a patient with Ebola."

B. "A soft-bristle toothbrush" A soft-bristle toothbrush is more effective than a foam stick applicator in removing plaque and tartar from the teeth. A foam stick applicator, a popular substitute for the toothbrush, stimulates the mucosal tissues but does not remove debris from the teeth. Lemon glycerin swabs are not recommended because they dry the oral mucosa. The nurse should never place his or her fingers into an unconscious or a debilitated patient's mouth because the normal response is to bite down.

A nurse is teaching a nursing assistant how to perform oral care with a debilitated patient. When asked which tool would be most effective in removing plaque and tartar from the patient's teeth, the nursing assistant would demonstrate an understanding of the information by giving which response? A. "A lemon glycerin swab" B. "A soft-bristle toothbrush" C. "A foam stick applicator" D. "Gauze wrapped around a gloved finger"

B. "ROM exercises help maintain joint and muscle function." ROM exercises help prevent joint contracture and muscular atrophy. ROM exercises are not vigorous enough to provide improvements in cardiovascular fitness, and no research connects ROM exercises to length of stay. ROM fulfills a separate rehabilitation role from continuous passive motion. Preventing boredom is not an evidence-based rationale for ROM exercises, and osteoarthritis is not an indication for ROM exercises.

A nurse is working with a nurse orientee on the orthopedic unit and is reviewing ROM exercises. The orientee asks the nurse why ROM exercises are important. Which of the following statements is the best reply? A. "ROM exercises help preserve cardiovascular fitness and lead to shorter inpatient stays." B. "ROM exercises help maintain joint and muscle function." C. "ROM exercises are superior to continuous passive motion machines." D. "ROM exercises prevent boredom and decrease the effects of osteoarthritis."

D. When providing care for a patient who has influenza A mask is correctly worn when caring for a patient with influenza because the disease is transmitted through the air. A mask is not required and provides no benefit when the nurse is assisting a patient to a chair, changing a dressing on a small wound, or obtaining a blood culture.

A nurse preceptor is evaluating the infection control procedure of a new graduate nurse. The new nurse demonstrates that she understands when a mask is needed by donning a mask in which situation? A. When obtaining a blood culture B. When assisting a patient to a chair C. While changing the dressing on a 1.5-cm diabetic foot ulcer D. When providing care for a patient who has influenza

C. The heel and elbow protectors should be removed at least daily to assess skin integrity. Skin and bony prominences should be inspected at least daily. Inspecting the skin on a regular basis provides data for each nurse to determine if there is further skin breakdown. Devices, shoes, socks, and heel and elbow protectors should be removed for the skin inspection. Photographs may be taken but do not prevent further breakdown. Total parenteral nutrition is used only if the patient is unable to take in nutrition by other means. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying blood vessels.

A patient has a Stage 2 pressure injury on the coccyx. The patient is being turned every 2 hours and is wearing elbow and heel protectors. What is needed to protect the patient from further injury? A. Photographs need to be taken to document the progress of the ulcer. B. The patient needs to begin receiving total parenteral nutrition. C. The heel and elbow protectors should be removed at least daily to assess skin integrity. D. A massage should be given in reddened areas over bony prominences.

A. Turn the patient's head to the affected side and tilt the head to the unaffected side. By turning the patient's head to the affected side and tilting the head to the unaffected side, the epiglottis is mechanically assisted to close so that thin liquids are not aspirated. If this technique does not help the patient, then a speech therapy consult is appropriate; the therapist is likely to recommend adding a thickening agent to the patient's liquids. Although prune juice is thicker than orange juice, most patients with dysphagia can drink orange juice; however, the patient may need either a gel or starch thickener added to adjust the consistency. Administering an expectorant is not indicated because the patient's cough is related to a mechanical swallowing function and not mucus in the lungs.

A patient is 6 days postoperative following a parotidectomy for adenocarcinoma of the salivary gland. During breakfast, the nurse notices that the patient swallows scrambled eggs and oatmeal without coughing; however, the patient coughs while drinking orange juice. What should the nurse's initial action be? A. Turn the patient's head to the affected side and tilt the head to the unaffected side. B. Add a starch or gel thickener to the orange juice so that the patient does not aspirate. C. Suggest the patient not drink orange juice and substitute prune juice instead. D. Administer an expectorant to promote swallowing and minimize the chance for aspiration.

C. Assess the skin around and beneath the collar. Inspection of the skin and bony prominences should occur at least daily. All bony prominences should be inspected, as well as skin around and beneath orthopedic devices, such as the cervical collar, braces, or casts. The cervical collar should not be removed without a physician's order or per the organization's practice. Any reddened or discolored areas should be palpated but not massaged. The patient should be placed in a position of comfort or as ordered by the practitioner until the orthopedic device is removed.

A patient is admitted to the trauma unit wearing a cervical collar. What precautions should be taken by the nurse? A. Remove the collar every shift to assess the skin. B. Massage the skin under the collar. C. Assess the skin around and beneath the collar. D. Place the patient in the supine position.

C. "A rocking motion gives the body momentum to stand." A rocking motion gives the patient's body momentum, reducing the muscular effort required to lift the patient. Rocking does not prevent postural hypotension, dangling their legs at the edge of the bed may prevent postural hypotension. Rocking may help motivate the patient and provide stimulation to stand, but that is not the main purpose.

A patient is being assisted to a standing position and is asked to rock back and forth. Which explanation best describes the benefits of using a rocking motion? A. "A rocking motion gives the patient the motivation to stand." B. "A rocking motion reduces the chance of the patient having postural hypotension." C. "A rocking motion gives the body momentum to stand." D. "A rocking motion provides stimulation to the body to stand."

C. The orientee holds the patient under the axilla for transfer. The under-axilla technique is uncomfortable for patients. A transfer belt allows the nurse to move the patient at the center of gravity. Nonskid shoes decrease the risk of slipping during transfer. A patient's weak leg should be supported by the nurse's knee.

A patient is being transferring from the bed to a chair by an orientee. Which action by the orientee indicates the need for further education? A. The orientee places a transfer belt on the patient before transfer. B. The orientee places nonskid shoes on the patient before transfer. C. The orientee holds the patient under the axilla for transfer. D. The orientee uses her knees to support the patient's weak leg.

D. Eat pureed foods Eating pureed foods is recommended when dysphagia is present but does not prevent it. Encouraging small, frequent meals and avoiding spicy food and substances that contain caffeine are all appropriate measures to prevent dysphagia.

A patient is receiving chemotherapy for tonsillar adenocarcinoma and is interested in ways to prevent dysphagia. Which of these is NOT recommended to prevent treatment related effects of dysphagia? A. Eat small, frequent meals B. Avoid hot, spicy foods C. Avoid caffeine-containing foods and drinks D. Eat pureed foods

A. "Cleaning dentures once a day is adequate." Cleaning dentures once a day may not be adequate for all patients because dentures should be cleaned as often as natural teeth. A soft-bristle brush is used because a hard-bristle toothbrush can damage or wear down dentures. Brushing the gums, tongue, and palate removes denture adhesive and plaque and stimulates circulation in the mouth.

A patient is receiving instructions on denture care. Which statement by the patient indicates the need for further instruction? A. "Cleaning dentures once a day is adequate." B. "Dentures should be cleaned as often as natural teeth." C. "I will use a soft-bristle toothbrush on my dentures." D. "I should brush my gums, tongue, and palate when I clean my dentures."

C. Add sauces or gravies to the food. Adding sauces and gravy to solid food coats the food and makes it easier for the patient to swallow. Placing the food on the unaffected side is appropriate only if the swallowing difficulty is related to a neurologic or structural limitation. Changing to a pureed diet may ultimately be required, but the nurse's first action is to maintain a normal lifestyle because the complaint is with swallowing, not mastication. Adding a thickening agent is indicated only when thin liquids have a potential to be aspirated.

A patient is receiving radiation therapy for esophageal cancer. The patient complains of having trouble swallowing solid foods. What should the nurse recommend first? A. Change to a pureed diet. B. Place food on the unaffected side. C. Add sauces or gravies to the food. D. Add a thickening agent to the food.

A. Inspect the integrity of the patient's lips, teeth, oral mucosa, and oral cavity. The patient should be evaluated for oral problems. After the dentures are removed, the integrity of the lips, teeth, buccal mucosa, gums, palate, and tongue should be inspected for common oral problems, including infection and gingivitis. Adhesive is commonly used to hold dentures in position, but the oral cavity and mucosa must be assessed first. Keeping the dentures clean and removing the dentures for prescribed periods are both methods of decreasing the risk of infection but do not address the patient's complaint of pain.

A patient is receiving routine oral and denture care. Which intervention should be initiated when the patient complains of pain while placing and wearing the dentures? A. Inspect the integrity of the patient's lips, teeth, oral mucosa, and oral cavity. B. Have the patient wear the dentures continuously to reduce the risk of infection. C. Clean the dentures daily with dentifrice and brush the surfaces. D. Apply extra adhesive to the undersurface of the dentures before inserting them.

A. "You will experience transient swallowing problems." Transient swallowing problems are associated with a total glossectomy. Few minor problems occur following a total laryngectomy, whereas a total glossectomy with bilateral neck dissection results in irreversible swallowing problems. A tracheostomy is associated with problems with all phases of the swallowing process.

A patient is scheduled to undergo a total glossectomy. The nurse is teaching the patient and spouse the effect of this procedure on the patient's ability to swallow. Which statement best describes how swallowing will be affected? A. "You will experience transient swallowing problems." B. "You will experience a minor effect on swallowing." C. "You will experience irreversible swallowing problems." D. "You will experience problems with all phases of swallowing."

B. Keep the door of the room closed. Isolation for a patient with suspected or confirmed TB includes placing the patient on airborne precautions in a negative-pressure AIIR with the door closed as much as possible. Contact isolation is not sufficient for TB, which requires airborne precautions. A surgical mask is not sufficient for TB, which requires a respirator mask because only high-efficiency particulate respirator masks have the ability to filter particles at a 95% or better efficiency. The patient should not wear a respirator mask because it does not prevent expulsion of droplet nuclei into the air.

A patient is suspected of having TB. Which is the most appropriate action to take? A. Implement airborne precautions. B. Keep the door of the room closed. C. Wear a surgical mask into the room. D. Instruct the patient to wear a respirator mask when family visits.

C. Grasp the upper denture with thumb and index finger wrapped in gauze and pull gently downward to break the seal. When the patient is unable to remove his or her dentures a health care team member needs to remove them. The upper plate at the front should be grasped with the thumb and index finger wrapped in gauze and pulled downward to break the seal. Both the upper and lower dentures should be removed before surgery. Adhesive remover is not necessary and should not be placed in a patient's oral cavity.

A patient is unable to remove his or her upper dentures before surgery. A member of the health care team should take which action? A. Replace the lower denture to maintain oral integrity in the operating room. B. Use adhesive remover to break the seal of the patient's denture. C. Grasp the upper denture with thumb and index finger wrapped in gauze and pull gently downward to break the seal. D. Leave the upper denture in the patient's mouth because only the lower denture must be removed.

B. Oral mucositis Chemotherapy drugs may cause mouth sores or oral mucositis. Although the patient may have dental caries, periodontitis, and halitosis, these are not caused primarily by chemotherapy.

A patient is undergoing chemotherapy. What oral complications may the patient experience? A. Dental caries B. Oral mucositis C. Periodontitis D. Halitosis

B. "A collaborative team approach can reduce the risk for dysphagia." The lack of access to collaborative or interdisciplinary management before, during, and after treatment is a risk factor associated with the development of dysphagia. Preventing dysphagia can result in improved quality of life, promote optimal nutrition, prevent dehydration, and reduce risk of symptoms including pneumonia and aspiration. A collaborative team will consult with the patient upon diagnosis and before treatment, on an ongoing basis, and as needed once treatment is completed. A collaborative approach is important for all cancers throughout treatment, not just at initial diagnosis.

A patient newly diagnosed with oropharyngeal cancer has been referred to a dentist, dietitian, speech and language therapist, and radiation oncologist in addition to being seen by a surgical oncologist. The spouse confides to the nurse that she is confused about the reason for all of the health care professionals involved so early on in his care. What response should the nurse provide? A. "A collaborative team approach improves overall survival." B. "A collaborative team approach can reduce the risk for dysphagia." C. "A collaborative team consults with your husband just once." D. "A collaborative team approach is used for patients initially diagnosed with cancer."

A. The patient The patient is the nurse's primary source of assessment data, even if the patient appears disorganized or distracted. Secondary sources, such as family, can add information or provide information when the patient is unable. Laboratory results and other diagnostic tests, such as magnetic resonance imaging, expand the source of data to assist with assessment.

A patient presents to the emergency department accompanied by family members. The patient appears disorganized and distracted. During the mental status evaluation, who or what should be the primary source of data? A. The patient B. Laboratory results C. The patient's family D. Magnetic resonance imaging

D. Providing a sitz bath A sitz bath cleanses and reduces pain and inflammation in the perineal and anal areas and is used for the patient who has undergone rectal or perineal surgery or childbirth. Oatmeal baths are for soothing irritated skin. Ice packs may cause more local discomfort. Antiinflammatory medications require a practitioner's order.

A patient reports moderate pain after undergoing a hemorrhoidectomy. Which is a priority nursing intervention to decrease the patient's pain? A. Administering an antiinflammatory medication B. Providing a medicated bath with oatmeal C. Providing an ice pack D. Providing a sitz bath

A. Type of behavior requiring application of restraint Most organizations require a practitioner's order for restraint; the order must specify the type of behavior or condition requiring restraint, the type of restraint, and where the restraint is to be placed. Not all patients easily accept the use of restraints; however, if all alternatives have been exhausted, restraints may be necessary, even though the patient requests removal. Restraint alternatives should be attempted before the practitioner decides to write an order for restraints. The restraint brand name varies from organization to organization and does not need to be included in the order.

A patient requires mitten restraints to prevent the removal of a dressing that has been applied. What must be included in the practitioner's order for restraint? A. Type of behavior requiring application of restraint B. An order to remove the restraint at the patient's request C. Alternatives to be used before restraint is used D. The brand of restraint to be used

C. Review the patient's clinical history for factors that could negatively affect the oral mucosa. Assessing the patient for risks related to oral hygiene delivery (e.g., oral surgery or trauma, coagulation disorders, diabetes, use of chemotherapeutic agents) is necessary before oral care begins to prevent possible complications. Raising the bed to a comfortable working height and positioning the patient are important steps to safely prepare the patient for oral care; however, assessing for risk factors is more important. Providing privacy is not a safety measure.

A patient requires oral care every 2 hours. What is the most important safety measure the nurse should take before initiating oral care? A. Position the patient. B. Raise the bed to a height that is comfortable for the nurse. C. Review the patient's clinical history for factors that could negatively affect the oral mucosa. D. Provide privacy.

A. Unexplained weight loss, night sweats, fever, and a productive cough TB should be suspected in any patient with a persistent cough lasting longer than 3 weeks or longer, accompanied by chest pain, bloody sputum, unexplained weight loss or loss of appetite, fever, chills, night sweats, malaise, or fatigue. Jaundice is usually suspected with liver disease. A stiff neck is usually suspected with meningitis. Elevated amylase is suspected with pancreatic disease. Nausea and vomiting are not associated with TB.

A patient should be suspected of having TB if the patient has which symptoms in addition to respiratory symptoms lasting longer than 3 weeks? A. Unexplained weight loss, night sweats, fever, and a productive cough B. Jaundice, night sweats, and a persistent fever C. A fever of at least 38.1°C (100.6°F), night sweats, and a stiff neck D. Elevated amylase, nausea and vomiting, and a productive cough

C. Obtaining the patient's permission The nurse evaluating a patient's mental status should begin the interview by obtaining permission from the patient; doing so enhances his or her cooperation and may reduce anxiety and allay fears. Assessing cultural dietary preferences, obtaining a sleep and appetite history, and reviewing laboratory data are important nursing interventions, but they are not the priority.

A patient who has been admitted to the psychiatric unit appears frightened and anxious. What is the most appropriate initial nursing intervention when performing a mental status assessment on this newly admitted patient? A. Obtaining a sleep and appetite history B. Assessing cultural dietary preferences C. Obtaining the patient's permission D. Reviewing laboratory data

D. Do not give the patient anything by mouth. The patient should not be given anything by mouth because patients who have experienced a stroke have a risk of aspiration. A swallowing evaluation should occur before the patient receives fluids. Straws allow fluids to be taken in quickly and with little control; therefore, patients who are at risk for aspiration should not use them. A thickening agent may not be needed for every patient who has experienced a stroke, but the patient should undergo swallowing evaluation before receiving any liquids.

A patient who has been admitted with a possible stroke asks for a glass of water. How should the nurse respond to this request? A. Allow fluids as needed. B. Use a thickening agent in the patient's liquids. C. Allow the patient to sip the water using a straw. D. Do not give the patient anything by mouth.

A. Candida-related stomatitis Removing the dentures at night will decrease the risk of Candida-related stomatitis and the incidence of pneumonia. Failing to remove the dentures does not put the patient at risk for mouth deformities, denture breakage, or oral cancer.

A patient who is hesitant to remove his or her dentures at night is at risk for which complication? A. Candida-related stomatitis B. Mouth deformities C. Breakage of the dentures D. Oral cancer

A. "Because you're immobile, any joint in your body can become stiff if it isn't exercised." Informing the patient about the risks associated with immobility directly answers his question in a clear and understandable manner. Leg spasms are not specifically associated with immobility. Foot drop is not related to back surgery. Although dorsiflexion is included in foot ROM, this explanation uses medical terminology that the patient may not understand.

A patient who is on bed rest after back surgery asks the nurse why he must exercise the feet and ankles when the surgery did not involve the legs. Which of the following is the best reply? A. "Because you're immobile, any joint in your body can become stiff if it isn't exercised." B. "If your feet aren't exercised, you may have leg spasms." C. "Foot exercises prevent foot drop, which is common in patients with back surgery." D. "Dorsiflexion is necessary to prevent foot contractures related to immobility."

A. Pressure injuries The patient may be at risk for any of these but is especially at risk for the development of pressure injuries. Patient characteristics that favor the development of pressure injuries include paralysis or immobilization caused by restrictive devices, sensory loss, and disorders that affect circulation (e.g., diabetes mellitus). Bladder stasis should not be a problem with an indwelling urinary drainage catheter in place. The patient is still at risk for falls, but because the patient is cooperative and asks for assistance, the risk is probably minimal. Urinary tract infection is always a risk for patients who are paraplegic, especially with catheters, but because the patient's urine is clear, the patient is probably free of infection at present.

A patient who is paraplegic has been admitted with a diagnosis of uncontrolled diabetes mellitus. The patient is able to move from the bed to a wheelchair with minimal assistance but always asks for assistance. The patient has an indwelling urinary drainage catheter in place draining clear yellow urine and requires manual disimpaction every other day. Even though the patient is alert and cooperative, which complication is still a high risk for the patient? A. Pressure injuries B. Urinary tract infection C. Bladder stasis D. Falls

A. Leaves dentures in the mouth for fear of losing them Dentures should be removed in order to visualize the entire mouth. Ill-fitting dentures chronically irritate the oral mucosa and gums. This can lead to breakdown. A tongue blade assists in positioning the tongue out of the visual field. A penlight facilitates visualization.

A patient with dentures has a history of tobacco and alcohol abuse. The nurse's need for further education regarding oral assessment techniques is indicated when the nurse performs which action? A. Leaves dentures in the mouth for fear of losing them B. Uses a tongue blade to lightly depress the tongue C. Uses a penlight to look inside the mouth D. Determines if the dentures fit well and are comfortable when in place

C. 20-30 minutes in chlorhexidine mouthwash Dentures with metal tips should be soaked for 20 to 30 minutes in a chlorhexidine mouthwash, then rinsed well with water. They should not be soaked longer than 20 to 30 minutes, or the solution could cause damage the dentures. Plastic dentures may be cleaned by soaking for 20 to 30 minutes in a solution of diluted sodium hypochlorite once a week; but this solution is not used for dentures with metal tips.

A patient with dentures with metal tips should be instructed to soak them for how long and in what solution? A. Overnight in chlorhexidine mouthwash B. 20-30 minutes in diluted sodium hypochlorite C. 20-30 minutes in chlorhexidine mouthwash D. Overnight in diluted sodium hypochlorite

D. Provide oral instructions one step at a time. If a patient has difficulty with comprehension, he or she should be provided with oral instructions given one step at a time, walking them through the process. A patient with head trauma and difficulty with comprehension may not be able to understand written instructions or a video. Describing the procedure is good overview but the patient will still need step by step instructions.

A patient with head trauma has difficulty with comprehension. Which is the best method to instruct the patient on how the transfer from bed to the chair will take place? A. Give written instructions outlining each step. B. Provide a video demonstrating each step. C. Provide a general overview of the procedure. D. Provide oral instructions one step at a time.

A. Standard and airborne precautions Any special isolation precautions should be used in addition to standard precautions. The health care team member should use airborne precautions for a patient with a known or suspected serious illness that is transmitted by small-droplet nuclei, such as pulmonary TB. Droplet precautions should be used for a patient with an illness that is transmitted by large-particle droplets. Contact precautions should be used for a patient who is known or suspected to have an illness that is easily transmitted by direct patient contact or by contact with items in the patient's environment. Wound precautions do not prevent the transmission of a pulmonary infection.

A patient with pulmonary TB is being admitted to the unit. Which type of precautions should be implemented? A. Standard and airborne precautions B. Droplet precautions C. Wound and standard precautions D. Contact precautions

D. Warping the dentures Hot water can cause the dentures to warp and bleach the pink area of the dentures. Rinsing in hot water does not cause bacterial growth, severe mouth burns, or a headache.

A patient's food encrusted dentures are rinsed for ten minutes in hot water. This action increases the risk for which complication? A. Bacterial growth B. Severe mouth burns C. Headache D. Warping the dentures

A. A speech therapist A speech therapist must perform the dysphagia assessment. This assessment results in a comprehensive description of the phases of swallowing and is usually accompanied by a judgment about the degree of dysfunction and aspiration risk. Bedside dysphagia assessments identify patients at risk for dysphagia and provide recommendations for dysphagia therapy. Dysphagia screening is less detailed and is used simply to identify possible neurologic dysfunction; therefore, the screening may be performed by a registered dietitian, physical therapist, or registered nurse.

A registered nurse, physical therapist, registered dietitian, or certified speech therapist may perform a dysphagia screening. However, who should perform a dysphagia assessment? A. A speech therapist B. A registered dietitian C. A physical therapist D. A registered nurse

C. Disinfecting gloves with either an EPA-registered disinfectant wipe or ABHR Disinfecting gloves with either an EPA-registered disinfectant wipe or ABHR is a required step after caring for the patient and after each step of the doffing process. This step is essential to prevent cross-contamination to the other components of the PPE. The gloves should never be removed while in the patient's room because of the increased risk of a breach. The gloves are removed only after disinfection with either an EPA-registered disinfectant wipe or ABHR and only when the trained observer monitors the nurse's actions.

After caring for a patient with Ebola, the nurse demonstrates an understanding of the safety measures by performing which action while still in the patient's room? A. Removing gloves and disinfecting hands by washing with soap and water B. Removing gloves and disinfecting hands with ABHR C. Disinfecting gloves with either an EPA-registered disinfectant wipe or ABHR D. Removing the outer gloves and donning another pair of outer gloves

D. Instruct the patient to remain sitting upright. Instructing the patient to remain sitting upright after the meal reduces the risk of gastroesophageal reflux, which may cause aspiration. Turning the patient on the side or keeping him or her lying flat after eating increases the risk of gastroesophageal reflux. Obtaining a chest x-ray after a meal is not necessary to evaluate for aspiration.

After feeding a patient who is at risk for aspiration, which action should the nurse take? A. Turn the patient on the side to prevent aspiration. B. Keep the patient lying flat. C. Obtain a chest x-ray to determine whether the patient has aspirated. D. Instruct the patient to remain sitting upright.

D. Rinse the dentures. After dentures have been soaked, they should be rinsed before the patient places them in the mouth. If the patient is unable to place the dentures in the mouth, a health care team member can assist.

After soaking the patient's plastic dentures in a commercially prepared denture solution, which action should be taken next? A. Soak the dentures for an additional 30 minutes. B. Place the dentures in the patient's mouth. C. Allow the patient to place the dentures in his or her own mouth. D. Rinse the dentures.

C. Providing a disposable bed bath A disposable bath offers a patient with dementia an alternative method of bathing and may be appropriate because of ease of use, reduced bathing time, and greater patient comfort. A shower is not a safe option for an older adult patient with cognitive impairment. This patient may become agitated if given a complete bed bath. An established routine for regular bathing is important for an older adult patient with cognitive impairment; therefore, waiting until the patient relaxes may interrupt his or her established routine.

An 88-year-old patient who is diagnosed with dementia frequently becomes agitated and aggressive with caregivers. What is the most appropriate approach for bathing this patient? A. Assisting the patient with a shower B. Providing a complete bed bath C. Providing a disposable bed bath D. Avoiding bathing until the patient becomes more relaxed

B. Skin tear The patient should be assessed for signs of injury associated with restraint application. Skin breakdown or skin tears are considered adverse outcomes associated with the use of the restraints. Confusion or restlessness may occur but is not necessarily related to the restraint use. Tight application of a wrist restraint may interfere with circulation; extremities are assessed for adequacy of circulation, not for warmth.

An ICU patient is in soft wrist restraints to prevent him from pulling at his lines. Which condition would be considered an adverse event associated with the restraints? A. Confusion B. Skin tear C. Warm extremities D. Restlessness

C. Perform the exercises in two sessions Older adult patients and chronically ill patients may require two or more ROM sessions to prevent fatigue. Pain medication does not reduce fatigue and may make the patient sleepy. ROM exercises must be completed on a regular basis, so the fatigue may not resolve with time. Skipping sessions places the patient at risk for joint contractures and further loss of mobility.

An older adult patient complains of fatigue after the last active-assisted ROM session. What is the most appropriate nursing response? A. Inform the patient that the fatigue is to be expected and should resolve B. Administer pain medication 20 minutes before the next session C. Perform the exercises in two sessions D. Skip ROM sessions for the next 2 days

C. Review the patient's speech therapy evaluation and recommendations Conditions that produce generalized muscle weakness with neurologic impairment of the swallowing mechanism or altered mental status (e.g., brain injury or stroke) places patients at risk for dysphagia. Patients with dysphagia must be evaluated for safe swallowing before they are offered fluids and food safely to avoid choking or aspiration. Patients at risk for aspiration should be referred to a speech therapist for an evaluation. Though a general diet provides the best food choices for the patient, the consistency of the diet may not be safe, and aspiration could occur. Patients with dysphagia who aspirate thin liquids may benefit from thickening agents added to their food. Providing the patient's favorite foods does increase oral intake but could be unsafe as consistency could contribute to aspiration.

An older adult patient recovering from a stroke on a neurology unit was recently found to have dysphagia, and she tells the nurse that she wants to eat. What should the nurse's first action be? A. Provide a general diet. B. Provide food and fluids thickened with clinical thickening products. C. Review the patient's speech therapy evaluation and recommendations. D. Ask family members to bring in some of patient's favorite foods.

B. Use of a timer for implementation of pressure-relief techniques The patient and family should be taught that position changes need to occur on a frequent basis. Suggest to the patient that using a watch with a timer would help him or her remember to complete pressure-relief techniques. The Braden scale is a specialized tool that is used by nursing practitioners. Discolored areas of the skin may indicate that deeper tissue damage is present and massage is contraindicated. Ambulation safety may be discussed at discharge but is not the primary concern associated with skin breakdown.

An older patient with skin breakdown is being discharged home. What additional teaching does the nurse provide at discharge? A. Use of the Braden scale B. Use of a timer for implementation of pressure-relief techniques C. Massage techniques D. Ambulation safety

A. The person applying the restraint should not be the child's parent. When a child must be restrained for a procedure, the person applying the restraint should not be the child's parent or guardian. Non-health care personnel who apply or remove restraints may increase harm to the child by failing to restrain the child effectively or by incorrect restraint application or removal. Parents and family members should be encouraged to stay with the child. The nurse should caution the family against removing, repositioning, or retying restraints.

An upset and screaming young child is to be restrained before a procedure. The parent offers to apply the restraint to calm the child. What should the nurse tell the parent? A. The person applying the restraint should not be the child's parent. B. Having the parent apply the restraint helps the child. C. The parent should leave the room because he or she is upsetting the child. D. Although the parent should not initially apply the restraint, he or she may reposition the restraint when necessary.

A. Practice appropriate and safe transfer techniques Before returning home, the family member or support person should practice appropriate and safe transfer techniques with the patient to avoid injury to the patient and the family member or support person. Assessing the safety of the home is important, but the first step for patient safety is practicing safe transfer techniques. Not all patients returning home need aids, shower stools, handrails on tubs, and nonskid shower surfaces. The nurse assesses the risks of patient falls.

Before a patient returns home, the first priority for the family member or support person should be which item? A. Practice appropriate and safe transfer techniques B. Assess the safety of the home environment C. Purchase aids such as shower stools and nonskid shower surfaces D. Assess the risks of patient falls

C. Assess the patient's ability to swallow. The nurse's main priority is assessing the patient's ability to swallow before assisting him or her with eating. The patient's swallowing ability determines what types of foods are appropriate to prevent aspiration. The nurse should prepare the room and remove unpleasant smells, but this is not as high a priority as assessing the patient's ability to swallow. The nurse should also assist the patient with elimination needs and oral hygiene to make the eating experience more pleasant, but assessing the patient's ability to swallow takes priority over these needs.

Before assisting the patient with eating, what should the nurse's first priority be? A. Assist the patient with elimination needs. B. Prepare the room and remove unpleasant smells. C. Assess the patient's ability to swallow. D. Assist the patient with oral hygiene.

B. Inspect the patient's mouth for pockets of food. Before feeding the patient, the nurse should use a penlight and tongue blade to gently inspect the patient's mouth for pockets of food, which may indicate difficulty swallowing. The patient should not be turned on the side before feeding; rather, the patient's head should be elevated at a 90-degree angle or the highest position allowed by his or her medical condition during mealtimes to reduce the risk of aspiration. Not every patient who is at risk for aspiration requires thickened liquids or feeding by health care personnel.

Before feeding a patient who is at risk for aspiration, what should the nurse do? A. Instruct the patient not to eat and to wait for a nurse to administer the food. B. Inspect the patient's mouth for pockets of food. C. Turn the patient on the side to prevent aspiration. D. Thicken the patient's liquids.

C. Store the dentures in tepid water in a labeled denture cup When not in use, dentures should be stored in tepid water in a labeled denture cup. A moist washcloth does not protect the dentures from drying out. Dentures should be soaked to ensure that they remain moist all night. Hot water may damage dentures. A clear plastic bag does not protect the dentures.

Before going to sleep for the night, a patient removes his or her dentures. How should the dentures be stored for the night? A. Soak the dentures in commercial cleanser mixed with hot water. B. Instruct the patient to wrap the dentures in a moist washcloth and place them in a bedside table drawer. C. Store the dentures in tepid water in a labeled denture cup D. Place the dentures in a labeled clear plastic bag on the bedside table.

A. Assess the patient's proprioceptive function. Before moving a patient, the nurse should assess the patient's proprioceptive function (awareness of posture and changes in equilibrium), including the ability to maintain balance while sitting in bed and the tendency to sway or position himself or herself to one side. Range of motion is not required before the simple motion of moving the patient. A thorough blood pressure assessment is not required before shifting the patient's position in bed because the patient's blood pressure is not affected adversely by this motion. Disconnecting tubing is not necessary to reposition a patient because tubing is normally long enough that it does not interfere with this motion.

Before lifting a patient in bed, the nurse should do perform which action? A. Assess the patient's proprioceptive function. B. Perform passive range of motion. C. Take blood pressure in four extremities. D. Disconnect tubing, including intravenous lines and catheters.

C. Follow the organization's practice for correcting documentation errors. Following the organization's practice for correcting documentation errors limits liability exposure and ensures consistency, which promotes patient safety. Scratching out an error may make the record illegible or may appear as if the nurse is trying to hide information or deface the record. Using correction fluid in a patient record can make it look as if the nurse is trying to hide information. All documentation that has been placed in a patient's record should be maintained as part of the permanent record.

How should the nurse correct a mistake made while recording the patient's vital signs on a flow sheet? A. Use correction fluid and write over the error. B. Scratch out the error and rewrite the notation. C. Follow the organization's practice for correcting documentation errors. D. Discard the flow sheet and record the notations on a new sheet.

A. A 30-degree angle or less Pressure is reduced to the sacral area when the head of the bed is not at a high elevation (30 degrees or less). A 45-degree angle or higher, or the high-Fowler position, increases pressure to the sacral area.

If not contraindicated, when positioning the patient in bed, the head of the bed should be in which position? A. A 30-degree angle or less B. A 45-degree angle or higher C. A 90-degree angle D. The high-Fowler position

B. The patient is attempting to harm self, staff, or other patients. When a patient is attempting to harm self, staff, or other patients, alternative measures may not be effective. To maintain a safe environment, a nurse may need to apply mechanical restraints immediately. A confused and disoriented patient may not require emergency application of restraints because the patient may be reoriented using alternative measures. A patient who is picking at his or her nasal cannula, IV tubing, or urinary catheter can be provided with alternative distractions (e.g., working a puzzle, watching television, talking with family or visitors) to prevent him or her from disrupting medical therapy. A patient who is becoming increasingly agitated and aggressive can be given medication to promote relaxation.

In which emergency is using a mechanical restraint acceptable? A. The patient is confused and disoriented. B. The patient is attempting to harm self, staff, or other patients. C. The patient is picking at his or her nasal cannula, IV tubing, or urinary catheter. D. The patient is becoming increasingly agitated and aggressive.

D. Touching blood, body fluids, or mucous membranes Standard precautions require that gloves be worn when touching blood, body fluid, secretions, excretions, nonintact skin, mucous membranes, or contaminated items. Wearing gloves appropriately, not just during sterile procedures, is an important component of standard precautions. Gloves are needed for medication preparation only when the medications are caustic. Gloves should be removed and hand hygiene performed before recording vital signs in the patient's record. Gloves are not necessary when providing a meal tray to a patient.

It is important for the health care team member to understand that standard precautions should be used for every patient. Which circumstance is a patient care situation in which gloves are needed? A. Recording vital signs B. Preparing a patient's medications C. Offering the patient a meal tray D. Touching blood, body fluids, or mucous membranes

D. Before restraints are considered, an assessment should be done to evaluate her mother's risk factors, orient her as needed, and modify the environment to prevent falls. Rationale: Promoting functional restoration by performing individual assessment of risk factors, orienting the patient as needed, modifying the environment, teaching muscle strengthening exercises, and meeting older patients' needs regarding activities of daily living help prevent falls and other traumatic injuries. Advanced age is not an indication for the use of restraints. The enforced immobility that results from using restraints can cause pressure ulcer formation, hypostatic pneumonia, constipation, incontinence, contractures, and neurovascular impairment. Therefore, restraints should be used only when all appropriate alternatives have been used. The Joint Commission does not prohibit the use of restraints.

The adult daughter of an older patient, worried that her mother might fall, suggests to the nurse that restraints be applied whenever her mother is alone in the room. What should the nurse tell the patient's daughter? A. Advanced age is usually in itself an indication for the use of restraints. B. Because the risk of complications with restraints is low, applying restraints on her mother is a good idea. C. All restraints are prohibited by The Joint Commission. D. Before restraints are considered, an assessment should be done to evaluate her mother's risk factors, orient her as needed, and modify the environment to prevent falls.

A. Saliva movement is lacking, and the oral mucosa dries. Proper oral hygiene requires keeping the oral mucosa moist and removing secretions that can otherwise lead to infection. The patient's comfort is also a concern, but preventing complications is essential. Many patients have no gag reflex as a result of a change in consciousness or a neurologic injury. Oral hygiene in unconscious and debilitated patients reduces the risk of infection but does not promote improvement in the atrophy that occurs in these patients.

The daughter of a patient who is unconscious asks the nurse why her father needs mouth care when he is not eating. Which response would best explain the need for oral hygiene? A. Saliva movement is lacking, and the oral mucosa dries. B. The gag reflex may become weak without oral stimulation. C. The patient's comfort is compromised without proper oral hygiene. D. Buccal muscles may atrophy without exercise.

D. Heavily soiled linen Heavily soiled linen or heavy, wet trash is to be double bagged. Single bags can be used for soiled articles if they are sturdy and impervious to moisture. Blood specimens are transported in a biohazard bag. Syringes are not placed in the trash.

The health care team member is caring for a patient in isolation. Which item requires double bagging prior to exiting the patient's room? A. Blood specimens B. Contaminated dressings C. Used syringes D. Heavily soiled linen

A. Show the child all barrier precaution equipment. All barrier precautions should be shown to the child. Health care personnel should let the child see their faces before applying the mask so that the child does not become frightened. Ensure that the child's family is actively involved in any explanations.

The health care team member is providing care to a pediatric patient in isolation. What action can the health care team member perform to reassure the child? A. Show the child all barrier precaution equipment. B. Any barrier precaution equipment should be kept from view. C. The child should see the providers' faces only after the provider dons PPE. D. Involvement of the child's family in explanations should be minimal.

D. Tooth decay is a disease that may begin with cavity-causing bacteria being passed from the mother to the infant. The mother should be taught not to share saliva with her infant. She could pass on tooth decay to her infant when she licks the pacifier if she has any cavity-causing bacteria in her mouth. Although the other answers are possible, they are not the best answers to explain to the mother why not licking the pacifier is important for her child. Licking the pacifier does not clean it and, if the pacifier has bacteria on it, putting a dirty pacifier in the mother's mouth is not sanitary, and she may become sick.

The mother of an infant is seen licking the pacifier in an attempt to clean it before giving it to her child. Why is teaching the mother not to lick the pacifier important? A. It does not clean the pacifier. B. It is not sanitary. C. The mother may get sick from bacteria on the pacifier. D. Tooth decay is a disease that may begin with cavity-causing bacteria being passed from the mother to the infant.

A. The orientee uses his or her arms to lift the patient. The orientee should not use his/her arms to lift the patient. Dividing the balance activity between arms and legs reduces the risk of back injury. Placing the patient in the supine position enables the nurse to assess the patient's body alignment. Raising the head of the bed decreases the amount of work needed by the patient and nurse to raise the patient to a sitting position. The orientee should remain in front of the patient until he or she regains balance.

The nurse and an orientee are sitting a patient up. Which action by the orientee indicates the need for further education? A. The orientee uses his or her arms to lift the patient. B. The orientee places the patient in the supine position. C. The orientee uses the bed controls to raise the head of the bed. D. The orientee remains in front of the patient.

B. "The mummy restraint is being used to help keep your child still while we insert an IV." A mummy restraint is a safe, efficient, short-term method to restrain a small child or infant for examination or treatment. Crib toppers, not mummy restraints, are used to prevent children from climbing over the crib side rails. Children are not restrained in lieu of supervision, and the use of restraints should be limited to clinically appropriate and adequately justified situations after all appropriate alternatives have been used. IV sites are carefully wrapped to prevent children from dislodging them.

The nurse applies a mummy restraint to a 2-year-old child. The mother becomes upset and wants to know why her child is wrapped up. What is the nurse's most appropriate response? A. "The mummy restraint is used only for short periods when your child cannot be supervised." B. "The mummy restraint is being used to help keep your child still while we insert an IV." C. "The mummy restraint may prevent your child from getting hurt by climbing over the side rail of the crib." D. "The mummy restraint must be used so your child does not pull out the IV."

B. 5 Muscle strength is graded on a scale of 0 to 5, with 5 being full ROM against gravity and full resistance. A grade of 4 indicates full ROM against gravity with some resistance. A grade of 2 indicates full ROM and passive resistance. A grade of 1 indicates slight contractility and no movement.

The nurse assessing a patient's muscle strength finds full ROM against gravity with full resistance. What grade would the nurse assign to this finding? A. 1 B. 5 C. 2 D. 4

A. The wound is healing and debridement is not needed. The wound has an increased amount of healthy red tissue, and there is no further evidence of yellow nonviable tissue. Because no yellow, nonviable tissue is present, debridement of the wound is not indicated. Red tissue indicates wound healing. No signs of infection are present. The wound is healing appropriately with the current intervention as evidenced by the reduction in nonviable tissue and the increase in healthy granulation tissue.

The nurse documents the wound assessment findings, noting that the wound base is 100% red granulation tissue. Last week the wound had 40% yellow tissue and 60% red tissue. What does this finding indicate? A. The wound is healing and debridement is not needed. B. Debridement is needed to remove excess nonviable tissue. C. The wound is not healing, likely related to infection. D. Debridement is needed to stimulate wound healing.

D. Dorsiflexion, plantar flexion Walking provides dorsiflexion and plantar flexion to the ankle. Walking does not provide internal rotation, external rotation, abduction, adduction, external rotation, or lateral flexion. These are important movements but involve different muscles with different activities.

The nurse explains to the patient that walking is an easy exercise for the ankle. What movement does walking provide to the ankle? A. Abduction, adduction B. External rotation, lateral flexion C. Internal rotation, external rotation D. Dorsiflexion, plantar flexion

B. "Patient sits alone and cries in room, states 'I feel bad' when questioned." Documenting that the "patient sits alone and cries in room, states 'I feel bad' when questioned" provides an objective assessment of the nurse's observation and the patient's response. Stating that the patient "appears" depressed is a subjective opinion. The nurse's subjective interpretation that the patient "appears" upset does not provide the objective detail that is necessary in documentation. The nursing interpretation that the patient is "obviously" upset does not provide an objective description of the patient's demeanor.

The nurse finds a patient sitting alone and crying. Which is the most objective statement for correct documentation? A. "Patient appears depressed." B. "Patient sits alone and cries in room, states 'I feel bad' when questioned." C. "Patient sits alone and appears upset." D. "Patient does not interact with others, obviously upset."

A. Place the patient's hand in the mitten, making sure the hook-and-loop strap is around the wrist and not the forearm. The thumbless mitten is applied by placing the patient's hand in the mitten, making sure the hook-and-loop strap is around the wrist and not the forearm. This positioning prevents the patient from dislodging invasive equipment, removing dressings, or scratching. If the mitten is tied to the bed frame, it is considered a restraint. Delegating assessments to assistive personnel while the mitten is in place is not an acceptable practice.

The nurse has determined that a patient needs mittens to prevent the removal of dressings. How should the nurse apply the mittens? A. Place the patient's hand in the mitten, making sure the hook-and-loop strap is around the wrist and not the forearm. B. Place the hand in the mitten, making sure the hook-and-loop strap is around the forearm and not the wrist. C. Tie the mitten to the bed frame after application. D. Request that assistive personnel reassess the patient in 30 minutes.

A. Write current date and time and write, "Late entry for (date and time of shift missed)." A nurse who forgets to document an entry during a shift should write the current date and time in the next available space and mark it as a late entry. It is important to document all care, even if added as a late entry. For legal purposes, information previously recorded should not be crossed out. Rewriting entries is not recommended because it creates confusing duplicate information.

The nurse has forgotten to document something. Going to the chart, the nurse finds that several people have added entries since the nurse's previous shift. Which choice contains the correct instruction for late documentation? A. Write current date and time and write, "Late entry for (date and time of shift missed)." B. Do not put in the missing data but be more careful the next time. C. Draw one line through the nurse's previous entry and rewrite an entry with the additional data and label entry as "Out of Sequence." D. Rewrite the nurse's last entry and all entries after it.

D. "Wound is 3 cm in diameter, no drainage noted." Describing the exact size and drainage amount provides an objective assessment as required for nursing documentation. "Appears" and "seem" are subjective terms and are not appropriate for nursing documentation. "Well" is also a subjective term, and the wound should be better described by specific details and measurements.

The nurse has just completed a dressing change. Which entry is the most complete and appropriate to write in the nurse's notes? A. "Wound is healing well." B. "Wound edges seem to be coming together." C. "Wound appears clean and dry." D. "Wound is 3 cm in diameter, no drainage noted."

A. Full-thickness tissue destruction Black or brown tissue is eschar, which represents full-thickness tissue destruction. Black is used to describe necrotic tissue or desiccated tissue such as tendon. Yellow tissue represents nonviable tissue and in some cases the presence of an infection. Red tissue represents the presence of granulation tissue. Black tissue does not indicate a recent surgery.

The nurse is assessing a new patient with a wound. The assessment indicates that the wound is covered in black tissue. What does the appearance of black tissue indicate? A. Full-thickness tissue destruction B. Infection C. Granulation tissue D. Recent surgical procedure

B. Holding the toothbrush at a 90-degree angle when brushing The ADA recommends holding the toothbrush at a 45-degree angle, not a 90-degree angle, to reach all surfaces of the teeth and to clean the gumline to remove accumulated plaque and tartar. The ADA also recommends brushing teeth twice a day to cleanse the teeth of food particles, plaque, and bacteria; at least a once-yearly dental professional cleaning and oral examination; and flossing teeth daily.

The nurse is assessing an adult patient's current oral hygiene practices. The patient says, "I brush my teeth once in the morning and before going to bed" and demonstrates holding the toothbrush at a 90-degree angle when brushing. The patient flosses after brushing in the evening and visits the dentist yearly. Which practice does the nurse need to instruct the patient to modify? A. Brushing the teeth once in the morning and before going to bed B. Holding the toothbrush at a 90-degree angle when brushing C. Flossing teeth after brushing in the evening D. Visiting dentist yearly

A. Blanching If the area of erythema does not blanch (turn lighter with finger pressure), this may indicate tissue damage. Reactive hyperemia is the blood rushing into the tissue and causing the redness. Maceration is softening of tissue caused by steeping in a fluid. There is no indication here that the patient has been lying in fluid (e.g., urine or feces). Skin turgor is not usually evaluated on the buttocks.

The nurse is assessing the patient for skin breakdown. The nurse notices an area of erythema on the patient's buttock and should press on the area to detect which condition? A. Blanching B. Reactive hyperemia C. Skin turgor D. Maceration

A. Stage 3 This is a Stage 3 (full-thickness) pressure injury because it extends to subcutaneous tissue but not muscle, tendon, or bone. A Stage 4 pressure injury would have muscle, tendon, or bone exposed. A Stage 1 or Stage 2 pressure injury is partial thickness and would not have visible subcutaneous tissue.

The nurse is assessing the patient's pressure injury and finds that some subcutaneous fat is showing, but no muscle tissue is exposed. What stage is the pressure injury? A. Stage 3 B. Stage 2 C. Stage 4 D. Stage 1

B. Arrange the food on the plate as if the plate were a clock. The patient who is visually impaired can locate items and eat independently if the nurse arranges the food on the plate as if the plate were a clock and communicates where on the clock the food is located. The nurse should assess for food aversions, but this does not enhance independence. Thickened liquids are appropriate for a patient with a decreased or absent gag reflex; this measure is not necessary for a visually impaired patient. The visual impairment does not impede the patient from using utensils.

The nurse is assisting a patient who has a visual impairment during mealtime. How should the nurse help the patient eat independently? A. Check for food aversions. B. Arrange the food on the plate as if the plate were a clock. C. Remove the utensils and let the patient eat with the fingers. D. Thicken the liquids.

A. Demonstrate respect and empathy. The nurse should maintain a respectful, sincere attitude and convey empathetic understanding of the patient's perspective. Professional boundaries are to be maintained in all situations; therefore, attempting to befriend the patient is inappropriate. Humor may be misunderstood and could be perceived as uncaring and insincere. Sympathy conveys pity, which the nurse should avoid; empathy, not sympathy, is the appropriate response.

The nurse is attempting to assess a patient with depression who is demonstrating angry behaviors. What is the most appropriate approach for the nurse to take? A. Demonstrate respect and empathy. B. Engage in casual conversation and self-disclosure to befriend the patient. C. Use humor to offset emotionally laden topics. D. Sympathize with the patient's feelings of sadness.

A. Document the medication administration without delay and, if necessary, have another nurse assist the other patient. The nurse should make every effort to document care in a timely manner, preferably right after care is rendered, to ensure accuracy and to avoid medication errors. If the nurse documents the medication administration later, another staff member may not realize that the patient has received the medication, leading to a medication error or an error in patient care. The nurse who rendered care or made an observation is responsible for documentation of the care or observation.

The nurse is called to another patient's room before having the opportunity to document a medication given to a patient. Which action should the nurse take? A. Document the medication administration without delay and, if necessary, have another nurse assist the other patient. B. Write the medication name and dose administered on a piece of paper as a reminder and document it later. C. Ask another nurse to document the medication administration. D. Document all administered medications at the end of the shift.

C. Hypertension Hypertension is not a complication of immobility from restraints. Pressure ulcer formation, hypostatic pneumonia, constipation, incontinence, contractures, and neurovascular impairment can result from the enforced immobility that results from using restraints. Humiliation, fear, anger, and a decreased sense of self-esteem may occur. Altered sensory perception and altered thought processes may also result.

The nurse is caring for a patient in the ICU who is restrained for nonviolent behavior. Which is not a potential complication of the enforced immobility resulting from being restrained? A. Decreased self-esteem B. Hypostatic pneumonia C. Hypertension D. Altered sensory perception

C. Untying the bottom strings of the mask first Untying the bottom strings first prevents the top part of the mask from falling and contaminating the uniform. Assistance is not required to remove a mask. If the nurse touches the outside of the mask to hold it in place while untying the strings, the hands become contaminated.

The nurse is caring for a patient who has been placed on droplet precaution. The nurse demonstrates the correct removal of a mask with ties by performing which action? A. Asking an assistant to untie and remove the mask B. Untying the top strings of the mask first C. Untying the bottom strings of the mask first D. Holding the mask to the face with one hand and untying both sets of strings before pulling the mask from the face

B. Infection Drainage that has a foul odor may indicate infection and should be reported to the practitioner. Maceration indicates excess moisture of the periwound. Granulation is a red appearance of the wound bed and indicates healing. Slough is yellow colored tissue.

The nurse is caring for a patient with a pressure injury. Upon assessment, the nurse notes a foul odor. What can this indicate? A. Maceration B. Infection C. Granulation D. Slough

A. The order for restraints is in effect until an assessment determines that the patient's behavior no longer requires restraints. Orders for restraints to manage nonviolent behavior remain in effect until the patient no longer exhibits the behavior. Guidelines require that the patient's need for continued use of restraints be reassessed at least every 24 hours. Orders for seclusion or restraint applied to manage violent or self-destructive behavior—not nonviolent behavior—remain in effect until an assessment determines that the patient's behavior or situation no longer requires restraint, but the period should be no longer than 4 hours. Documentation should be done as restraints are applied and during subsequent assessments, which often occur more frequently than every 24 hours. The patient's physical and psychological status and comfort should be assessed every 2 hours.

The nurse is caring for an adult patient who is restrained for nonviolent behavior. What should the nurse know regarding this patient? A. The order for restraints is in effect until an assessment determines that the patient's behavior no longer requires restraints. B. Documentation about the use of restraints should be done at least every 24 hours. C. The patient's need for continued use of restraints should be assessed at least every 48 hours. D. The patient's physical and psychological status and comfort should be assessed once during every shift.

C. A mask The immunosuppressed patient is at risk for acquiring an infection from the nurse if the nurse does not wear a mask when performing a central line dressing change. A mask decreases the incidence of microorganisms escaping from the nurse's mouth and nose and contaminating the field. A gown and eye protection may be worn during a central line dressing change, but they are worn to protect the nurse, not the patient, from blood splattering. A cap also may be worn during a central line dressing change to secure the nurse's hair and prevent site contamination, but a mask is a better protective barrier than a cap to prevent spreading infection to the immunosuppressed patient.

The nurse is changing a central line dressing for a patient who is immunosuppressed. The best way to decrease the risk of transmitting infection to the patient is for the nurse to wear sterile gloves and which other item? A. Eye protection B. A gown C. A mask D. A cap

D. "Complete ROM exercises only to the point of resistance and stop if you experience pain." The nurse should instruct the patient to complete ROM exercises only to the point of resistance and to stop if pain is experienced. The patient should not push past the point of resistance because this could cause injury. Pain is not normal when completing ROM exercises and should be reported to the practitioner. ROM exercises can be completed independently when the patient is able to perform independent activity.

The nurse is educating a patient on ROM exercise. What is important for the nurse to tell the patient? A. "Complete ROM exercises to the point of resistance and push yourself a little farther each time." B. "It is normal to experience pain during ROM exercises as you regain your muscles." C. "You should only complete ROM exercises with someone present to assist you." D. "Complete ROM exercises only to the point of resistance and stop if you experience pain."

A. Begin a proper weight-bearing exercise program To reduce bone demineralization, the nurse should instruct older adult patients to begin a proper weight-bearing exercise program that includes activity three or more times a week. Increased vitamin D aids in calcium absorption. Postmenopausal women who are not taking estrogen should consume increased doses of calcium daily.

The nurse is educating an older female adult about preventing bone demineralization. Which instruction would be included in the patient's education plan? A. Begin a proper weight-bearing exercise program B. Avoid exercise that requires weight bearing of the lower extremities C. Postmenopausal women who are not taking estrogen require low doses of calcium D. Avoid vitamin D supplements if taking calcium

C. Before tooth formation The parents should begin cleaning the infant's mouth by wiping gums with clean moist gauze before teeth appear. The parents should not delay oral hygiene until the child begins or finishes teething or until the child is old enough to brush his or her own teeth.

The nurse is educating parents about oral care for their infant. When should the parents begin routine oral care? A. When the child is old enough to brush his or her own teeth B. When the child begins teething C. Before tooth formation D. When the child finishes teething

C. Halitosis Brushing the tongue is important because microorganisms collect and grow on the tongue's surface and contribute to bad breath. Brushing the tongue does not prevent periodontitis, dental caries, or gingivitis.

The nurse is explaining why brushing the tongue is important. What common oral problem may occur if the tongue is not brushed? A. Periodontitis B. Dental caries C. Halitosis D. Gingivitis

A. Eye protection Removing gloves first prevents contamination of the hair, neck, facial area, and body when removing cap, mask, and eye protection. The nurse should remove gloves first, followed by eye protection, mask, and cap. Shoe covers should be removed after gloves, eye protection, mask, and cap. The nurse's scrubs are not removed unless soiled.

The nurse is performing a routine wound irrigation using sterile technique. At the end of the procedure, the nurse should first remove gloves, followed by which item? A. Eye protection B. Mask C. Shoe covers D. Scrubs

A. Hold the distal portion of the extremity to support the joint. The distal portion of the extremity should be held to support the joint. Holding the proximal, posterior, or anterior portion of the extremity would not support the joint

The nurse is precepting a new orientee and explaining how to perform passive ROM exercises. Where does the nurse tell the orientee to hold the patient's extremity to support to the joint? A. Hold the distal portion of the extremity to support the joint. B. Hold the proximal portion of the extremity to support the joint. C. Hold the posterior portion of the extremity to support the joint. D. Hold the anterior portion of the extremity to support the joint.

B. Gloves act as a barrier to reduce the risk of exposure to blood The use of gloves during the administration of injections acts as a barrier to reduce the risk of exposure to blood. The use of gloves does not decrease the risk of needlestick injury. The primary purpose of wearing gloves is not for patient protection during an injection. The use of gloves minimizes the transfer of microorganisms for a patient in isolation but is not the primary purpose of donning gloves for an injection.

The nurse is preparing to administer an injection to a patient. What is the purpose of donning gloves before the procedure? A. Gloves minimize the transfer of microorganisms. B. Gloves act as a barrier to reduce the risk of exposure to blood. C. Gloves reduce the risk of needlestick injury. D. Gloves provide protection to the patient.

C. Stage 1 pressure injury Nonblanchable erythema or skin temperature changes may be an important early indicator of a Stage 1 pressure injury. Blanchable erythema blanches when it is pressed. Stage 2 pressure injuries involve partial-thickness loss of dermis and presents as a shallow open injury with a red-pink wound bed without slough. Stage 2 may also present as an intact or open or ruptured serum-filled blister. A deep tissue pressure injury is a purple or maroon localized area of discolored intact skin or blood-filled blister because of damage to the underlying soft tissue from pressure or shear.

The nurse notices an area of redness on the patient's hip. The nurse presses the area and finds that it is an area of nonreactive erythema. What condition does this indicate? A. Stage 2 pressure injury B. Blanchable erythema C. Stage 1 pressure injury D. Deep-tissue pressure injury

B. Arrange for more frequent position changes Early detection of pressure indicates a need for more frequent position changes or the use of a pressure-relief device. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massaging this area may worsen the inflammation by damaging underlying blood vessels. Because there is no break in the skin, dressings are not required.

The nurse observes an area of nonblanchable erythema on the patient's back. The nurse realizes that this is caused by a decrease in circulation. What action should the nurse take to relieve the erythema? A. Cover the area with a transparent dressing B. Arrange for more frequent position changes C. Apply a dry sterile dressing D. Provide a 5-minute massage

B. "Incorporate these ROM exercises into your ADLs." The nurse should instruct the patient to incorporate ROM exercises into ADLs, such as eating, bathing, and grooming. These routine exercises help increase independence, slow the progression of musculoskeletal conditions, and improve strength while completing activities that must be done every day. ROM exercises that are incorporated into ADLs should occur at the time of day that works best for the patient.

The nurse provides a patient who is being discharged with examples of ROM exercises that can be completed at home. Which suggestion can the nurse give the patient for continuing strength training? A. "Perform these ROM exercises first thing in the morning before you become tired throughout the day." B. "Incorporate these ROM exercises into your ADLs." C. "Perform these ROM exercises after lunch when you are feeling energized." D. "Perform these ROM exercises in the evening when you are feeling relaxed."

B. Grasp the bottom elastic and then the top elastic and pull the mask away from the face The correct way to remove the mask is to grasp the bottom elastic and then the top elastic and pull the mask away from the face. The front of the mask is considered to be contaminated and should not be touched. Touching only the elastic protects ungloved hands from contamination.

What is the correct way to remove a PAPR or respirator mask? A. Grasp the top elastic and pull the mask down below chin level B. Grasp the bottom elastic and then the top elastic and pull the mask away from the face. C. Gently grasp the outer surface of the mask and pull away from the face D. Grasp the outer surface of the mask and both elastics and pull the mask away from the face.

A. Consider use of a pressure-reducing pad for the chair. If the patient requires a pressure-reduction surface for the bed, an appropriate pressure-reduction surface should also be considered for the chair. Placing a patient in a chair for the entire shift is not much better than keeping the patient in bed all day. The patient may not be quite ready for ambulation yet. Visitors can be a source of encouragement for patients as well as a distraction from the routine in the health care setting.

The patient has Stage 2 pressure injuries on the buttocks and hips and is on a pressure-redistribution mattress while in bed. The nurse obtains an order to get the patient out of bed as tolerated. The nurse decides to get the patient up in a chair for meals and to put the patient back in bed 1 hour after meals to rest. What else should the nurse do? A. Consider use of a pressure-reducing pad for the chair. B. Consider keeping the patient in a chair for the entire shift. C. Limit the patient's visitors so that the patient can rest. D. Get an order for ambulation.

D. To reduce the risk of aspiration The tongue is a primary organ in the swallowing cascade. Because the floor of the mouth has been surgically disrupted, encouraging swallowing exercises reduces the risk of aspiration and improves oral intake. Although topical analgesics may be used for pain, the exercises may increase the patient's pain without promoting analgesia absorption. Oral exercises have no effect on saliva production or on the strength of tooth enamel.

The patient is 3 days postoperative secondary to adenocarcinoma in the floor of the mouth. The speech and language therapist recommends that the patient perform tongue base range-of-motion exercises and the tongue-hold maneuver. What is the primary reason for this recommendation? A. To maintain tooth enamel B. To enhance absorption of topical analgesics C. To increase saliva production D. To reduce the risk of aspiration

A. "Help your mother to the side of the bed, let her sit for a moment, and determine if she has dizziness or pain." When moving a patient to a chair, a family member should allow the paint to sit on the bedside to stabilize blood pressure, reducing the risk of dizziness. A transfer belt enhances patient safety. A family member should remain in front of the patient to use good body mechanics during the transfer. A family member should never assume that he or she can hold the patient and get the patient into position without assistance.

The patient's family is being taught how to move the patient from bed to a wheelchair at home. The patient has normal weight-bearing capacity and normal upper-body strength. Which response is the most appropriate safety advice? A. "Help your mother to the side of the bed, let her sit for a moment, and determine if she has dizziness or pain." B. "When your mother is sitting on the side of the bed, bring the wheelchair to a 45-degree angle and move her into the chair." C. "A transfer belt is not needed because your mother has good strength and mobility." D. "When moving your mother, stay behind her at all times. You may need to hold her under her arms to ease her into the chair."

A. To prevent the patient from falling out of a wheelchair Belt restraints are used to prevent the patient from falling from a bed or wheelchair. The restraint is placed at the center of gravity to prevent the patient from rolling off a stretcher, sitting up while on a stretcher, or falling out of bed. Ankle or wrist restraints are used to immobilize one or all extremities. Mitten restraints are used to prevent patients from dislodging invasive equipment, removing dressings, or scratching. The elbow restraint is commonly used with infants and children to prevent elbow flexion.

The physician has assessed a patient and ordered the application of a belt restraint. What is the goal of this type of restraint? A. To prevent the patient from falling out of a wheelchair B. To immobilize one or all extremities C. To prevent the patient from removing dressings D. To prevent elbow flexion when an IV is placed in the antecubital fossa

C. Apply a light sensation with a cotton ball to symmetric areas of the face CN V (trigeminal) is assessed by applying light sensation with a cotton ball to symmetric areas of the face. The nurse must check CN V by assessing if the sensations are symmetric; thus, the nurse must evaluate both sides of the face. CN VII (facial) is evaluated by having the patient frown, smile, puff out the cheeks, and raise the eyebrows. CN IX (glossopharyngeal) and CN X (vagus) are assessed by having the patient speak and swallow.

To assess a patient's CN V, what action would the nurse take? A. Apply a light sensation with a cotton ball to one side of the face B. Have the patient frown, smile, puff out the cheeks, and raise the eyebrows C. Apply a light sensation with a cotton ball to symmetric areas of the face D. Ask the patient to speak and swallow

A. Insert a cotton-tipped applicator into the deepest section of the PI or wound. To measure the depth of a PI or wound, the nurse should insert a moistened cotton-tipped applicator into the deepest section of the PI or wound and measure the depth. Estimating the PI or wound depth based on the original depth does not provide an accurate PI or wound depth measurement. The PI or wound depth should be obtained only at the deepest section of the PI or wound, not in three different sections of the PI or wound. PI or wound depth cannot be estimated; it must be measured.

To measure the depth of a PI or wound, what should the nurse do? A. Insert a cotton-tipped applicator into the deepest section of the PI or wound. B. Document the original depth of the PI or wound and subtract 0.5 cm for each day of healing. C. Insert a cotton-tipped applicator into three sections of the PI or wound and calculate the average depth. D. Estimate the depth of the PI or wound based on the number of days of healing.

D. Have the patient stand with his or her feet together and arms at sides, both with eyes open and eyes closed, and observe for swaying The Romberg test, used to evaluate balance, is performed by having the patient stand with feet together, arms at sides, with eyes open and then with eyes closed, and observe for swaying. The nurse checks for scoliosis by observing postural alignment. The nurse observes gait as part of the musculoskeletal assessment. The nurse tests for Homan sign by supporting the leg while flexing the foot in dorsiflexion.

To perform a Romberg test, what action would the nurse take? A. Have the patient walk across the room and observe for a limp B. Stand behind the patient and observe postural alignment (position of hips relative to shoulders) C. Place the patient in a supine position, support the leg while flexing the foot in dorsiflexion, and assess for pain D. Have the patient stand with his or her feet together and arms at sides, both with eyes open and eyes closed, and observe for swaying

B. Cognition The MMSE and the MOCA were designed to measure cognitive function: the patient's ability to understand and remember information. A comprehensive mental assessment includes additional assessments of psychosocial functioning, emotional health, and perceptual disturbances such as auditory or visual hallucinations.

Upon admission, a patient presents with confusion, memory loss, and agitation and is experiencing visual hallucinations. The nurse plans to use standardized assessments to provide a systematic evaluation of the patient. The nurse would choose the MMSE to measure what aspect of the patient's evaluation? A. Psychosocial function B. Cognition C. Mood disturbance D. Perception

C. Reaching to turn on an overhead light Reaching to turn on an overhead light is a good shoulder exercise and part of ADLs. Although moving to a side-lying position, moving the neck so that the right ear is near the right shoulder, and walking are all good exercises, they do not target the shoulder.

What is a good shoulder ROM exercise that is part of ADLs? A. Moving to a side-lying position B. Moving the neck so that the right ear is near the right shoulder C. Reaching to turn on an overhead light D. Walking

D. Have the patient sit up during and after eating. If a patient is at risk for aspiration, the nurse should have him or her sit up during and after the meal. This helps prevent gastroesophageal reflux, which may cause aspiration. Other techniques to prevent aspiration include feeding small amounts at a time and assessing the patient's ability to chew, manipulate the tongue to form a bolus, and to swallow. Thin-consistency foods pose a greater risk for aspiration; most patients with dysphagia tolerate fluids and foods that have been thickened with a clinical thickening product. Thin-consistency foods and liquids increase risk for aspiration, so offering large amounts of fluids potentially increases the patient risk for aspiration.

What is an appropriate technique the nurse may use to help a patient eat, while also decreasing the risk for aspiration with meals? A. Offer thin-consistency foods. B. Offer large bites of foods. C. Provide large amounts of fluids. D. Have the patient sit up during and after eating.

C. Reduce the number of trips in and out of the patient room Trips in and out of the room should be reduced to limit the exposure of health care team members to microorganisms. Multiple trips, including those of short duration, increase the exposure of the health care team member to infectious microorganisms. The room should be stocked by enlisting another person on the health care team to hand in new supplies without entering the room.

What is the best action for the health care team to take to reduce exposure of team members to infectious microorganisms? A. Enlist multiple personnel to provide care for a patient on isolation precautions. B. Implement a plan for multiple, short trips into the patient room C. Reduce the number of trips in and out of the patient room D. Designate only two health care team members to restock the patient room at the end of the shift.

C. Undermining The development of tunneling or undermining is reported to the practitioner as an unexpected outcome and may change the treatment plan. Granulation or a red wound bed is an expected outcome and should be included in the wound documentation. Wound exudate is documented with an amount, color, and consistency. Serous drainage is not an unexpected outcome.

When caring for a patient with a wound, which unexpected outcome should the nurse report? A. Red wound bed B. Granulation C. Undermining D. Serous drainage

B. Maintain moist environment The goal of managing a red granulated PI or wound is to select a dressing that maintains a clean and moist PI or wound environment and minimizes damage to healing tissue. Red tissue represents granulation. The red color is the result of an increasing number of new blood vessels in the PI or wound and is considered healthy. The goal of PI or wound management is not to dry the PI or wound bed or to debride or soften the tissue.

What is the goal of managing a red granulated PI or wound? A. Dry the PI or wound bed B. Maintain moist environment C. Debride the tissue D. Soften the tissue

B. Lack of daily oral care Many factors contribute to poor oral health among nursing home residents, but lack of daily oral care is a significant factor. Daily oral care requires an integrated approach to provide consistent care, especially to those who need assistance. Daily oral care is especially important when residents wear dentures, have dry mouth from their medications, or have poor nutritional intake.

What is the major risk factor contributing to poor oral health in nursing home residents? A. Wearing of dentures B. Lack of daily oral care C. Dry mouth from medications D. Poor nutrition

A. Enhance debridement For patients with a low infection risk, the use of moisture-retentive dressings enhances debridement. These moisture-retentive dressings may include moist dressings, as well as hydrocolloids, hydrogels, or alginates. If the wound is infected, topical antimicrobials are used. Moisture-retentive dressings are not used to protect the skin or treat maceration.

What is the purpose of using moisture-retentive dressings? A. Enhance debridement B. Treat infection C. Protect the skin D. Treat maceration

A. At least once a year The ADA recommends regular dental checkups (at least once a year) and advises against waiting until the older person experiences pain or has a dental problem. Waiting longer than once a year is not advised.

What is the recommended frequency of dental checkups for older persons? A. At least once a year B. At least every 2 years C. Only when they experience oral pain D. Only when they have a dental problem

C. Twice a day Oral care should be performed at least twice daily. Some debilitated patients may require mouth care more frequently until the mucosa returns to normal. Frequency of care should be based on the condition of the oral cavity and the patient's comfort level.

What is the recommended minimum frequency of oral care for an unconscious or a debilitated patient? A. Every shift B. Every 4 to 6 hours C. Twice a day D. Daily

A. Local infection Enlarged, fixed, inflamed, or tender lymph nodes may occur as a result of infection, systemic disease, or a malignancy. Stress, allergy, and recreational drug use do not result in enlarged, fixed, inflamed, or tender lymph nodes.

What problem do enlarged, fixed, inflamed, or tender lymph nodes suggest? A. Local infection B. Allergy C. Recreational drug use D. Stress

D. Place the mask over the nose, mouth, and chin and ensure that the bottom flap is pulled out completely. The respirator mask should be donned by placing the mask over the nose, mouth, and chin and ensuring that the bottom flap is pulled out completely. A crimp in the mask may create an air leak; the mask should be molded to the nose instead. Respirator masks are reusable, so there is no need to use a new mask each time the a health care team member enters the patient's room. If the respirator mask needs to be adjusted, the health care team member should leave the isolation area to readjust.

What should a health care team member remember to do when donning a fit-tested respirator mask? A. Readjust the respirator mask frequently while in the patient's room. B. Pinch the mask and create a crimp at the bridge of the nose. C. Use a new mask each time he or she enters the patient's room. D. Place the mask over the nose, mouth, and chin and ensure that the bottom flap is pulled out completely.

B. The lower the center of gravity, the greater the nurse's stability. When transferring a patient from lying to sitting, the nurse should remember that the lower the center of gravity, the greater the nurse's stability. Dividing the balanced activity between the arms and the legs reduces the risk of back injury. The nurse avoids abnormal twisting of the spine by facing the direction of movement. The actions of leveraging, rolling, turning, and pivoting require less work than lifting.

When a patient is able to assist with a transfer from the lying position to the sitting position, the nurse should remember which information? A. Dividing the balanced activity between the arms and the legs increases the risk of back injury. B. The lower the center of gravity, the greater the nurse's stability. C. Facing away from the direction of movement prevents abnormal twisting of the spine. D. Leveraging, rolling, turning, or pivoting requires more work than lifting.

C. Scoliosis Scoliosis, lateral curvature of the spine, is often revealed by asymmetry of the shoulders and hips. Lordosis is evidenced by an increased lumbar curvature. Kyphosis presents as an exaggerated posterior curvature of the thoracic spin. A patient with a slipped disk usually has numbness, tingling, and pain

When assessing a 12-year-old patient, the nurse notices asymmetry of the shoulder and hips. The patient has no complaints of pain. The nurse realizes that this finding may be indicative of what problem? A. Kyphosis B. Lordosis C. Scoliosis D. Slipped disk

A. Notify the practitioner immediately A fully conscious patient is oriented to name, time, and place. As consciousness diminishes, the patient may show an unwillingness to cooperate. The practitioner should be notified immediately of this change. The deterioration in LOC should not be disregarded for any period of time because the patient may deteriorate further in that time. Documenting unwillingness to cooperate does not result in interventions to treat the underlying problem.

When assessing a patient's LOC, the nurse notes that the previously alert patient will not identify his name or location. What would the nurse do next? A. Notify the practitioner immediately B. Report this change in response at the change of shift C. Reassess the patient in 4 hours D. Document the patient's unwillingness to cooperate

D. Place the chair at a comfortable angle to the bed. The chair should be placed at a comfortable angle to the bed to avoid twisting motions. Locking the knees and bending from the waist engage the back muscles and increase the risk of injury. The feet should be placed wide apart to improve balance during transfer. The patient should be permitted to dangle his or her legs at the side of the bed to reduce the risk of dizziness or fainting when standing.

When assisting a patient from bed to chair, which action should be performed to facilitate the transfer? A. Move the patient quickly from the side of the bed to the chair. B. Keep the knees locked and bend from the waist. C. Stand with the feet together to allow more room to maneuver. D. Place the chair at a comfortable angle to the bed.

D. Have family members practice safe transfer techniques before discharge. Rationale: The first priority for educating family and support persons before discharge is to practice appropriate and safe transfer techniques. Giving them a pamphlet of safe transferring is helpful for reinforcement. Making the home environment free of hazards, such as throw rugs, electric cords, and slippery floors, is important, but safe patient transfers should be practiced before the return home. The family and support person should lower their centre of gravity for stability not raise it.

When educating family members how to get the patient out of bed to the chair before they go home, the nurse should take which action first? A. Assess whether the home is free of safety hazards. B. Instruct the family members to raise their centre of gravity for stability. C. Give the family members a pamphlet of safe transferring upon discharge. D. Have family members practice safe transfer techniques before discharge.

D. It provides clues to the effectiveness of PI or wound treatment. Periwound assessment provides clues to the effectiveness of the wound treatment. Periwound assessment is done for all wounds, with or without a drain or rash, and regardless of whether the patient is mobile.

When evaluating a PI or wound, what should the nurse know about the periwound assessment? A. It is included for all immobile patients. B. It is performed only when the PI or wound is surrounded with a rash. C. It is performed only when the patient has a PI or wound drain. D. It provides clues to the effectiveness of PI or wound treatment.

C. Gown and gloves, eye protection, and mask or respirator There is only one correct sequence for removing PPE to prevent the health care team member from coming into contact with contaminated materials. Gloves and gown should be removed first, then eye protection, and then the mask or respirator. All other scenarios increase the risk of contact with contaminated material.

When leaving a patient's room and preparing to remove disposable isolation garments, what is the appropriate order of PPE removal to prevent cross-contamination? A. Gloves, mask, eye protection, and gown B. Gown, gloves, mask, and eye protection C. Gown and gloves, eye protection, and mask or respirator D. Gown, eye protection, mask, and gloves

C. Apart in a wide base of support with the foot closer to the head of the bed in front of the other foot When the nurse places the feet apart with the foot farther from the bed behind the other foot, balance is improved, and the transfer of body weight is facilitated as the patient is moved to a sitting position. The feet need to be apart to help the nurse maintain balance. The foot farther from the bed should be behind the other foot to prevent the nurse from twisting his or her body. One foot should be in front of the other for balance.

When moving a patient into a sitting position, the nurse should place her feet in which way? A. Apart with the foot nearer the bed behind the other foot continuing at a 45-degree angle to the head of the bed B. Close together to allow the nurse to maintain balance C. Apart in a wide base of support with the foot closer to the head of the bed in front of the other foot D. Apart at least 24 inches (2 feet) with neither foot in front of the other

D. Wear two pairs of gloves with extended cuffs. Two pairs of gloves with at least one pair having extended cuffs are required to provide an extra barrier between the patient and a staff member. The cuffs minimize the risk of the gloves rolling down and exposing skin between the gown and gloves. Either an N95 or a PAPR respirator is used, not both. Both the N95 and the PAPR provide equal protection, and staff members should choose the one they are most comfortable wearing. Gloves must be worn at all times in the presence of a patient suspected of or diagnosed with Ebola because the virus is highly contagious.

When preparing to enter the room of a patient suspected of having Ebola, which of the following precautions should be followed? A. Wear gloves only when touching the patient. B. Wear one pair of gloves with extended cuffs. C. Wear an N95 and a PAPR respirator with a hood. D. Wear two pairs of gloves with extended cuffs.

D. Gloves and a gown Contact precautions require the use of both gloves and a gown, not just gloves alone. Because Clostridium difficile is not an airborne disease, components of the barrier protection used with airborne precautions, such as a negative-airflow room and a mask or respirator, are ineffective barriers.

When preparing to enter the room of a patient who has a Clostridium difficile infection, the health care team member should follow contact precautions. These precautions would include the use of which item(s)? A. A negative-airflow room B. Gloves only C. A mask or respirator D. Gloves and a gown

C. Organization-approved disinfectant Systematic disinfection of equipment with an organization-approved disinfectant minimizes the risk of spreading infectious organisms among patients. Using povidone-iodine or hydrogen peroxide and wiping the equipment with a clean cloth are not acceptable methods for disinfecting equipment.

When removing equipment from a patient's isolation room, which item is best to use for disinfecting the equipment? A. A clean cloth B. Hydrogen peroxide C. Organization-approved disinfectant D. Povidone-iodine

A. Include the principles of body mechanics and the hazards of immobility. Teaching the pathophysiology of immobility (including information on transfer skills, principles of body mechanics, and hazards of immobility) helps the patient and family understand why proper transfer skills are important. A patient's mobility generally increases over time, and the family should be taught to notify the practitioner if strength is decreasing unexpectedly. The patient does not need to sit up most of the time. One person can be trained to lift a patient in bed.

When teaching transfer skills, the nurse should perform which action? A. Include the principles of body mechanics and the hazards of immobility. B. Inform the family that the patient most likely will have a decreased level of mobility each day. C. Call attention to the importance of having the patient remain sitting up in bed most of the time. D. Tell the family to have at least two individuals to reposition the patient in bed.

C. Remain in front of the patient until the patient regains balance. After transferring the patient, health care personnel should remain in front of the patient until the patient regains balance and continue to provide physical support if the patient is weak or cognitively impaired. Withholding the transfer because the patient is weak or cognitively impaired is not appropriate. Mobility is an important intervention in the healing process. The patient who needs assistance to get out of bed to the chair should not use the commode independently.

When transferring a patient to a chair, which action should be taken to prevent complications? A. Delay the transfer if the patient is weak. B. Withhold the transfer if the patient is cognitively impaired. C. Remain in front of the patient until the patient regains balance. D. Place the commode next to the chair so the patient can use it independently.

B. Nares The patient with an NG tube would be prone to developing skin breakdown of the nares because that is where the tube rests while in position. An orogastric tube, oral airway, or endotracheal tube can cause breakdown of the tongue and lips. A cervical collar can cause skin breakdown around the neck, as can tracheostomy tube ties. Skin breakdown of the ears can be caused by an oxygen cannula or a pillow.

Where might a patient with an NG tube in place experience a skin breakdown? A. Tongue and lips B. Nares C. Neck D. Ears

C. Explain the procedure to the patient. The nurse should never assume that an unconscious person is unable to hear and should always explain procedures to him or her. A thin layer of water-soluble moisturizer is applied to the patient's lips at the end of oral care. The suction machine is used mostly for patients with an impaired gag reflex caused by a change in consciousness or a neurologic injury. The nurse should never place his or her fingers into an unconscious or a debilitated patient's mouth; the normal response is to bite down.

Which action is appropriate before providing oral care to an unconscious patient? A. Apply a thin layer of water-soluble moisturizer to the patient's lips. B. Palpate the buccal mucosa and look for lesions. C. Explain the procedure to the patient. D. Turn on the suction machine.

A. Have the patient wear a surgical mask A surgical mask prevents TB transmission from the patient to personnel or others. The patient should be instructed to use a tissue when coughing up sputum. Health care personnel do not need to wear a respirator mask if the patient is wearing a surgical mask. Outside department health care personnel do not need to wear a respirator mask if the patient is wearing a surgical mask.

Which action should be taken when transporting a patient with TB outside the room? A. Have the patient wear a surgical mask B. Instruct the patient to use a basin when coughing up sputum C. Wear a fitted respirator mask and have the patient wear a surgical mask D. Notify the outside department of the need to wear respirators when the patient arrives

A. Slurred speech and a weak, involuntary cough When observing the patient or giving mouth care, the nurse should look for various signs, including slurred, indistinct speech and a weak, involuntary cough. If these are present, the patient may have swallowing problems and may need referral to a speech therapist. Drowsiness and an inability to sit upright warrant further evaluation because they may be unrelated to dysphagia. For example, for a patient who is near the end of life, a dysphagia referral may not be appropriate. For the patient who has a baseball-size tumor in the esophagus, a surgical intervention may be needed before a dysphagia referral.

Which condition places a patient at greatest need for a dysphagia referral? A. Slurred speech and a weak, involuntary cough B. A baseball-size tumor in the esophagus C. Drowsiness and an inability to sit upright D. An inability to swallow near the end of life

C. Mashed potatoes and pureed meats Patients on a dysphagia pureed diet require uniform pureed foods that are cohesive and pudding-like in texture. These include smooth hot cereals cooked to a pudding consistency, mashed potatoes, pureed meat, pureed pasta or rice, pureed vegetables, and yogurt. Dry cereals moistened with milk are found in a dysphagia mechanical soft diet. Baked potatoes without the skin and peeled soft fruits are part of a dysphagia advanced soft diet.

Which foods may a patient on a dysphagia pureed diet eat? A. Peeled soft fruits B. Baked potatoes without the skin C. Mashed potatoes and pureed meats D. Dry cereals moistened with milk

A. Instill prescribed eyedrops and keep the patient's eyes closed with eye patches. Patients who are unconscious have lost the normal protective corneal reflex of blinking, increasing the risk of corneal drying, abrasions, and eye infections; instilling prescribed eyedrops and keeping the eyes closed maintain eye moisture and prevent injury. Eye patches should be used instead of tape to keep the eyes closed. Tape may harm the sensitive skin around the eyes when it is removed.

Which interventions should the nurse perform to prevent excessive drying of the corneas when preparing to bathe an unconscious patient? A. Instill prescribed eyedrops and keep the patient's eyes closed with eye patches. B. Tape both eyelids closed after instilling the prescribed eye ointment. C. Instill saline eyedrops and provide frequent cleansing of the uncovered eyes. D. Cleanse the eyelids, instill the prescribed eye ointment, and then tape the eyes closed.

B. Using correct body alignment The nurse prevents self-injury by using correct posture and body alignment, a low center of gravity, minimal muscle strength, effective body mechanics and lifting techniques. If the patient can assist the nurse that is helpful but not always possible. The nurse should face the direction of movement to prevent abnormal twisting of the spine not opposite. The nurse should divide balanced activity between arms and legs reducing the risk of back injury and not rely solely on the arm muscles.

Which is the best method for the nurse to prevent self-injury when assisting a patient to a sitting position? A. Asking the patient to assist B. Using correct body alignment C. Facing the opposite direction of the movement D. Using arm muscles to assist

D. Label the specimen in the presence of the patient. The first step to take after obtaining the specimen is to label the specimen per the organization's practice in the presence of the patient. If the specimen requires ice for transport, place the specimen in a biohazard bag and then place the bag with the specimen into a second biohazard bag filled with ice slurry. If gloves become excessively soiled and further care is necessary, remove gloves, perform hand hygiene, and don new gloves.

Which is the correct action to take immediately after obtaining a specimen from a patient in isolation? A. Take the specimen immediately to the laboratory and label the specimen there. B. Place all the specimens requiring ice for transport into one biohazard bag. C. Retain the original pair of donned gloves, even if soiled from obtaining the specimen. D. Label the specimen in the presence of the patient.

B. Raising the side rail and lowering the bed if the nurse leaves the bedside Raising the side rail and lowering the bed maintains the patient's safety if the nurse leaves the bedside. The patient who requires a complete bed bath should never be left alone and unassisted on the side of the bed or with the side rails lowered. If an extremity is injured or has reduced mobility, the nurse should care for the unaffected side first.

Which is the most important safety measure the nurse can take when providing care for the patient during a complete bed bath? A. Allowing the patient to sit unassisted on the side of the bed B. Raising the side rail and lowering the bed if the nurse leaves the bedside C. Lowering the bed and leaving the side rail down for the patient to bathe himself or herself D. Washing the affected or injured extremity before cleansing the unaffected extremity

A. Disinfect outer gloves, remove apron, disinfect outer gloves. Before each step in the doffing process, the gloves should be disinfected to remove any possible contamination and minimize the risk of touching the skin or PPE with contaminated gloves. Removing the apron and then removing the boot or shoe covers without disinfecting the gloves puts the staff member at risk of self-contamination with soiled gloves. The outer gloves are disinfected before each step of the PPE removal process but are not removed before removing the apron to maintain an extra layer of protection during the doffing process.

Which of the following sequences is correct when doffing PPE? A. Disinfect outer gloves, remove apron, disinfect outer gloves. B. Disinfect outer gloves, remove apron, remove boot or shoe covers. C. Disinfect outer gloves, remove outer gloves, remove apron. D. Remove outer gloves, remove apron, disinfect inner gloves.

D. A 49-year-old female with hypertension Risks for skin impairment include reduced mobility, reduced sensation, nutritional and hydration alterations, excessive moisture on the skin (particularly on skin surfaces that rub against each other), vascular insufficiencies, external devices applied to or around the skin, old age, shearing and friction, and incontinence. Hypertension is not an identified risk factors for skin impairment. Skeletal traction creates immobility, a risk factor for skin impairment. Large breasts can lead to rubbing and skin friction, a risk factor for skin impairment. A chest tube limits the patient's ability to move about in bed, a risk factor for skin impairment.

Which patient has the lowest risk of skin impairment? A. A 12-year-old male in skeletal traction B. A 27-year-old male with a chest tube C. A 45-year-old female with large breasts D. A 49-year-old female with hypertension

A. Orthostatic hypotension A patient who has been immobile for several days or longer may develop orthostatic hypotension or become dizzy when transferred. It is unlikely that transferring a patient will cause an arrhythmia or chest pain unless there is an underlying cardiac history. Nausea maybe a result of orthostatic hypotension but not because of the transfer.

Which potential complication can occur when transferring a patient who has been immobile for several days? A. Orthostatic hypotension B. Cardiac arrhythmia C. Chest pain D. Nausea

D. Rinsing with cosmetic mouthwash Therapeutic mouthwashes are recommended to help prevent oral hygiene problems. The ADA states that although cosmetic mouthwashes may temporarily freshen bad breath and leave a pleasant taste, they do not help reduce plaque, gingivitis, or cavities or kill bacteria that cause bad breath. The ADA recommends toothbrush replacement every 3 to 4 months, brushing teeth twice a day, and once-a-day flossing.

Which practice may contribute to oral hygiene problems? A. Toothbrush replacement every 3 to 4 months B. Brushing teeth twice a day C. Flossing teeth once a day D. Rinsing with cosmetic mouthwash

B. "I keep my dentures in all the time because it is easier that way." A patient should be taught to take the dentures out at night in order to prevent candida-related stomatitis. Taking them out also allows for soaking and thorough cleaning. Failure to clean the dentures could lead to gum disease. Dentures with metal tips should be soaked in chlorhexidine mouthwash for 20 to 30 minutes, then rinsed well with water. Any pain or swelling should be reported to the doctor, as it could indicate an infection or other problem.

Which statement by a patient with metal-tipped dentures indicates the need for more education? A. "If I don't clean my dentures, I could get gum disease." B. "I keep my dentures in all the time because it is easier that way." C. "I should soak my dentures in chlorhexidine mouthwash, then rinse them well." D. "If my dentures start hurting my mouth, I will call the doctor."

A. A powdered air-purifying respirator (PAPR) has the same filtering properties as a mask-type respirator. If facial hair or unusual facial features make it difficult to fit a mask-type respirator properly, a powered air-purifying respirator (PAPR) may be used. A PAPR is not a standard face mask and cannot be removed by grasping ties. A PAPR is a type of respirator used when caring for patients known or suspected to have tuberculosis and are part of isolation precautions. This type of respirator covers the head and uses a blower to move air through the filter and into the face piece, helmet, or hood. A PAPR does not require fit testing before use.

Which statement is true regarding a powdered air-purifying respirator? A. A powdered air-purifying respirator (PAPR) has the same filtering properties as a mask-type respirator. B. A PAPR is donned as part of standard precautions. C. A PAPR is removed by grasping the top ties first and pulling away from the face. D. A PAPR must be fit-tested prior to first use.

B. Masks are donned as part of droplet precautions. Droplet precautions are standard precautions plus a mask. One method of removal is to grasp the bottom ties or elastics first and then the top ties or elastics and pull the mask away from the face. The outer surface of the mask should not be touched as it is considered contaminated.

Which statement is true regarding the use and removal of a face mask? A. Masks are donned as part of standard precautions. B. Masks are donned as part of droplet precautions. C. Masks are removed by grasping the top ties first and pulling away from the face. D. Masks are removed by grasping the outer surface of the mask first.

D. Respirators are disposable and the same individual may use them more than once. Respirators are disposable, but the same individual may use them more than once. Respirators should be stored between uses in a plastic bag. The respirators should be stored in a dry place, and out of direct sunlight.

Which statement is true regarding use and storage of respirators? A. Respirators are disposable and should be used only once. B. Respirators should be stored in the most convenient location for future use C. Respirators may be stored in a humid location in direct sunlight D. Respirators are disposable and the same individual may use them more than once.

A. Palpate lymph nodes using the pads of the middle three fingers in a circular motion. Palpating lymph nodes using the pads of the middle three fingers in a circular motion provides the most effective method of assessment. Lymph nodes are not located in the frontal areas. The nurse should inspect the lymph nodes with the chin raised (not down) and head tilted slightly. The nurse should also face or stand to the side of the patient (not behind) and palpate gently in a rotary motion for superficial lymph nodes using the pads of the middle three fingers. Instructing the patient to swallow is done when assessing the thyroid and neck anatomy.

Which technique is the correct method for assessing lymph nodes? A. Palpate lymph nodes using the pads of the middle three fingers in a circular motion. B. Palpate over the frontal areas in a circular motion. C. Instruct the patient to put his or her chin down and inspect the area where lymph nodes are distributed. D. Stand behind the patient and have him or her swallow while palpating the lymph nodes.

D. A water-moistened foam stick applicator For patients with a sore mouth or no teeth, a water-moistened foam stick applicator minimizes trauma to the oral mucosa and the gums. A toothbrush may be too harsh. The nurse should never place his or her fingers into an unconscious or a debilitated patient's mouth; the normal response is to bite down. Even if the patient has no teeth, a clenched jaw can cause harm. Lemon glycerin swabs are not recommended because they dry the oral mucosa.

Which tool should be used to provide oral hygiene for an unconscious or a debilitated patient with a sore mouth or no teeth? A. Lemon glycerin swab B. Gauze wrapped around a gloved finger C. A small soft-bristled toothbrush D. A water-moistened foam stick applicator

B. Sanguineous drainage Sanguineous (bright red) drainage indicates fresh bleeding. Serous drainage is clear, like plasma. Serosanguineous drainage is pink. Purulent drainage is thick and yellow, pale green, tan, or white.

Which type of drainage indicates fresh bleeding? A. Serous drainage B. Sanguineous drainage C. Serosanguineous drainage D. Purulent drainage

D. Stop and notify the practitioner of the assessment findings To prevent injury, the nurse should report an inflamed or infected joint before any further exercise. Medicating the patient may mask the pain and allow further damage to the joint. Reducing repetitions or using a continuous passive motion machine is still painful for the patient and may damage the swollen joint.

While performing ROM exercises, the patient reports pain when the left knee is moved in any direction. The joint appears red and swollen. What is the most appropriate nursing action? A. Medicate the patient and perform ROM exercises in 60 minutes B. Use a continuous passive motion machine to exercise this joint C. Move the joint as much as possible, but reduce the number of repetitions to three D. Stop and notify the practitioner of the assessment findings

C. It indicates the level of assistance that the patient requires with activities of daily living. Measuring visual acuity helps the nurse determine how safely the patient is able to function independently at home. Measurement does not predict future changes in visual acuity. Assessment of visual acuity is not a measurement of fatigue and does not determine the need for skin precautions.

Why is it important to assess visual acuity in older adults? A. It indicates the amount of fatigue that the patient is experiencing. B. It suggests future deterioration of the patient's vision. C. It indicates the level of assistance that the patient requires with activities of daily living. D. It implies the need to place the patient on skin and wound precautions.

A. Receding gum lines Periodontitis is a condition characterized by receding gumlines, inflammation, and gaps between the teeth. Pink gums are a normal, healthy finding. Cracking of the lips (cheilosis) and white or grey patches on the tongue, inside the cheek, or on the floor of the mouth (leukoplakia) are not features of periodontitis.

he nurse is preparing to provide oral care for a patient with known periodontitis. What is an expected assessment finding in this patient? A. Receding gum lines B. Cracked lips C. Pink gums D. White coating on the tongue

B. Bring the transfer aid to the room and ensure that enough assistants are available to move the patient. A patient who has diminished weight-bearing capacity is at higher risk of a fall and needs more support through the process than a routine transfer belt can provide. The transfer aid or other appropriate device gives the most appropriate support. Additional assistants may be needed, but the number and activity are based on the patient's needs. Allowing the patient to sit on the side of the bed is part of the process, but unless unexpected complications occur, a full transfer is most beneficial.

patient is being evaluated for transfer to a chair. The patient has limited mobility, diminished weight-bearing capacity, and normal upper-body strength. Which action should be taken next? A. Apply a transfer belt around the patient's waist and teach the patient the correct position for transfer. B. Bring the transfer aid to the room and ensure that enough assistants are available to move the patient. C. Obtain three or four additional assistants to help with the transfer. D. Abort the transfer and instead allow the patient's feet to dangle for 20 minutes because transfer at this time is too difficult.

A. Three consecutive AFB sputum specimens are negative In order the remove a patient from isolation precautions, the patient must have three consecutive AFB sputum specimens that are negative or the patient has another diagnosis that explains the current clinical status of the patient. Each of the specimens should be collected 8 to 24 hours apart.

solation precautions may be discontinued when the likelihood of infectious tuberculosis is deemed negligible. In order to remove the patient from isolation precautions, which laboratory results need to be confirmed? A. Three consecutive AFB sputum specimens are negative B. Two recent AFB sputum specimens are negative C. The most recent AFB sputum specimen is negative D. The AFB specimens are negative and were obtained hourly for three consecutive hours.