Intro to Nursing - Exam 3 Concepts - Modules 9, 10, 11, 12

Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? A. Micrococcus B. Staphylococcus C. Corynebacterium D. Helicobacter pylori (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. Marshall and Warren first identified Helicobacter pylori in 1984. It is a bacteria that causes up to 85% of peptic ulcers and is confirmed by laboratory tests. It is treated with antibiotics that control the bacterial infection.

The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A, C, D. Caution older adults to avoid grapefruit and grapefruit juice because these impair absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; thus older adults should be encouraged to ingest adequate fluids. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures.

To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.) A. Smoking is prohibited around oxygen. B. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. C. Do not use electrical equipment around oxygen. D. Special precautions may be required when traveling with oxygen (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: A, C, D. When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen.

How does a nurse accurately calculate a client's body mass index (BMI)? A. BMI = weight (kg)/height (in meters)2 B. BMI = weight (lb)/height (in inches)2 C. BMI = weight (kg)/height (in meters) D. BMI = weight (lb)/height (in meters) (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: A.

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A. Nasal cannula B. Venturi mask C. Simple face mask without inflated reservoir bag D. Plastic face mask with inflated reservoir bag (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. A nasal cannula delivers precise, high-flow rates of oxygen.

A nurse is preparing to complete a fall risk assessment for a patient. Which factor places the patient at the highest risk for a fall? A. A previous fall B. Confusion C. Age greater than 65 years D. Impaired judgment (Lisa Ray Pre-Simulation)

Answer: A. A patient who has experienced a fall has an increased risk of recurrent falls. The remaining factors are of concern but are not the greatest indicator.

The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? A. Raise head of bed to 90 degrees B. Turn patient to left lateral decubitus position C. Notify health care provider immediately D. Have patient perform the Valsalva maneuver (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. An air embolus possibly occurs during insertion of the catheter or when changing the tubing or cap. Have the patient assume a left lateral decubitus position first. Then have the patient perform a Valsalva maneuver (holding the breath and "bearing down"). The increased venous pressure created by the maneuver prevents air from entering the bloodstream during catheter insertion. Maintaining integrity of the closed intravenous system also helps prevent air embolus.

Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? A. Placing an order for x-ray film examination to check position B. Confirming the distal mark on the feeding tube after taping C. Testing the pH of the gastric contents and observing the color D. Auscultating over the gastric area as air is injected into the tube (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. At present the most reliable method for verification of placement of small-bore feeding tubes is x-ray film examination. The measurement of the pH of gastric secretions withdrawn from the feeding tube helps to determine the location of the tube. Auscultation has repeatedly been shown to be ineffective in detecting tubes accidentally placed in the lung. Further, it is not effective in distinguishing between gastric and intestinal placement for feeding tubes.

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: A. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently.

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A. Record the amount and continue to monitor drainage B. Notify the health care provider C. Strip the chest tube starting at the chest D. Increase the suction by 10 mm Hg (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.

Which intervention is appropriate to include on a care plan for improving sleep in the older adult? A. Decrease fluids 2 to 4 hours before sleep B. Exercise in the evening to increase fatigue C. Allow the patient to sleep as late as possible D. Take a nap during the day to make up for lost sleep (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: A. Decreasing fluids 2 to 4 hours before sleep reduces the likelihood that the older adult's sleep will be disrupted during the night by the need to void.

_______ result in the greatest number of injuries to older adults. A. Falls Correct B. Medication errors C. Incidences of domestic violence D. Suicide attempts (Lisa Ray Pre-Simulation)

Answer: A. Falls, automobile accidents, and fires are the incidents that result in the greatest number of injuries to the older adult population.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? A. No observable respiratory difficulty or shortness of breath over the last 24 hours. B. A decrease in the amount of nasal drainage and sneezing. C. No sputum production, and a decrease in coughing episodes. D. Relief of an acute asthmatic attack. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: A. Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.

A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: A. A safe environment promotes patient activity. B. Assessment focuses on environmental factors only. C. Teaching home safety is difficult to do in the hospital setting. D. Most accidents in the older adult are caused by lifestyle factors. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: A. Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity.

A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. The nurse's best response is A. "Your father may be having ministrokes; I will notify his physician." B. "Your father is just confused about some things since he is in the hospital." C. "The confusion will pass. Your father just has to get up and move around." D. "Talk with your father about past events, and that will help with the confusion." (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: A. Periods of confusion may be related to ministrokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified.

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A. Raise the head of the bed to 45 degrees. B. Take his oxygen saturation with a pulse oximeter. C. Take his blood pressure and respiratory rate. D. Notify the health care provider of his shortness of breath. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? A. TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. B. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. C. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. D. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: A. The TPN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. Maintaining blood glucose within acceptable limits helps prevent complications from the TPN.

At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? A. Prepare for an influx of patients B. Contact the American Red Cross C. Determine how to restore essential services D. Evacuate patients per the disaster plan (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: A. The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address organizational system exemplars, such as A. Care coordination. B. Communication. C. Diagnostic workup. D. Fall prevention. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: A. The most common safety issues at the blunt end include documentation/electronic records, team systems, environmental systems, error reporting/analysis systems, and regulatory systems. Each of the other options is classified as a point-of-care, sharp-end exemplar.

The nurse is taking a sleep history from a patient. Which statement made by the patient needs further follow-up? A. I always feel tired when I wake up in the morning. B. I go to bed at the same time each night. C. It takes me about 15 minutes to fall asleep. D. Sometimes I have to get up during the night to urinate. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: A. This statement indicates that the patient is not experiencing quality sleep and should be followed up with more extensive questions and assessment of the problem. Patients are the best resource for describing sleep problems and how these problems are a change from their usual sleep and waking patterns. A general description of the problem followed by more focused questions usually reveals specific characteristics that are useful in planning therapies. To begin you need to understand the nature of the sleep problem, its signs and symptoms, its onset and duration, its severity, any predisposing factors or causes, and the overall effect on the patient. Ask specific questions related to the sleep problem.

The nurse is caring for a patient diagnosed with peptic ulcer disease (PUD). The patient was prescribed the proton pump inhibitor Prevacid (lansoprazole). Which of the following supplements may be prescribed to prevent deficiency? A. Vitamin B12. B. Vitamin C. C. Vitamin D. D. Omega-3 fatty acids. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answer: A. Vitamin B12 deficiency can occur as a result of the reduced gastric acidity associated with use of proton pump inhibitors, and supplementation is often warranted. Vitamin C deficiency is not a known deficiency associated with medications. Vitamin D deficiency may occur in patients who take cholesterol medication, and this link is currently being investigated. Omega-3 fatty acids may be used as monotherapy or in conjunction with cholesterol medication for patients with hyperlipidemia.

Which of the following manifestations would be an early sign of silent aspiration? A. Heart rate: 129 B. Blood pressure: 90/60 C. Respiratory rate: 30 D. Temperature: 38.2° C (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Tachypnea (respirations above 26) is an early sign of silent aspiration. (REF: p. 769)

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A. Fever increases metabolic demands, requiring increased oxygen need. B. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C. Carbon dioxide production increases as result of hyperventilation. D. Carbon dioxide production decreases as a result of hypoventilation. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? A. Sharp pleuritic pain that worsens on inspiration B. Crackles over lung bases of affected lung C. Tracheal deviation toward the affected lung D. Increased diaphragmatic excursion on side of rib fractures (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: A. When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

A malnourished client is being discharged on enteral nutrition products. Which suggestion from the registered dietitian does the nurse implement to make the enteral feeding experience more normal for the client? A. Administering the feeding product on a regular schedule B. Bringing the enteral product and napkin to the client on a tray C. Emphasizing the need to take iron medications before the feeding D. Once feeding is completed, putting equipment out of view (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. "Serving" the enteral product and napkin on a tray will help normalize the feeding experience for the client.

A hemoglobin level of _________ is needed to promote wound healing. A. 11 mg/dL B. 12 mg/dL C. 13 mg/dL D. 14 mg/dL (Lisa Ray Pre-Simulation)

Answer: B. A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia.

The nurse incorporates which priority nursing intervention into a plan of care to promote sleep for a hospitalized patient? A. Have patient follow hospital routines B. Avoid awakening patient for nonessential tasks C. Give prescribed sleeping medications at dinner D. Turn television on low to late-night programming. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: B. Avoiding awakening patient for nonessential tasks promotes sleep. Cluster activities and allow the patient time to sleep. Do not perform tasks such as laboratory draws and bathing during the night unless absolutely essential. Patients should try to follow home routines related to sleep habits. The other tasks do not promote sleep.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A. Stimulates hyperventilation, causing respiratory alkalosis B. Forms a strong bond with hemoglobin, creating a functional anemia. C. Stimulates hypoventilation, causing respiratory acidosis D. Causes alveoli to overinflate, leading to atelectasis (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: B. Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

Which statement made by the patient indicates a need for further teaching on sleep hygiene? A. "I' m going to do my exercises before I eat dinner." B. "I'll have a glass of wine at bedtime to relax." C. "I set my alarm to get up at the same time every morning." D. "I moved my computer to the den to do my work." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: B. Drinking alcohol before bed in an effort to relax indicates a need for further teaching. Alcohol should be avoided before bed because it speeds onset of sleep, reduces REM sleep, awakens the person during the night, and causes difficulty returning to sleep.

A nurse is preparing a care plan for a patient. Which of the stated diagnoses from the nurse's plan of care is of the highest importance? A. Risk for imbalanced body temperature B. Risk for injury C. Deficient knowledge D. Disturbed thought processes (Lisa Ray Pre-Simulation)

Answer: B. Each of the nursing diagnoses is representative of an actual or potential problem. The patient's safety is of the greatest importance.

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of A. Ischemia B. Pneumonia C. Myocardial infarction D. Peptic ulcer disease (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: B. Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A. Antibiotics B. Frequent change of position C. Oxygen humidification D. Chest physiotherapy (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: B. Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A. A 55-year-old obese man recently diagnosed with diabetes mellitus B. A recently widowed 76-year-old woman recovering from a mild stroke C. A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery D. A 46-year-old man recovering at home following coronary artery bypass surgery (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently this group lives alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. This contributes to a risk for food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia.

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: A. Fastens the tube to the gown with tape. B. Places the patient supine while giving a bath. C. Performs oral care for the patient. D. Elevates the head of the bed 45 degrees. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated. Laying the patient supine increases the risk of aspiration of the feeding and should be avoided. This needs to be addressed to maintain patient safety.

A patient is questioning the nurse about circulation and perfusion. The nurse's best response to explain this concept is A. Perfusion assists the body by preventing clots and increasing stamina. B. Perfusion assists the cell by delivering oxygen and removing waste products. C. Perfusion assists the heart by increasing the cardiac output. D. Perfusion assists the brain by increasing mental alertness. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: B. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? A. Fat B Protein C. Vitamin D. Carbohydrate (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein.

A nurse is caring for a patient in a Posey restraint. The nurse recognizes the need to remove the Posey restraint at a minimum of every _____________ hour(s). A. 1 B. 2 C. 3 D. 4 (Lisa Ray Pre-Simulation)

Answer: B. Restraints should be removed at least every 2 hours. This allows for provision of hydration, toileting, and range of motion.

Which medication type is associated with an increased risk for a fall? A. Antibiotics B. Antidepressants C. Nonsteroidal anti-inflammatory drugs D. Hormone replacement (Lisa Ray Pre-Simulation)

Answer: B. Some medication types are associated with an increased risk for falls, including antidepressants, antihypotensive agents, diuretics, antihypertensive agents, and hypnotic agents.

The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and A. Accountability. B. Attitude. C. Education. D. Value. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: B. The Robert Wood Johnson Foundation funded the national initiative called Quality and Safety for Nurses (QSEN), which builds on the work of the Institute of Medicine (IOM), defines safety, and outlines the necessary elements of knowledge, skill, and attitude to demonstrate safety in one's practice. Accountability is a critical aspect of a culture of safety; recognizing and acknowledging one's actions is a trademark of professional behavior and is incorporated into, but not considered one of the three major elements, of QSEN.

The client is an older adult with severe rheumatoid arthritis in the upper extremities. On assessment, the nurse determines that the client is malnourished. What does the nurse suspect as the cause for this client's malnutrition? A. A decrease in the client's appetite B. Decreasing ability to manipulate eating utensils C. Inadequate income to purchase sufficient food D. Metabolic requirements that are increased owing to immobility (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: B. The client's severe rheumatoid arthritis in the hands and arms would produce a decrease in the client's ability to manipulate utensils.

A nurse is caring for a patient. While assessing the patient, the nurse notes that the patient has a pressure ulcer. As a result of the assessment, the nurse includes Impaired skin integrity as a diagnosis in the plan of care for the patient. This nursing diagnosis can best be described as: A. a risk nursing diagnosis. B. an actual nursing diagnosis. C. a potential nursing diagnosis. D. a wellness nursing diagnosis. (Lisa Ray Pre-Simulation)

Answer: B. The patient in question has already experienced a skin breakdown, which was discovered upon assessment. Risk nursing diagnoses refer to health conditions or life processes that could possibly develop, and wellness nursing diagnoses refer to a patient's desire to increase well-being and actualize human health potential. Potential nursing diagnoses do not exist.

What is the most significant modifiable risk factor for the development of impaired gas exchange? A. Age. B. Tobacco use. C. Drug overdose. D. Prolonged immobility. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use.

What is the priority assessment that should be performed before a patient is given food and fluids? A. Auscultating breath sounds B. Determining orientation C. Checking for bowel sounds D. Asking about food preferences (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: B. Use simple orientation questions and single-step commands to determine the potential for both aspiration and safe oral intake before providing dysphagia screening.

The nurse is assessing a group of patients to determine their risk of vitamin D deficiency. Which of the following patients has the highest risk for vitamin D deficiency? A. A Caucasian female who is breastfeeding. B. An African-American female who is breastfeeding. C. An Asian female diagnosed with hypoglycemia. D. A Hispanic female who has a BMI of 24.1. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answer: B. Vitamin D deficiency is more frequently found among persons of African heritage and has increased in prevalence, especially among the infants of breastfeeding African-American mothers. Caucasian females do not share these risk factors. There is no known risk of hypoglycemia and vitamin D deficiency; however, diabetes increases the risk for vitamin D deficiency. There is no known risk of vitamin D deficiency in normal-weight females of Hispanic heritage; however, obesity is a risk factor.

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? A. Ratio of hemoglobin and hematocrit. B. Status of acid-base balance in arterial blood. C. Adequacy of oxygen transport. D. Presence of a pulmonary embolus. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: B. The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus.

A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? A. Give the child milk. B. Give the child syrup of ipecac. C. Call the poison control center. D. Take the child to the emergency department. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: C. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A. Postural drainage B. Chest percussion C. Incentive spirometer D. Suctioning (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: C. An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

The nurse teaches a patient taking a benzodiazepine that this group of medications causes which symptom of a sleep problem? A. Nocturia B. Hyperactivity C. Grogginess and feeling hung over D. Increased sleep time (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Benzodiazepines cause a hangover effect and rebound insomnia. The other sleep problems are not related to benzodiazepines.

The nurse is teaching the patient who is taking Coumadin about what foods to limit. Teaching has been effective when the patient avoids which of the following from the menu? A. Peas B. Artichokes C. Broccoli D. Cucumbers (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Broccoli should be avoided because vitamin K-rich foods (dark green leafy vegetables) interfere with the action of Coumadin (anticoagulant).(REF: p. 762)

The nurse's first action after discovering an electrical fire in a patient's room is to: A. Activate the fire alarm. B. Confine the fire by closing all doors and windows. C. Remove all patients in immediate danger. D. Extinguish the fire by using the nearest fire extinguisher. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: C. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum easily after nebulization C. Decreased independent ability to cough D. Lung sounds clear only after coughing (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: C. Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem A. Is disciplined according to established protocols. B. Must communicate the problem to the patient. C. Knows that near misses are used to improve care. D. Shares details to locate the individual at fault. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: C. In an agency with a culture of safety, a nurse knows that near misses are used to improve care. Individual people are not punished for flawed systems, and there are no protocols for discipline. Consequences are individualized to improve the system and minimize the opportunity for future problems. Telling the patient is part of the transparency and the sharing and disclosure among stakeholders but is generally the responsibility of the risk management staff, not the staff nurse. Through a strategy such as root cause analysis, the reasons for errors in medication administration can be identified and strategies developed to minimize future occurrences, not to point a finger at a certain person.

A young adult man says that he cannot stay on a diet because of trouble finding one that will incorporate his food preferences. How does the nurse effectively plan nutritional care for this client? A. Calculates his body mass index (BMI) B. Keeps a 24-hour diary of his physical activities C. Maintains a 24-hour recall (diary) of his food intake D. Obtains his accurate height and weight measurements (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. Maintaining a 24-hour recall of food intake will determine the client's food preferences and eating patterns so that they can be incorporated into the diet to the greatest extent possible.

Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? A. I need to stop eating red meat. B. I will increase the servings of fruit juice to four a day. C. I will make sure that I eat a balanced diet and exercise regularly. D. I will not eat so many dark green vegetables and eat more yellow vegetables. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: C. Obesity is an epidemic in the United States. Proposed contributing factors are sedentary lifestyle and poor meal choices. Healthy eating and participation in exercise or other activities of healthy living promote good health.

Which statement made by an older adult best demonstrates understanding of taking a sleep medication? A. "I'll take the sleep medicine for 4 or 5 weeks until my sleep problems disappear." B. "Sleep medicines won't cause any sleep problems once I stop taking them." C. "I'll talk to my health care provider before I use an over the- counter sleep medication." D. "I'll contact my health care provider if I feel extreme sleepy in the mornings." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Talking to a health care provider before using an over-the-counter sleep medication shows an understanding of the risks of over-the-counter sleep medications. The use of nonprescription sleep medications is not advisable. Over the long term these drugs lead to further sleep disruption, even when they initially seemed to be effective. Caution older adults about using over-the-counter antihistamines because of their long duration of action, which can cause confusion, constipation, urinary retention, and increased risk of falls.

A nurse is teaching a middle-aged adult client with a body mass index (BMI) of 27.5 and a height of 5'2" about what the BMI number means. Which client statement indicates a need for further instruction? A. "If I could get my BMI below 25, my risk for malnutrition would decrease." B. "I realize that this means that I have some increased health risks." C. "My goal should be to get my BMI below 18.5." D. "This means that I have an increased amount of total fat stored in my body." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. The least risk for malnutrition is actually seen in adult clients whose BMI is between 18.5 and 25.

Which statement made by a mother being discharged to home with her newborn infant indicates a need for further teaching? A. "I won't put the baby to bed with a bottle." B. "For the first few weeks we're putting the cradle in our room." C. "My grandmother told me that babies sleep better on their stomachs." D. "I know I'll have to get up during the night to feed the baby when he wakes up." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: C. Thinking that babies will sleep better on their stomachs indicates that the mother needs further teaching. She needs to be educated on the "back to bed" concept for infant sleeping. Infants' beds need to be safe. Parents should place infants on their back to prevent suffocation and decrease the risk of sudden infant death syndrome (SIDS).

A nurse is performing a health assessment on an obese client. The client states, "I have tried many diets in an effort to lose weight but have been unsuccessful!" How does the nurse assess whether the client's response to stress is related to the client's obesity? A. "Do you have a history of mental problems, especially depression?" B. "Do you usually use alcohol or drugs when you feel stressed?" C. "Tell me what you do to relieve stress in your daily life." D. "What is it about your obesity that causes you to feel uncomfortable?" (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: C. This is the only question that allows the client to verbalize stress-relieving mechanisms. It is also a question that cannot be answered with a simple "yes" or "no."

Which nursing measure best promotes sleep in a school-age child? A. Encourage evening exercise B. Offer a glass of hot chocolate before bedtime C. Make sure that the room is dark and quiet D. Use quiet activities consistently before bedtime (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. A bedtime routine (e.g., same hour for bedtime, snack, or quiet activity) used consistently helps young children avoid delaying sleep. Quiet activities such as reading stories, coloring, and allowing children to sit in a parent's lap while listening to music or a prayer are routines that are often associated with preparing for bed. Parents need to reinforce patterns of preparing for bedtime.

Which serum albumin level does the nurse expect to see in the healthy, ambulatory older adult client? A. 3.3 g/dL B. 3.7 g/dL C. 3.9 g/dL D. 4.3 g/dL (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. A level of 4.3 g/dL would be expected for this client.

The nurse is developing a plan of care for a patient experiencing narcolepsy. Which intervention is appropriate to include on the plan? A. Instruct the patient to increase carbohydrates in the diet B. Have patient limit fluid intake 2 hours before bedtime C. Preserve energy by limiting exercise to morning hours D. Encourage patient to take one or two 20-minute naps during the day (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. A person with narcolepsy has the problem of falling asleep uncontrollably at inappropriate times. Brief daytime naps no longer than 20 minutes help reduce subjective feelings of sleepiness. Other management methods that help are following a regular exercise program, practicing good sleep habits, avoiding shifts in sleep, strategically timing daytime naps if possible, eating light meals high in protein, practicing deep breathing, chewing gum, and taking vitamins. Patients with narcolepsy need to avoid factors that increase drowsiness (e.g., alcohol; heavy meals; exhausting activities; long-distance driving; and long periods of sitting in hot, stuffy rooms).

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A. Sonorous wheezes in the left lower lung B. Rhonchi midsternum C. Crackles only in apex of lungs D. Inspiratory crackles in lung bases (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.

The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? A. Gastric pH of 4.0 during placement check B. Weight gain of 1 pound over the course of a week C. Active bowel sounds in the four abdominal quadrants D. Gastric residual aspirate of 350 mL for the second consecutive time (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: D. Delayed gastric emptying is a concern if 250 mL or more remains in the patient's stomach on each of two consecutive assessments. The North American Summit on Aspiration in the Critically Ill Patient made the following recommendations regarding gastric residual volumes (GRVs): (1) stop feedings immediately if aspiration occurs; (2) withhold feedings and reassess patient tolerance to feedings if GRV is over 500 mL for two successive measurements; and (3) routinely evaluate the patient for aspiration and use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

Which action by the nursing assistant at bedtime requires the nurse to intervene? A. Giving the patient a back rub B. Turning on quiet music C. Dimming the lights in the patient's room D. Giving a patient a cup of coffee (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answer: D. Encourage patients not to drink or ingest caffeine before bedtime. Coffee, tea, cola, and chocolate act as stimulants, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.

The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? A. Activity intolerance B. Impaired bed mobility C. Acute pain D. Risk for falls (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: D. For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls.

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A. "I'll make sure that I rest between activities so I don't get so short of breath." B. "I'll rest for 30 minutes before I eat my meal." C. "If I have trouble breathing at night, I'll use two to three pillows to prop up." D. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

Which statement made by a patient of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 4 months. D. I'm going to alternate formula with whole milk starting next month. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answer: D. Infants should not have regular cow's milk during the first year of life. It causes gastrointestinal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine-motor skills of the hand and fingers parallels the infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein.

A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? A. Begin cardiopulmonary respiration. B. Restrain the child to prevent injury. C. Place a tongue blade over the tongue to prevent aspiration. D. Clear the area around the child to protect the child from injury. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: D. Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.

An older adult client needs additional dietary protein but refuses to drink the prescribed liquid protein supplements. Which nursing intervention is most effective in increasing the client's protein intake? A. Administering the liquid supplement with routine medications B. Giving a glucose polymer modular supplement C. Keeping a food and fluid intake diary for at least 3 days D. Providing protein modular supplements in the form of puddings (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Providing protein modular supplements in the form of puddings would increase the client's protein intake in an alternate format, other than a liquid supplement.

A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? A. Home accidents B. Physiological changes of aging C. Poisoning and child abduction D. Automobile accidents, suicide, and substance abuse (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answer: D. Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? A. "Suctioning the patient requires sterile technique." B. "I'll apply suction while rotating and withdrawing the suction catheter." C. "I'll suction the mouth after I suction the endotracheal tube." D. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answer: D. Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

Based on nutritional screening findings and assessments, which client will be most successful with surgical treatment for obesity? A. Man with a BMI of 40, weight 75% above ideal body weight B. Man with a BMI of 41, weight 80% above ideal body weight C. Woman with a BMI of 38, weight 50% above ideal body weight D. Woman with a BMI of 42, weight 100% above ideal body weight (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. The best candidate for surgical intervention is the one with a BMI of 40 or more and a weight 100% above the ideal body weight.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. C. Encourage coughing and deep breathing to clear the airway. D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: D. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

A student nurse receives an order for Valium to be given intravenously. Valium tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? A. Communication error. B. Diagnostic error. C. Preventive error. D. Treatment error. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answer: D. The nurse avoided a treatment error; she was prevented from giving the wrong type of medication. Valium for intravenous administration is clear and comes prepared in a vial labeled for intravenous administration. According to Leape, treatment errors occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in an avoidable delay in treatment or in responding to an abnormal test. A communication error results from a failure to communicate. Diagnostic errors are the result of a delay in diagnosis, a failure to employ indicated tests, the use of outmoded tests, or a failure to act on results of monitoring or testing. Preventive errors occur when there is a failure to provide prophylactic treatment when monitoring is inadequate, or when follow-up of treatment is inadequate.

A bariatric client is recuperating after injury. Which nursing intervention most effectively prevents injury to the client who is being repositioned postoperatively? A. Administering pain medication B. Making sure to not move the client's nasogastric (NG) tube C. Monitoring skin-fold areas and keeping them clean and dry D. Using a weight-rated extra-wide bed for the client (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answer: D. Using a special bed will allow adequate room for repositioning the client comfortably without causing the bed rails to touch his or her body, causing pressure and injury. Monitoring skin-fold areas will prevent the development of skin breakdown but will not prevent injury to the client that might occur during repositioning.

The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is A. Open a window to let fresh air into the room. B. Use nasal strips to assist with breathing. C. Sleep in a side-lying position. D. Use pillows to prop yourself up while sleeping. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answer: D. Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat.

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? A. A patient with asthma and severe shortness of breath. B. A patient undergoing a bronchoscopy for a biopsy. C. A patient with a pleural effusion requiring fluid removal. D. A patient experiencing a problem with a pneumothorax. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 16)

Answer: D. When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A. SpO2 levels B. Amount of sputum production C. Change in respiratory rate and pattern D. Pain in lower calf area (Potter: Fundamentals of Nursing, 8th Edition, Chapter 40)

Answers: A, B, C.

How does the nurse support a culture of safety? (Select all that apply.) A. Completing incident reports when appropriate B. Completing incident reports for a near miss C. Communicating product concerns to an immediate supervisor D. Identifying the person responsible for an incident (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: A, B, C. Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required.

A nursing student has been assigned to care for a patient who is confused and has repeatedly tried to get out of bed. The student is concerned that the patient will be injured. Which of the student's planned interventions are not appropriate for this patient? (Select all that apply.) A. Raising the bed to deter the patient from attempting to get out of bed B. Encouraging the patient to stay in bed by putting up all the side rails C. Blocking the patient's exit from the bed by using the over-bed table D. Sitting with the patient for extended periods of time (Lisa Ray Pre-Simulation)

Answers: A, B, C. Raising the bed constitutes a safety hazard and would put the patient at risk. The bed should be kept in the lowest possible position. Using full side rails would be considered a restraint and is not permissible. Blocking the bed with the table is considered imprisoning and presents a possible source of injury and therefore cannot be done. Sitting with the patient is the only intervention that would be appropriate in this situation. Sitting with the patient may increase their level of orientation and reduce fears, thus reducing attempts to ambulate alone.

Which of the following places the patient at risk for aspiration pneumonia? (Select all that apply.) A. Pocketing of food B. Fatigue C. Cough D. Distractions E. Poor oral hygiene (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answers: A, B, D, E. Pockets of food may be found inside the cheeks when the patient has difficulty moving food from the mouth into the pharynx. The patient is usually unaware of pocketing, which may lead to aspiration. Chewing and sitting up for feeding accelerate the onset of fatigue. Fatigue increases risk for aspiration, and eating may lead to aspiration. Poor oral hygiene can result in decayed teeth, plaque, and periodontal disease and can cause growth of bacteria that can be aspirated. Environmental distractions and conversations during mealtime increase the risk for aspiration. (REF: p. 771-772)

Appropriate approaches used by the long-term care nurse to provide education for a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply): A. Schedule a visit by another resident who is diabetic. B. Demonstrate food choices using food photographs. C. Avoid discussion of the patient's favorite foods. D. Remind the patient that a lot of damage has already occurred. E. Encourage the patient's family to participate in teaching sessions. F. Ask the patient about past experiences with lifestyle changes. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: A, B, E, F. Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patient's favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

The school nurse is teaching health-promoting behaviors that improve sleep to a group of high school students. Which points should be included in the education? (Select all that apply.) A. Do not study in your bed. B. Go to sleep each night whenever you feel tired. C. Turn off your cell phone at bedtime. D. Avoid drinking coffee or soda before bedtime. E. Turn on the television to help you fall asleep. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A, C, D. Adolescents need to practice good sleep hygiene practices. Beds should be used for sleeping only. Activities other than sleep should not be done in bed. A person should try to go to bed at the same time each night. Create an environment that is quiet and free of distractions. Turning off cell phones prevents sleep disruptions. Coffee or soda contains caffeine. Caffeine acts as a stimulant, causing a person to stay awake or awaken throughout the night. Coffee, tea, colas, and alcohol act as diuretics and cause a person to awaken in the night to void.

The nurse is gathering a sleep history from a patient who is being evaluated for obstructive sleep apnea. Which common symptoms does the patient most likely report? (Select all that apply.) A. Headache B. Early wakening C. Excessive daytime sleepiness D. Difficulty falling asleep E. Snoring (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A, C, E. Common symptoms for obstructive sleep apnea include headache, snoring, and excessive daytime sleepiness caused by poor sleep during the night. The other symptoms are not related to obstructive sleep apnea.

The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) A. Sit the patient upright in a chair. B. Give liquids at the end of the meal. C. Place food in the strong side of the mouth. D. Provide thin foods to make it easier to swallow. E. Feed the patient slowly, allowing time to chew and swallow. F. Encourage patient to lie down to rest for 30 minutes after eating. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

Answers: A, C, E. Patients with dysphagia are at risk for aspiration and need more assistance with feeding and swallowing. Feed the patient with dysphagia slowly, providing smaller-size bites, and allow the patient to chew thoroughly and swallow the bite before taking another. Position the patient in an upright, seated position in a chair or raise the head of the bed to 90 degrees. If the patient has unilateral weakness, teach him or her and caregiver to place food in the stronger side of the mouth. Additional interventions include providing a 30-minute rest period before eating. Have the patient slightly flex the head to a chin-down position to help prevent aspiration. Determine the viscosity of foods that the patient tolerates best through the use of trials of different consistencies of foods and fluids. Thicker fluids are generally easier to swallow. More frequent chewing and swallowing assessments throughout the meal are necessary. Allow the patient time to empty the mouth after each spoonful, matching the speed of feeding to the patient’s readiness. If the patient begins to cough or choke, remove the food immediately.

A nurse in a home setting is assessing a 79-year-old male patient's risk for malnutrition. The nurse suspects malnutrition when reviewing the following laboratory results: (Select all that apply): A. Body mass index (BMI) of 17. B. Waist-to-hip ratio of 1.0. C. Weight loss of 6% since last month's visit. D. Prealbumin level of 16 mg/dL. E. Hematocrit level of 50%. F. Hemoglobin level of 8.2 g/dL. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: A, C, F. A BMI of 18.5 to 24.9 is normal, and this patient's BMI is below normal; a major weight loss is defined as more than a 2% weight change over 1 week; and the expected hemoglobin level for a man is 14 to 18 g/dL. The patient's values may also indicate dehydration. The expected level for prealbumin is 15 to 36 mg/dL. A hematocrit level of 50% is within normal limits.

Exercise and activity are included in a cardiac rehabilitation program in order to (Select all that apply): A. Increase cardiac output. B. Increase serum lipids. C. Increase blood pressure. D. Increase blood flow to the arteries. E. Increase muscle mass. F. Increase flexibility. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 15)

Answers: A, D, E, F. A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure.

The patient reports vivid dreaming to the nurse. Through understanding of the sleep cycle, the nurse recognizes that vivid dreaming occurs during which sleep phase? A. REM sleep B. Stage 1 NREM sleep C. Stage 4 NREM sleep D. Transition period from NREM to REM sleep (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: A. Although dreams occur during both NREM and REM sleep, the dreams of REM sleep are more vivid and elaborate; and some believe they are functionally important to learning, memory processing, and adaptation to stress.

Which of the following concepts would a nurse think has the strongest link to safety? (Select all that apply): A. Cognition. B. Communication. C. Quality. D. Regulation. E. Teamwork. (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 43)

Answers: B, C, D, E. Communication, quality, regulation, and teamwork are the concepts with the strongest links to safety and include processes that are essential for the nurse to consider related to safety. Safety refers to the prevention of injuries or freedom from accidents. Quality and safety are interrelated, overlapping concepts, and it is difficult to achieve outcomes in one without working on the other. Regulation refers to the mandates that have been credited with many of the improvements in health care systems, such as those from the Joint Commission, and to the oversight for the safety of the public provided by state boards of nursing. Teamwork and the ability of health care professionals to work together account for as much as 70% of health care errors. Cognition dependent on an optimally functioning brain could affect vigilance but would not be considered a concept that has one of the strongest links to safety.

A nurse is instructing a group of overweight clients on the complications of obesity that develop when weight is not controlled through diet and exercise. Which lifestyle changes does the nurse emphasize? Select all that apply. A. "Begin a weight-training program for building muscle mass." B. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." C. "Eat a variety of foods, especially grain products, vegetables, and fruits." D. "Engage in moderate physical activity for at least 30 minutes each day." E. "Foods eaten away from home tend to be higher in fat, cholesterol, and salt and lower in calcium than foods prepared at home." F. "Liquid dietary supplements can be substituted safely for solid food while attempting to lose weight." (Ignatavicius: Medical-Surgical Nursing, 7th Edition, Chapter 63)

Answers: B, C, D, E. Consuming a diet that is moderate in salt and sugar and low in fats and cholesterol is a smart strategy for a person who wants to lose weight.

An person of Northern heritage is at an increased risk for which of the following: (Select all that apply): A. Vitamin C deficiency B. Type 1 diabetes C. Celiac disease D. Type 2 diabetes E. hypertension F. metabolic syndrome (Giddens: Concepts for Nursing Practice, 1st Edition, Concept 13)

Answers: B, C. Type 1 diabetes and Celiac disease are more common in Northern heritage. African Americans and Hispanics are at increased risk for Type 2 diabetes, Hypertension, and metabolic syndrome. Vitamin C deficiency is not a common deficiency related to heritage or ethnicity.

The nurse is providing health teaching for a patient using herbal compounds such as melatonin for sleep. Which points need to be included? (Select all that apply.) A. Can cause urinary retention B. Should not be used indefinitely C. May cause diarrhea and anxiety D. May interfere with prescribed medications E. Can lead to further sleep problems over time F. Are not regulated by the U.S. Food and Drug Administration (FDA) (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Answers: B, D, F. Melatonin is a neurohormone produced in the brain that helps control circadian rhythms and promote sleep. Short-term use of melatonin has been found to be safe, with mild side effects of nausea, headache, and dizziness occurring infrequently. Caution patients about the dosage and use of herbal compounds because the FDA does not regulate them. Herbal compounds may create interactions with prescribed medication, and patients need to avoid using these together.

The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) A. Insert a urinary catheter. B. Leave a night light on in the bathroom. C. Ask the physician to order a restraint. D. Keep the bed in low position with upper and lower side rails up. E. Assign a staff member to stay with the patient. F. Provide scheduled toileting during the night shift. G. Keep the pathway from the bed to the bathroom clear. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: B, F, G. Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury.

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) A. Smokes a pack a day B. Used a cane to walk at home C. Takes antihypertensive and diuretics D. History of recent fall E. Neglect, spatial and perceptual abilities, impulsive F. Requires assistance with activity, unsteady gait G. IV line, urinary catheter (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: C, D, E, F, G. Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status.

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives with the family that are appropriate for this patient. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 27)

Answers: C, D, F. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided.

Older adults are cautioned about the long-term use of sedatives and hypnotics because these medications can: A. Cause headaches and nausea. B. Be expensive and difficult to obtain. C. Cause severe depression and anxiety. D. Lead to sleep disruption. (Potter: Fundamentals of Nursing, 8th Edition, Chapter 42)

Long-term use of sleeping medications in older adults can lead to sleep disruption. Because of slower metabolism and excretion of sleep medications, the potential for sleep impairment occurs. If sleep medications are needed, the lowest dose possible should be used short term.

Which of the following should be avoided for the patient consuming a dysphagia mechanically altered diet? A. Moist cake B. Canned peaches C. Peanut butter D. Spaghetti (Potter: Fundamentals of Nursing, 8th Edition, Chapter 44)

The basis of the dysphagia mechanically altered diet is that foods are moist and easily form a bolus to facilitate swallowing. Canned fruit and soft noodles are allowed. Sticky foods such as peanut butter are not allowed because it is difficult for the patient to form a bolus that can be easily swallowed.(REF: p. 769-770)