Medical-Surgical Nursing I Test 1

When can the LPN/LVN apply a physical restraint to a resident in a long-term care facility? *(Select all that apply)*

-if documentation is made on all failed attempts. -if the least restrictive device is chosen. -if the family is unable to stay with the resident. -if all other measures have been attempted and failed.

The nurse is communicating with a patient who voices concern about an upcoming high-risk procedure. Which statement best demonstrates empathy?

" it must be difficult preparing for the procedure; how are you feeling?

An RN student asks a friend who is an LPN student, "will you be able to start IVs when you get out of school?" Which is the best response?

" it will depend on the Nurse Practice Act of the state where I work."

Which patient statement indicates a need for further discharge teaching that the vocational nurse should address?

"I have no idea of how this drug will affect me."

A patient furiously says, "my doctor was so busy giving me instructions that he didn't hear what I was trying to ask him!" Which response is most empathetic?

"I'll bet that made you feel very frustrated"

The nurse is caring for a patient who has been on antidepressants for 3 days. The patient tearfully says, "I still feel terrible. I don't think anything can help how I feel." Which response is best?

"It must be frustrating to be going through this difficult time."

The best communication given by the nurse to the unlicensed assistive personnel (UAP) would be:

"Please measure each urine output and report it to me."

The nurse educates the nursing assistant about the importance of locking the wheels of a wheelchair. Which statement indicates that the nursing assistant understands the nursing's teaching?

"The locks help to prevent falls."

The nurse observed a client who is fidgeting, wringing the hands, and has body tenseness and a wrinkled brow. What is the best response to the client by the nurse?

"You look tense, can you tell me if something is making you afraid or nervous?"

What action should the LPN/LVN take when delegating care to a nursing assistant? *(Select all that apply)*

-List information that needs to be reported. -Be aware that the nurse is responsible for outcome of delegated care. -Give specific instruction as to what is to be done. -instruct how the task is to be done.

Which statement(s) accurately describes the role of the LPN/LVN regardless of employment placement? *(Select all that apply.)*

-communicate effectively. -educate patients. -uphold clinical standards. -collaborate with the health care team.

Which treatment resource focuses on restorative care for people within chronic illness and disabilities? *(Select all that apply)*

-rehabilitation agencies -outpatient clinic -home care -long-term health care facilities

The nurse is assessing a group of patients. Which patient would most likely qualify for Medicaid?

A 35-year-old unemployed single mother with diabetes

The patient complains to the nurse that he is confused about his "deductible" that he owes the hospital. Which statement accurately explains a deductible?

An annual amount of money the patient must pay out-of-pocket for medical care.

The LPN/LVN making care assignments to nursing assistants would not assign a patient who has which problem?

An unstable condition

The nurse is seeking to motivate a frustrated patient who is learning to walk again after a stroke. Which intervention would be most effective?

Arrange a visit with another stroke victim who has learned to ambulate.

The nurse is caring for an obese resident with a pressure ulcer on her coccyx. The patient frequently lies on her back because it is difficult to turn due to her weight. Which intervention most effectively encourages independence?

Arrange for a trapeze so the patient can assist with positioning.

A resident with advanced Parkinson's disease stays in his wheelchair all day. He reports that he is too tired to walk and is fearful of failing. Which intervention to increase the patient's mobility should the nurse add to the patient's care plan?

Assist the resident with ambulating in the hallway with a gait belt.

What is an eligibility requirement for an individual to qualify for Medicare services?

At least 65 years old

An overweight male patient rips off his hospital gown, throws it out the door, and shouts, "I'm not wearing this stupid gown! It is too small, too short and exposes my backside to the world!" Which response is most appropriate?

Confer with the patient for methods to acquire a larger gown.

The charge nurse instructs the nursing assistants about the policy concerning call lights. The nurse teaches that patients taking which type of medication require especially prompt call light attention?

Diuretics

When the confused resident pours his cereal in a cup and "drinks" it, how should the nurse respond?

Do nothing to interrupt the behavior.

After assessing reddened heels on a bed-bound patient with a history of a stroke, which intervention should the nurse add to the care of plan?

Elevate feet on pillows

The long-term care facility nurse is caring for a newly admitted 80-year-old patient who is depressed. Which approach is best for the nurse to employ?

Encourage the resident to engage in an activity.

The nurse is caring for a disoriented resident. Which intervention is most appropriate for the nurse to include when planning care for this patient?

Ensure that activities are scheduled for the same time each day.

The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient?

Every 120 minutes

The nurse is caring for a patient who states, "you are the only nurse who understands about my pain. Can't you give me an extra dose of pain medication?" How should the nurse respond to the patient's request?

Explain that dosage schedules are by physician's orders.

Which area is the major focus of Healthy People 2020 and the primary mechanism through which to improve the health of Americans in the second decade of the century?

Healthy lifestyle encouragement

Which term explains the type of care that addresses interventions for all dimensions of a patient's life?

Holistic care

A cost-efficient way to provide care to people who are confined to their homes because of illness or disability in the use of:

Home health care

The rehabilitation nurse describes a patient who is blind, works full time as a Spanish interpreter, and lives with his wife in a downtown apartment. How should the nurse classify this person?

Impaired

When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on which goals?

Independence

The charge nurse asks the new LPN to start and intravenous infusion, a skill that the LPN has not been taught during her educational program. How should the LPN respond?

Inform the charge nurse of her lack of training in this procedure.

An older adult client has fallen twice while getting up to go to the bathroom at night. The nurse implements which of the following to decrease the risk of further client falls?

Leave the call bell within reach, and turn on the bathroom light.

A patient asks the nurse what Medicare Part A covers. Which response is correct?

Medicare Part A covers inpatient hospital costs

The nurse is caring for a 76-year-old patient in a long-term care facility who sent his food tray back to the kitchen untouched for the second time today. Which intervention is most effective to increase nutrition?

Offer the patient a high-protein drink .

What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a patient who is paraplegic from a spinal cord injury?

Perform passive range-of-motion exercises

The nurse is making recommendations to the plan of care for a patient who has limited mobility. On which skin condition should the nurse focus as the greatest risk for this patient?

Pressure ulcer

The LPN/LVN may provide many services to the patient in the home. Several of these are high-level skills. Under whose supervision should these high-level skills be directed and performed?

RN

The nurse is caring for a resident who has a security device for safety purposes. What intervention should the nurse include in the plan of care.

Reassess the need for security device every 4 to 8 hours.

The long-term care facility nurse is discussing fall prevention measures with the charge nurse. Which replacement should the nurse suggest?

Replacing area rugs with a nonslip pad.

The nurse is aware that when a task is delegated to an unlicensed assistive personnel (UAP), the nurse is:

Responsible for overall patient care.

The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient?

The need for some type of exercise

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls?

The patient takes a hypnotic.

The nurse is explaining differences in a therapeutic relationship and a social relationship to a patient. Which information about therapeutic relationships is most important for the nurse to include in the explanation?

Therapeutic relationships are goal directed.

Which statement accurately describes the primary purpose of the state Nurse Practice Act (NPA)?

To define the scope of LPN/LVN practice.

Which statement describes the chief goal of a long-term care facility?

To promote individual independence

The nurse is planning a group TV activity in a long-term care facility. The nurse should select a channel that offers which type of program?

Travel documentaries

According to most state nurse practice acts, the LPN acting as charge nurse in a long-term care facility acts in which capacity?

Working under general supervision by the RN available on site or by phone.

The patient who has been in traction for bilateral femur fractures complains of constipation. Which action(s) should the nurse take? *(Select all that apply)*

-encourage increased fluid intake. -administer prescribed stool softeners. -arrange for high-fiber foods such as cauliflower and broccoli. -provide prune juice from the snack cart.