NCLEX NUR 111 QUESTIONS & important info

Ace your homework & exams now with Quizwiz!

1000 mL

1 L = ? mL

1000 mg

1 g = ? mg

1000 g

1 kg = ? g

2.2 lbs

1 kg = ____ lbs

30 mL

1 oz = ? mL

480 mL (16 oz)

1 pt = ? mL

2 pt

1 qt = ? pt

15 mL

1 tbsp = ___ mL

5 mL

1 tsp = ? mL

4. Purulent

1) A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: 1. Sanguineous 2. Serous-sanguineous 3. Serous 4. Purulent

1 Cut in the skin from a kitchen knife

1) A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? 1. Cut in the skin from a kitchen knife 2. Excoriated perineal area 3. Abrasion of the skin 4. Pressure ulcer

3- Wash hands thoroughly.

1) Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first? 1. Slowly remove the soiled dressing 2. Assess the drainage in the dressing. 3. Wash hands thoroughly. 4. Put on latex gloves.

4 Pouring solution onto a sterile field cloth

1) Nurse JV is performing wound care. Which of the following practices violates surgical asepsis? 1. Opening the outermost flap of a sterile package away from the body 2. Holding sterile objects above the waist 3. Considering a 1" edge around the sterile field as being contaminated 4. Pouring solution onto a sterile field cloth

2 Post a turning schedule at the client's bedside.

1) Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? 1. Vigorously massage lotion into bony prominences 2. Post a turning schedule at the client's bedside. 3. Turn and reposition the client at least once every 8 hours. 4. Slide the client, rather than lifting, when turning.

4 Partial-thickness skin loss of the dermis

1) The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? 1. Exposed bone, tendon, or muscle 2. Intact skin 3. Full-thickness skin loss 4. Partial-thickness skin loss of the dermis

4- An older female

1) The nurse is reviewing the healthcare record of all clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder? 1. An outdoor construction worker 2. An adolescent 3. A physical education teacher 4. An older female

1 Well approximated, with minimal or no drainage.

1) When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: 1. Well approximated, with minimal or no drainage. 2. Going to take a little longer than usual to heal. 3. Going to have more scarring than most incisions. 4. Draining some serosanguineous drainage.

3 Presence of an indwelling urinary catheter

1) Which condition places the client at the greatest risk for developing an infection? 1. Implantation of an artificial limb 2. Small burn on the left arm 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery

1 & 5 Keep the client well hydrated. Changing an incontinent client right away

1) Which nursing interventions can help a client maintain healthy skin? Select all that apply. 1. Keep the client well hydrated. 2. Recommend wearing tight-fitting clothes in hot weather. 3. Remove adhesive tape quickly from the skin. 4. Avoid bathing the client with mild soap. 5. Changing an incontinent client right away

2. Sitting in Fowler's position

1) Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad

2 Stage II

1) You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

1 kg

1000 g = ? kg

1 kg

2.2 lbs = ? kg

A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first? a. How would you describe your pain? b. How much medication do you take for the pain? c. How long have you had this pain? d. How many times a day do you medicate for pain?

A Chinese-American client has recently been diagnosed with hypertension. The nurse asks if he has been limiting his salt intake as directed. The patient does not make eye contact with the nurse but nods his head. Which response is appropriate? A- Ask the patient how much sodium he consumes each day B - Discuss risks of sodium and high blood pressure C - Remind the patient that soy sauce may contain "hidden sodium" Suggest low-sodium dietary alternatives

A Native American pt refuses to take the antibiotic prescribed for his infection. He expresses a belief that his herbal tea remedy will cure any ailments. The nurse's best response would be: a- advising the pt on good & bad therapies b- recommending herbal remedies the pt should use c- educate the pt about use of alternative therapies d- discouraging the pt from using his herbal tea

A client experiences nausea after receiving a dose of antibiotic medication orally. Interventions to treat the nausea are unsuccessful. When attempting to administer the next dose of antibiotic, the client refuses the medication. Which nursing intervention is best? A) Administer the antibiotic 1 hour after the next nausea medication B) Have the client eat ice chips several minutes before taking the antibiotic C) Crush the antibiotic and mix in applesauce for administration D) Report the information to the healthcare provider

A client has been instructed to follow a low fat diet to lose weight. Which diet choice indicates that the client has understood the instructions? A. Hamburger with cheese, French fries and a soda B. Tempura vegetables C. Broccoli, lean chicken and carrots D. BLT sandwich with potato chips

A client receiving abdominal surgery has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

a b c d

A client reports to the nurse that he wakes up early because of a need to urinate. The nurse recommends that the client avoid which of the following liquids after 8 pm.? (Select all the apply.) A. Tea B. Cola C. Wine D.Coffee E. Juice

A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One 1) admitted with unstable diabetes mellitus. 2) who underwent surgical repair of a perforated bowel. 3) with a stage 3 sacral pressure ulcer. 4) admitted with a urinary tract infection.

A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? a) Fidelity. b) Autonomy. c) Nonmaleficence. d) Justice.

A client undergoes ultrasonography of a kidney. The nurse providing postprocedure care remembers that: A. There are no special precautions that must be taken. B. Each urine specimen must be assessed for blood for 24 hours. C. All urine must be saved in a radiation-safe container for 12 hours. D. Contact with the client must be limited to 10 minutes each hour for 6 hours

A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? 1) Infection at the catheter insertion site 2) Side effect of the epidural analgesic 3) Epidural catheter migration 4) Spinal cord damage

A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? 1) A clean gown and gloves must be worn when in contact with the client. 2) Everyone who enters the room must wear a N-95 respirator mask. 3) All linen and trash must be marked as contaminated and send to biohazard waste. 4) Place the client in a room with a client with an upper respiratory infection.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? 1. Tomato soup 2. Boiled shrimp 3. Instant oatmeal 4. Summer squash

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? a) Decide on a treatment plan if the client can't. b) Inform the client or legal guardian of his right to execute an advance directive. c)Respect individuals' moral rights. d) Advise clients not to execute an advance directive because it limits treatme options.

A client's meal contains 30 grams of carbohydrates, 8 grams of fat and 12 grams of protein. How many calories in this meal? A. 240 calories B. 300 calories C. 210 calories D. 170 calories

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because: a)Nurses are highly vulnerable to criminal and civil prosecution in the course of their work. b) Nurses interact with clients and families from diverse cultural and religious backgrounds. c)Nursing practice involves numerous interactions between laws and individual values. d) Nurses are responsible for carrying out actions that have been ordered by other individuals.

A health care provider prescribes aspirin 650 mg every 4 hours PO when febrile. For which patient will this order be appropriate? A) 7 year old with a bleeding disorder B) 21 year old with a sprained ankle C) 35 year old with a severe headache from hypertension D) 62 year old with a high fever from an infection

B Carbs = 4 cal per gram fat = 9 cal per gram protein = 4 cal per gram

A name-brand ice cream contains the following nutrition information for each serving: 30 g carbohydrates, 19 g fat, 5 G protein. The total number of calories in a serving would be a- 366 b- 311 c- 435 d- 176

A nurse is bathing a pt who has a fever. Why should the nurse use tepid (lukewarm) bath water for this procedure? a- increases heat loss b- removes surface debris c- reduces surface tension of skin d- stimulates peripheral circulation

A nurse is caring for an elderly pt who was in a MVA b/c he thought the stop light was green. The pt asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic? a - yes, you should stop driving. As you age, your cognitive function declines & becoming confused puts everyone else on the road at risk b- yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident c. no, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop & if the bottom is illuminated it means go d - no, instead you should see your ophthalmologist & get some glasses to help you see better

c- quasi-experimental

A nurse is conducting quantitative research to examine the effects of following nursing protocols in the emergency department (ED) on pt outcomes. This is also known as what type of research? a- descriptive b- correlational c- quasi-exoerimental d- experimental

A nurse is discussing principles in healthcare ethics with the nursing students. Which of the following would be an appropriate example of nonmaleficence? a)To protect clients from a chemically impaired practitioner. b) To preform dressing changes to promote wound healing. c) To provide emotional support to clients who are anxious. d) To administer pain medications to a client in pain.

A nurse is discussing with an older female patient the factors that affect sleep. What fact does the nurse teach her? a. Drinking a cup of regular tea at night induces sleep. b. Using alcohol moderately promotes a deep sleep. c. Aging decreases the amount of REM sleep a person experiences. d. Exercising decreases REM and NREM sleep.

A nurse researcher who intends to interview pts about the factors that influence their compliance w/ insulin therapy & summarize the data as themes id doing quantitative research a- true b- false

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as: a) The relationship between law and culture. b) Moral values are considered to be universal. c) The principles that determine whether an act is right or wrong. d) The laws that govern acceptable and unacceptable behavior.

D E

A nurse working the night shift at a hospital observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By the age of 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults

A patient being treated for chronic musculoskeletal pain tells the nurse, "I feel depressed because I can't even go out and play a round of golf." The patient describes the pain as "aching" and says it is usually at a level 7 of a scale of 1 to10. Based on these assessment data, which patient goal is most appropriate? After treatment, the patient will a. state that pain is at a level 2 of 10. b. be able to play 1 to 2 rounds of golf. c. exhibit fewer signs of depression. d. say that the aching has decreased.

A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1) Apply a vest restraint. 2) Move the patient to a quieter room. 3) Ask another nurse to care for the patient. 4) Provide comfort measures.

A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with the right leg. In responding to the question, the nurse understands that the patient a. is experiencing referred pain from the kidney stone. b. has neuropathic pain from nerve damage caused by inflammation. c. has acute pain that may be progressing into chronic pain. d. is experiencing pain perception that has been affected by the morphine received earlier.

A patient prefers not to take the daily allergy pill this morning because it causes drowsiness throughout the day. Which response by the nurse is best? A) "The physician ordered it; therefore, you must take your medication every morning at the same time whether you're drowsy or not." B) "Let's see if we can change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping." C) "You can skip this medication on days when you need to be awake and alert." D) "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon."

A patient receiving prn intermittent IV administration of opiates following gastric surgery watches a favorite television program every morning. The patient does not request pain medication during this time and when questioned denies the need for medication. The nurse's evaluation of this situation is that a. lying quietly in bed is the best method of controlling the patient's incisional pain. b. encouraging the patient to watch other television programs will decrease the pain. c. the distraction of the television enables the patient to decrease the perception of pain. d. the patient's dose of opiates needs to be decreased because her pain is well controlled.

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order? 1. Encourage ambulation, maintain NPO status, and monitor intake & output 2. Insert an NG tube attached to intermittent suction 3. Administer IV fluids 4. Encourage at least 3000 mL of fluids per day

A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (of a 0-10 scale) and requests "something for pain that will work quickly." The best way for the nurse to document this information is as a. breakthrough pain. b. neuropathic pain. c. somatic pain. d. referred pain.

B) N96 mask, face shield, gown & gloves

A patient with disseminated herpes zoster requires respiratory care. Select the appropriate PPE you will wear: A) surgical mask, goggles & gown B) N95 mask, face shield, gown & gloves C) N95 mask, gown, face shield D_ Surgical mask, face shield, gown & gloves

A patient with extensive second-degree burns on the legs and trunk is using patient-controlled analgesia (PCA) with IV morphine to be delivered at 1 mg every 10 minutes to control the pain. Several times during the night, the patient awakens in severe pain, and it takes more than an hour to regain pain relief. The most appropriate action by the nurse is to a. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain. b. consult with the patient's health care provider about adding a continuous morphine infusion to the PCA regimen at night. c. teach the patient to push the button every 10 minutes for an hour before going to sleep even if the pain is minimal. d. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.

A B C

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply A) Broth B) Coffee C) Gelatin D) Pudding E) Vegetable juice

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, "I can tough it out." In encouraging the patient to use pain medication, the best explanation by the nurse is that a. very few patients become addicted to opioids when using them for acute pain control. b. there is little need to worry about side effects because these problems decrease over time. c. there are many pain medications and if one drug is ineffective, other drugs may be tried. d. unrelieved pain can be harmful due to the effect on respiratory function and activity level.

A pt has pitting pedal edema, crackles & an elevated bp. The nurse concludes that the pt has fluid volume excess. Which type of reasoning did the nurse use? a-theoretical b- inductive c- deductive d- conceptual

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? A) Health care provider B) Pharmacist C) Hospital D) Nurse

B & D

A root cause analysis of a sentinel event focuses on the following: select all that apply a- focuses mainly on individual performance & not on systems or processes b- identifies factors that might have contributed to the event c- focuses only on the nursing aspects of pt care d- is forward focused to prevent the same thing happening again e- mainly involves pharmacy & their processes

d- traditional knowledge

A student nurse asks an experienced nurse why it is necessary to change the pt's bed every day. The nurse answers: "I guess we have just always done it that way". This answer is an example of what type of knowledge? a- instinctive knowledge b- scientific knowledge c- authoritative knowledge d- traditional knowledge

3, 4 & 5

A woman of Islamic faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Select all that apply. 1) Male nursing assistant 2) Male licensed practical nurse 3) Female graduate nurse 4) Female student nurse 5) Female nursing assistant

According to the World Health Organization, what is the best definition for "health"? a. Simply the absence of disease b. Involving the total person and environment c. Strictly personal in nature d. Status of pathological state

After rounding on his assigned clients, the healthcare provider attempts to provide a verbal medication order to the nursing student. Which of the following actions should the nursing student take? A) Follow ISMP guidelines for approved abbreviations B) Explain that the order should be given to a registered nurse C) Write down the order and repeat back to the healthcare provider D) Ensure the 6 rights of medication administration are followed

After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient? 1. Side positioning 2. Semi-Fowlers 3. Prone 4. Low-Fowlers

After the nurse informs the surgeon that a chest tube is malfunctioning, the health care provider asks the nurse to reposition the tube and obtain a chest radiograph. The nurse should: a) Inform the surgeon this is not within the safe scope of practice. b) Report the surgeon to the Ethics Committee. c) Report the surgeon to the nursing supervisor. d) Follow the prescription as requested by the surgeon.

negative pressure room pt wear mask when out of room ppe- n95, gown, gloves, face protection if possible for splashing/spraying

Airborne precautions

2. Impaired Skin Integrity

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is: 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection

An argument for passing "universal health care" legislation is that it would help fulfill the Healthy People 2030 goal of a. Increasing quality of life in America. b. Prolonging healthy life in America. c. Eliminating health disparities in America. d. Promoting healthy behaviors.

An employee health nurse is assisting a stressed working mother with value clarification. Which of the following best defines value clarification? a) A process by which people come to understand their own values and value systems. b) A belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. c) An organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. d) A systematic inquiry into principles of right and wrong conduct, of virtue and vice, and of good and evil, as they relate to conduct

required to be reported by many states

Are Never ever events required to be reported?

not required but highly encouraged to report

Are sentinel events/ SREs required to be reported?

a - e

Assessment of the skin includes the following (select all that apply): a- texture b- turgor c- hydration d- temperature e- color

no tea or coffee adults- no blood transfusion or donate or get organs child- will consent for transfusion & other tx if doc considers it essential & they are required by law

Christian science dietary & medical restrictions

e- all of the above

Concept mapping is one way to: a- connect concepts to a central subject b- relate ideas to pt health problems c- challenge a nurse's thinking about pt needs & problems d- graphically display ideas by organizing data e- all of the above

EVIDENCE-BASED PRACTICE IS DEFINED AS: 1. THE INTERGRATION OF THE BEST RESEARCH WITH CLINICAL EXPERTISE AND PATIENT VALUES 2. SCHOLARLY INQUIRY OF NURSING AND BIOMEDICAL RESEARCH LITERATURE 3. NURSING CARE BASED ON TRADITION 4. QUALITY NURSING CARE PROVIDED IN AN EFFICIENT AND ECONOMICALLY SOUND MANNER

A B C E

Effects of immobility on the cardiac system include which of the following? Select all that apply a- blood clot formation b- increased cardiac workload c- weak peripheral pulses d- irregular heartbeat e- orthostatic hypotension

C D E

Elimination changes that result from obstruction to the flow of urine in the urinary collecting system may cause which of the following? (Select all that apply.) A. Blood clots B. Dehydration C. Renal damage D. Urinary retention E. Urinary tract infection (UTI)

Falls- arm band, alarm on bed/chair, bed in low position & locked, fall identification on room/door, pt has on nonskid footwear

For QI of falls what are some things that we look at?

IV site dated, time & initialed IV tubing dated

For Qi of IVs what are some things that we look at?

If they use hand sanitizer, soap & water or neither

For the QI of hand hygiene what do we look at?

do they do their rounds each hour

For the QI of hourly rounds what do we look at?

b- what is the meaning of health for migrant farm worker women?

For which of the following research questions would qualitative methods be most appropriate ? a- which pain meds decrease the need for sleep meds in elderly clients b- what is the meaning of health for migrant farm worker women? c- under what conditions does a stage IV pressure injury heal more quickly? d- how does frequency of pain med administration impact the degree of pain experienced following knee surgery?

For which sleep disorder would the nurse most likely need to include safety measures in the pt's plan of care? a- snoring b- enuresis c- narcolepsy d- hypersomnia

goes 3 to 15 3 = totally unresponsive 3 - 8 = coma 15 = the best

Glasgow coma scale

vegetarians women may prefer treatment by female staff

Hinduism dietary & medical restrictions

Hospital-acquired urinary tract infections (UTIs) are often related to poor hand washing and: A. Poor urinary output B. Poor perineal hygiene C. Use of urinary drainage bags D. Improper catheter care

If the number on topic decrease (EX: less number of falls), quality surveys & if procedures and policies are established

How do we know if a QI is successful?

if there is a change of policy or procedure based off recommendation from QI project

How do we know there is QI compliance?

a - e

Identify the factors which can affect hygiene (select all that apply) a- personal preference b- socioeconomic status c- cultural variables d- developmental stage e- physical condition

In identifying clients at greatest risk for health disparities, the nurse understands that which of the following is most accurate? A - Clients who live in urban areas have readily available access to healthcare B - Cultural differences exist in clients' ability to communicate with healthcare providers C - A client receiving care from a healthcare provider of a different culture will have decreased quality of care D - Male clients are more likely that female clients to have symptoms ignored by their healthcare provider

1- establish mutual goals w/ clients

In order to demonstrate safe & effective nursing care (Thinking, Doing, and Caring) during the physical exam, the best best action for the nurse is to 1- establish mutual goals w/ clients 2- maintain a strict routine, regardless of pt values, religious beliefs, needs & preferences 3- implement interventions in a manner that will save time 4- direct questions & decision making to the client's spouse or support person

c- develop an effective pain management plan

It is most important for the nurse to understand the various ways in which pain is classified so that he or she can a- document the client's pain using accurate terms b- be clear in communication w/ the physician c- develop an effective pain management plan d- educate the client thoroughly

no raw meat, red met, no meat that hasn't been bled properly no blood transfusion

Jehovah witness dietary & medical restrictions

Orthodox: forbid contraception & organ transplant. most all boys circumcised at 8 days conservative- kosher food- no pork, based on how animals are killed. can't have certain types of seafood or combinations of diary & meat deconstructionism & reform- basic tenets of jewish faith but use western values

Jews dietary & medical restrictions

a- degree of agreement of disagreement

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. He plans to use. Likert scale to determine: a- degree of agreement or disagreement b- compliance to expected standards c- level of satisfaction d- degree of acceptance

a- random

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked? a- random b- accidental c- quota d- judgement

c- age of patients

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. Which of the following is an extraneous variable of the study? a- date of admission b- length of stay c- age of pts d- absence of complications

a- validity

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure? a- validity b- reliability c- meaningfulness d- objectivity

c- salary of nurses

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. Which of the following variables will he likely exclude in his study? a- competence of nurses b- competence of other hospital personnel c- salary of nurses d- responsiveness of staff

c - sensitivity

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied? a- validity b- reliability c- sensitivity d- objectivity

B- reliability

Kevin is a member of the nursing research council of the hospital. His first assignment is to determine the level of pt satisfaction on the care they received from the hospital. He plans to include all adults pts admitted from April - may w/ average length of stay 3 - 4 days, 1st admission & w/ no complications. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration? a- validity b- reliability c- sensitivity d- objectivity

Maintaining a Foley catheter drainage bag in the dependent position prevents: A. Urinary reflux B. Urinary retention C. Reflex incontinence D. Urinary incontinence

Many variables influence a patient's health beliefs and practices. Internal and external variables influence how a person thinks and acts. An example of an internal variable would be a. Perception of functioning. b. Family practices. c. Socioeconomic factors. d. Cultural background.

Morphine 10 mg IV every 4 to 6 hours prn is ordered for a patient with a pancreatic tumor who has a distant history of opioid abuse. After 3 days of receiving the morphine every 6 hours, the patient tells the nurse that the medication is needed more frequently to control the pain. The best initial action by the nurse is to a. administer the morphine every 4 hours as needed. b. consult with the doctor about initiating an appropriate weaning protocol for the morphine. c. remind the patient that the previous substance abuse increases the risk for addiction. d. use alternative therapies such as heat or cold.

Mr. Jennings makes major & frequent changes in positions in bed w/o assistance. What mobility score would u assign mr. Jennings? a- 1 b- 2 c- 3 d- 4

b- I'll call the primary care provider & ask for an increased dose

Mr. Zenobia's chronic cancer pain has recently increased & he asks the home health nurse what can be done. In relation to his long-acting morphine, which is an appropriate response by the nurse a- if you take more morphine, it will not change your pain relief b- I'll call the primary care provider & ask for an increased dose c- the amount you are taking now is all I can give you d- I'm worried if we increase your dose that you will stop breathing

4- perceived constipation

Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the pt states "I've taken a tablespoon of Milk of Magnesia every day for 3 years". Which nursing diagnosis is most appropriate for the nurse to use in her plan of care? 1- diarrhea 2- constipation 3- risk for ineffective therapeutic regimen 4- perceived constipation

Mrs. Jones rarely eats a complete meal & generally eats about 1/2 of any food offered. What nutrition score would you give Mrs. Jones? a- 1 b- 2 c- 3 d- 4

Of the following interventions for the pt who is immobile, the nurse will give priority to a- encouraging a diet high in fiber & extra fluids b- administering the prn med for sleep c- having the pt use the incentive spirometer q 2 hrs d- massaging the pt's legs every hour

a - d

Older adults may bathe less frequently because of the following factors (select all that apply): a- the skin is more fragile b- loss of mobility c- the skin dries out easily d- cognitive factors such as resistance to hygiene e- they dont need baths anymore

Performing a cultural assessment is best accomplished with which of the following? A - Judging the client's cultural values based on observations B - Using a cultural assessment guide during the nursing process C - Seeking guidance from a nurse from the client's cultural background D - Relying on the nurse's previous experience with clients of the same cultural group

Postoperative pt has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The nurse should: a- avoid moving the pt until he or she is motivated b- have family members move the pt around c- decrease the frequency of movement to be performed d- educate the pt about the importance of repositioning

a- contact precautions

Pt has a draining abdominal wound that has become infected. In caring for the pt, the nurse will implement: a- contact precautions b- droplet precautions c- no precautions d- airborne precautions

Pt is elderly male w/ severe kyphosis who is immobile from a stroke several years earlier. The nurse must turn the pt frequently to prevent complications of immobility. Which of the following statement is most accurate for this pt? a- pt should be turned onto his back for meals b- pt may have to be turned more frequently than every 2 hrs c- pt may be allowed to remain in his favorite position as long as he doesn't complain of discomfort d- skin breakdown is not an issue for this pt

d- secondary infection

Pt living w/ AIDS develops oral hairy leukoplakia, an infection caused by the Epstein-Barr virus. The leukoplakia is considered a: a- nosocomial infection b- primary infection c- systemic infection d- secondary infection

Pt newly diagnosed w/ type 2 diabetes mellitus needs to make lifestyle changes. In relationship to the Trans-theoretical Model of Change, which nursing action would best support the pt during the "contemplation" stage? a- showing the pt how to use the finger stick blood glucose monitor b- providing info about various types of exercise to facilitate weight loss c- teaching the pt about the purpose for having his HbA1C tested monthly d- telling the pt that if he does not change his lifestyle, he will die

D- contact w/ enteric

Pt w/ CDIFF & is incontinent of stool. What type of precautions would you use? a- contact b- standard c- droplet d- contact w/ enteric

Situation Background assessment recommendation

S B A R

C, D & E ---- Measles, Varicela & disseminated Varicela Zoster

Select all conditions that use airborne precautions: A- noravirus b- Hep A c- measles D- Varicela E- disseminated varicela zoster

A C E

Select all that apply What is the intent for performing laboratory tests? a) Aids in diagnosis b) Determines amount of specimen needed for collection c) Provides information about the stage of disease process d) Determines what collection container is appropriate for collection e) Measures response to therapy

Select all that apply The nurse instructed the NAP regarding how to collect a urine specimen from a patient. Which of the following statements, if made by the NAP, indicates further instruction is needed? a) I should wear clean gloves while handling the specimen and transport it in a biohazard bag. b) I should get the specimen to the lab within 20 minutes or put it in the refrigerator. c) I should ask the patient to state her name and check the patient identification number on the armband. d) I should label the lid of the cup with the patient's name, date and time collected, and source of specimen

A B C

Select all that apply Which of the following are appropriate measures to help reduce embarrassment when collecting a urine specimen from a patient? a) You should close the door and/or pull the curtain and allow the patient time to obtain the specimen. b) You are nonjudgmental in your approach to the patient. c) You should instruct the patient regarding how to correctly obtain his own sample, if appropriate. d) You should provide the specimen kit with written instructions rather than informing the patient verbally.

The NAP is obtaining a midstream urine specimen from a female patient. Which action, if made by the NAP, requires correction and indicates that further instruction is needed? A) The NAP cleans the patient using a new swab for each cleansing. B) The NAP cleans the patient in a front -to-back motion. C) The NAP cleans the patient starting at the center and then uses the same swab to clean the sides. D) The NAP cleans in a direction going from the least contaminated to the most contaminated area.

The Nurse has four patients with gastrointestinal alternations/disorders. She knows this one is particularly prone to dehydration: A. The client with an NG tube for nutrition B. The client with esophageal reflux C. The client with an ileostomy D. The client with a colostomy

The client has been instructed to minimize risk factors for a second heart attack. Which finding by the home health nurse would require follow-up? A. The nurse observes that the client owns a treadmill B. The nurse observes two cans of soup in the recycling bin C. The nurse observes that the client turns off all electronic devices two hours before bedtime. D. The nurse observes that the client talks on the phone with her friend a lot

The client has diabetes and is limiting sugar intake. Which would be the best mid-afternoon snack for her? A. An apple B. Cut up celery with peanut butter C. Snickers bar D. Large soda

The client is a vegetarian. Which item would be an acceptable meal to serve? A. Chicken noodle soup B. Broccoli casserole C. Steak and cheese sandwich D. Burger and fries

The client is on a clear liquid diet. Which item, if observed, should the nurse remove from the tray? A. Black coffee B. Broth C. Yogurt D. Jello

A B E

The family of a hospitalized client demonstrates understanding of the teaching about legal documents related to end-of-life care such as "advance directive" and "power of attorney" when they make which statements? Select all that apply. a) "Advance directives give instructions about future medical care and treatment." b) "If people are not capable of communicating their wishes, health care providers and family together can agree on measures or actions that will be taken." c) "Ethics experts agree that the family is the sole deciding factor when the client is competent." d) "Medical power-of-attorney gives primarily financial access to the designee." e) "Medical power-of-attorney or durable power-of-attorney for health care is a document that lists who can make health care decisions should a person be unable tomake an informed decision for himself or herself."

The following clients have GI diversions. Which one is not normal in condition or appearance? A. The client with an NG tube to suction with the nosepiece firmly attached B. The client with a G-tube whose skin is red, itching and irritated around the skin opening. C. The client with a ileostomy draining liquid stool. D. The client with a colostomy that is moist and red.

c- randomized clinical trials

The gold standard of evidence gathering in evidence-based practice is: a- clinical knowledge & judgement b- expert opinions c- randomized clinical trials d- theories of practice

The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a laceration on the patient's forearm from a dog bite. The patient asks the nurse how ibuprofen will control the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the a. production of pain-sensitizing chemicals. b. spinal cord transmission of pain impulses. c. sensitivity of the brain to painful stimuli. d. modulating effect of descending nerves.

c- purposeful, analytical thinking that results in a reasoned decision

The most correct definition of critical thinking is: a- a problem-solving process that enables one to show others they are wrong b- an examination of one's own beliefs in order to defend them intelligently c- purposeful, analytical thinking that results in a reasoned decision d- rational thinking that results in obtaining the one correct answer

The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? 1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes

The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: 1) Crackles 2) Rhonchi 3) Stridor 4) Wheezes

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? A) Reduced glomerular filtration B) Reduced esophageal stricture C) Increased gastric motility D) Increased liver mass

b- R (focus charting uses DAR (data, action & response)

The nurse documents the following: "Client able to administer own insulin per subcutaneous injection using correct technique." In Focus charting this statement would be followed by which letter A) D B) R C) P D) E

The nurse has instructed a patient regarding the procedure for obtaining a midstream urine specimen. The patient asks, why does the urine sample need to be collected in this manner? A) The initial stream flushes out resident microorganisms that accumulate at the urethral meatus. B) It is performed this way to in order to verify that fresh urine is obtained for testing. C) This method will prevent you from developing urinary incontinence. D) By waiting to catch the middle of the urine stream, it provides time to ensure that the bladder will empty completely.

A B D E

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply. a) Maintain integrity and shape social policy. b) Develop, maintain, and improve health care environments. c) Ask the hospital for fair compensation for work. d) Be responsible and accountable for individual practice. e) Increase professional competence and personal growth.

The nurse is assessing a client's protein nutrition. He knows to check which of the following lab results? A) Hemoglobin B) Prealbumin C) Vitamin D level D) Blood sugar

The nurse is assessing a pt's glossopharyngeal nerve (cranial nerve IX). The nurse understands this involves assessment of the pt's ability to do which of the following? a- shrug b- smell c- smile d- swallow

The nurse is aware that which pt is most at risk for sensory deprivation? a- pt in ICU under constant monitoring following a myocardial infarction b- pt on the unit w/ TB on airborne precautions c- pt who recently had a stroke & has left-sided weakness d- pt receiving hospice care for end-stage brain cancer

The nurse is caring for a client admitted with multiple chronic health conditions. The client is receiving care from three healthcare providers and has medication orders from each of them. The client is to receive 13 medications this morning. What is the most appropriate action for the nurse to take first? A) Identify the client and administer the medications as scheduled B) Provide education regarding all medications to be given C) Review the list of medications to ensure safe mediation administration D) Develop a medication schedule for the client to follow when discharged

A B C

The nurse is caring for a client with end-stage cancer whose health status is declining. A prescription is written by the attending health care provider (HCP) to withhold all fluid, but the health care team cannot locate a family member or guardian. The nurse requests an ethics consultation. Which information is true of an ethics consultation? Select all that apply. a) Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. b) Ethics consultations may prevent poor outcomes in cases involving ethical problems. c) The recommendations of ethics consultants are advisory only. d) Requests for ethics consultations may only be made by the HCP or nurse. e) Ethics consultation is intended to provide legal advice on client care.

The nurse is caring for a pt admitted for acute respiratory distress. Pt has multiple monitoring systems on that constantly beep & make noise. Pt is becoming agitated & frustrated over the inability to sleep. Which action by the nurse is most appropriate for this pt? a- administer an opioid med to help pt sleep b- keep door open during the night c- open the shades at nigh d- provide pt w/ earplugs

The nurse is caring for a pt who is having difficulty understanding written & spoken word? The nurse suspects the pt has _______ aphasia.. a- expressive b- receptive c- Broca's D- Wernicke's

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? A)Vitamin B12 B)Vitamin C C)Vitamin D D)Iodine

B, C & D identify new knowledge, improve professional practice & enhance effective use of resources

The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit. The nurse realizes that nursing research is important in that it is designed to (select all that apply) a- enhance the nurse's chance at promotion b- identify new knowledge c- improve professional practice d- enhance effective use of resources e- lead to decreases in budget expenditures

The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for a patient who is receiving the medication to help relieve chronic cancer pain. Which information is the best indicator that the imipramine is effective? a. The patient states, "I feel much less depressed since I've been taking the imipramine." b. The patient sleeps 8 hours every night. c. The patient says that the pain is manageable and that he or she can accomplish desired activities. d. The patient has no symptoms of anxiety.

The nurse is meeting with a group of sedentary adults who are developing an exercise plan. Which adult's statement requires that the nurse clarify the expected goals? A. The person states that they will jog three times weekly for 30 minutes and walk two other days for 30 minutes. B. The person states that they will swim laps for an hour 3 days per week. C. The person states that they will hike for two hours every Saturday. D. The person states that they will lift weights for 30 minutes two days per week and bike 30 minutes four days per week.

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? 1. 24 hour urine output of 300 mL 2. BP 100/80 3. Pain rating of 4 on a 1-10 scale 4. Temperature of 99.3

The nurse is performing an admission assessment of a client with French heritage. Which question asked indicates the nurse is stereotyping the client? A) "Do you have any specific dietary preferences?" B - "What time do you typically go to sleep?" C - "Do you bathe and use deodorant more than once per week?" D- "What types of health conditions have you experienced?"

The nurse is planning to teach a client about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food item on the list? A)Oranges B)Broccoli C)Broiled fish D)Cream cheese

A B E

The nurse is reviewing newly prescribed medications for her assigned client. Which of the following orders will require the nurse to clarify the order with the healthcare provider? Select all that apply. A) Aspirin 325 mg PO QD B) MS 4 mg IV q1hr PRN C) Furosemide 40 mg IV now D) D5W continuous IV infusion at 125 ml/hr E) Heparin 5,000 u SQ BID

The nurse is teaching a Spanish-speaking client about diabetes. The best interpreter for the nurse to select would be: A - A family member who lives with the client B - An interpreter who translates words and nonverbal messages C - An interpreter who translates all words into Spanish D - An interpreter who can translate words into oral and written format

A & D

The nurse knows that the following are examples of primary prevention (select all that apply): A) Offering a class on plant-based nutrition for optimal health B) Offering free mammograms for low-income women C) Offering rehabilitation care through Medicaid for people with strokes D) Offering free sunscreen for beachgoers E) Offering blood pressure checks

4. All of the above

The nurse knows that the results of a fecal occult blood test can be inaccurate if 1- client has had an excessive intake of red meat 2- female client is menstruating 3- client takes high doses of vitamin c 4- all of the above

The nurse knows that which trace mineral is necessary for proper thyroid function? A)Cadmium B)Iron C)Iodine D)Nickel

The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? 1) Maceration 2) Abrasion 3) Excoriation 4) Pressure ulcer

The nurse observes the client is receiving oatmeal, pureed sweet potato soup and a shake for lunch. She looks at the diet order, expecting the client is on what special diet? A. Low carbohydrate B. Low residue C. Clear liquid D. Full liquid

1 2 4

The nurse receives a change-of-shift report for a 76-year-old client who had a total hip replacement. The client is not oriented to time, place, or person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which action by the nurse would be appropriate?Select all that apply: 1. Assess and document the behavior that requires continued use of restraints. 2. Tie the restraints in quick-release knots. 3. Tie the restraints to the side rails of the bed. 4. Ask the client if he needs to go to the bathroom and provide range-of-motion exercises every 2 hours. 5. Position the vest restraints so that the straps are crossed in the back

The nurse receives report on four clients. Which one should he assess first? A. The client with a colostomy who has a temperature of 38. B. The client with an ileostomy who has a blood pressure of 88/59. C. The client with an NG tube to intermittent suction, who is complaining of dry mouth. D. The client who has a blood pressure of 95/65 and has had a poor appetite.

The nurse recognizes that the organism that most frequently causes urinary tract infections (UTIs) in women is: A. Aspergillus B. Streptococcus C. Escherichia coli D. Staphylococcus aureus

b- complete the log off for the physical therapist before beginning her documentation

The nurse sits at the unit computer to begin her shift documentation for her client. She notes the previous user of the computer, the physical therapist, did not log off appropriately. The nurse should a- report the physical therapist to the unit manager b- complete the log off for the physical therapist before beginning her documentation c- proceed w/ her documentation b/c it will be in a different screen d- call the physical therapist & have her come back & log off

The nurse understands that forcing one's own cultural beliefs and practice on another is an example of which of the following? A - Stereotyping B- Ethnocentrism C - Cultural relativity D - Cultural imposition

The nurse uses the Glasgow Coma Scale to assess a client who sustained a head injury during a snowboarding accident. The nurse identifies which of the following scores warrants immediate attention? a- 6 b- 9 c - 12 d - 15

b- palpation

The nurse would be able to gather the most complete data about a client's pedal edema using the assessment skill of a- inspection b- palpation c- percussion d- auscultation

d- critical thinking skills

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to pts, nurses need to incorporate nursing process and: a- decision making b- problem solving c- intellectual standards d- critical thinking skills

The parents of a preschooler are refusing a blood transfusion to treat severe hypovolemia because they are Jehovah's Witnesses. The parents are aware of the potential consequences of refusing the treatment. The priority intervention for the nurse at this point is to: a) Contact social services and report the parents for abuse. b) Perform the blood transfusion as directed by the physician. c) Notify the hospital ethics committee to overrule the parents decision. d) Pursue obtaining orders for alternative treatments to a blood transfusion.

b- haphazardly

The use of diagnostic reasoning involves a rigorous approach to clinical practice & demonstrates that critical thinking cannot be done: a- logically b- haphazardly c- independently d- systematically

d- dispose of the urine already collected & begin an entirely new 24-hr collection

There is a 24-hr urine collection in process for a pt. The nursing assistive personnel inadvertently empties one specimen into the toilet instead of the collection "hat". The nurse should a- continue w/ collection of urine until 24-hr time period is finished b- make a note to the lab to inform them that 1 specimen was missed during the collection c- begin filling a new collection container & take both containers to lab at the end of the collection period d- dispose of the urine already collected & begin an entirely new 24-hr collection

To increase quality and years of healthy life, Healthy People 2030 focuses on four areas. One of those areas is a. Allowing people to continue current behaviors to reduce the stress of change. b. Focusing only on individual health changes that will lead to better communities. c. Creating social and physical environments that promote good health. d. Focusing on illness treatment to provide fast recuperation.

b- slander

Trina, an RN on the nursing unit, states to the student nurse, "I see you are working with Beth today. Make sure you watch your patient carefully because I think Beth is one of our worst nurses." The student knows that this statement could be considered: a- libel b- slander c- fraud d- invasion of privacy

Two days after the client donated the right lobe of the liver to his father, he tells the nurse, "I was pressured by my family to donate a piece of my liver." What is the nurse's priority intervention in this situation? a) Provide written documentation of conversation to the ethics committee. b) Inform all the surgeons who harvested and transplanted the liver. c) Explore the client's statement obtaining additional, detailed information. d) Notify the supervisor to determine if a psychiatric evaluation is necessary.

serious reportable events pt safety event that causes death, permanent harm or sever temporary harm clearly identifiable & measurable serious usually prevented

What are SREs/sentinel event?

faintly hear breath sounds limited air movement pneumonia - lack of air movement in 1 area COPD- diminished all over

What are diminished/dullness breath Sounds?

low sonorous rumbling sound heard more over trachea & bronchi may clear w/ coughing

What are rhonci breath sounds?

IU QD, QOD U MS MSO4 MGSO4 trailing zeros lack of leading zeros

What are some abbreviations that we don't use?

iridology aromatherapy magnet therapy

What are some alternative med?

chiropractic care biofeedback certain supplements

What are some complementary med?

Fall risk, hourly rounds, IV labeling & hand hygiene

What are some examples of QI projects?

meat, fish, eggs, diary, chicken

What are some examples of complete protein?

nuts, grains & tofu

What are some examples of incomplete protein?

Surgery on wrong site/pt pt suicide or self harm in healthcare unstageable, stage 3 or 4 pressure ulcers after admission

What are some examples of never ever events?

assessment of pt status or evaluation of pt response to restraints

What are some things that we can not delegate in regards to restraints?

application, remove & reapply for skin care, supervise movement

What are some things we can delegate in regards to restraints?

Oral, IV

What are somethings that are measured for Intake?

swelling of upper airway sign of respiratory distress can mean airway obstruction

What are stridor breaths?

4 cal per gram

What are the calories for carbs?

9 calories per gram

What are the calories for fat?

4 cal per gram

What are the calories for protein?

BNP & CXR

What are the tests for crackles?

bronchodilators steroids

What are the treatment for wheezing?

Racemic Epinephrine breathing treatment

What are the treatments for stridor breaths?

Urine, stool, emesis

What are things that are measured for output?

assess, measure & report performance in providing safe care

What does SREs help with in health care?

reason for it restraint, type of restraint, location of restraint, how long to use restraint & behavior for restraint

What does a prescription for restraints have to include?

fluid in chest. extra rough noises like pt needs to clear airway does not clear w/ coughing sit them up normally 1st heard in bases as water runs downhill ex- CHF fluid volume excess

What does crackles sound like?

Assessment- physical assessment, meds, treatment, identified problems

What does the A in SBAR stand for?

Background- reason for admission, date, name of HCP, relevant history, most recent VS & lab data

What does the B in SBAR stand for?

What does the Code of Ethics for Registered Nurses include? a) Tips for correctly performing a procedure in the hospital environment. b) Bylaws that state clients' rights. c) A code of ethics that states the nurse's obligation and responsibility to the client. d) Regulations stating criteria for nursing licensure

Recommendation- whats needed, recommended, tests/meds/orders that should be done

What does the R in SBAR stand for?

Situation- nurse name, pt name, hospital, room number & major reason for calling

What does the S in SBAR stand for?

c- clinical implications

What explains the findings of the article & if it can be used in the clinical setting? a- manuscript narrative b- introduction c- clinical implications d- methods of design

example of person or thing that is recurrent & has its basis in facts. Often becomes symbol for remembering some culture specifics

What is archetypes?

CXR & CBC

What is the diagnostic test for dullness/diminished breath?

What is the goal of using a client history assessment tool to gather data about nutrition, exercise, leisure activities, spirituality & home environment? a- to gather data required by insurers & regulatory agencies b- to assist the physician in developing a medical diagnosis c- to gather data about the causes of the pt's illness d- to increase the pt's awareness of lifestyle choices & his or her role in wellness

What is the involuntary motion of retreating the body from painful stimuli? a- sensation b- reception c- perception d- reaction

Abstract w/ PICOT P- phenomena of interest I- intervention of interest C- comparison of interest O- outcome of interest T- timing

What is the most important part of a research article?

Gown mask face shield/ goggles gloves

What is the order to put on PPE?

repeat back the order to the prescriber, ask for spelling of something like a medicine we are unfamiliar with, have a second nurse listen to it.

What is the procedure for a phone order?

danger to self &/or others 15 mins check constant supervision

What is the reason we use behavioral restraints?

protect pt from self (pulling out IVS & tubes) 2 - 4 hours

What is the reason we use medical restraints? How often do we do checks?

antibiotics

What is the treatment for dullness/diminished breath?

What nursing action can the nurse implement to comfort an elderly pt w/ sensory deprivation to improve meaningful stimuli? a- placing a "do not disturb" sign on the pt's door b- offering the pt a back rub c- asking the pt if he would like a newspaper to read d. placing the pt in the room farthest from the nurses' station

4- results or conclusions

What part of the article explains outcomes or if the PICOT question was answered? 1- literature review 2- purpose statement 3- abstract 4- results or conclusions

d- methods of design

What section explains how a research study was conducted & designed? a- manuscript narrative b- introduction c- clinical implications d- methods of design

CBC CXR ABG

What tests are there for wheezing?

quality improvement using data to watch the outcomes of care processes & using improvement methods to design & test changes to improve quality & safety of the health care system

Whats QI?

R- rescue affected pts A- alarm = sound alarm C- confine fire = shut doors E- extinguish if possible

Whats RACE?

ability to answer for one's own actions

Whats accountability?

assume characteristics of that culture the person accepts both his own & the new culture adopting elements of each

Whats acculturation?

support & defend client's health, wellness, safety, wishes & personal rights including privacy

Whats advocacy?

new members take on the values, beliefs & behaviors of the dominant culture. person fully merged into dominant cultural group

Whats assimilation?

the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest

Whats autonomy?

action that promotes good for others, without any self-interest

Whats beneficence?

nurses apply their knowledge of a pt's culture to their delivery of care

Whats cultural appropriateness?

nurse impose the rules of their culture onto another person

Whats cultural imposition?

being aware of the differences between cultures, being sensitive to the fact that they are different without judging the differences.

Whats cultural sensitivity?

ability to integrate the best current evidence w/ clinical expertise & pt/family preferences and values for delivery of optimal healthcare.

Whats evidence based practice?

in Hispanic culture & rooted in buddhism fatal disease are predestined by nature & acceptance = sign of wisdom & maturity

Whats fatalism?

asian culture & noted in christianity disease seen as predetermined w/ a predictable outcome

Whats fatalismo?

fulfillment of promises

Whats fidelity?

fairness in care delivery and use of resources

Whats justice ?

a commitment to do no harm & to prevent harm

Whats nonmaleficence?

pus & blood (infection)

Whats purosanguineous?

yellow w/ pus (infection)

Whats purulent?

life, subjective information, information isn't numerical

Whats qualitative research?

numbers, usually objective

Whats quantitative research?

would the same results happen if you repeated the test elsewhere

Whats reliability ?

willingness to respect obligations and follow through on promises

Whats responsibility?

bloody (indicate capillary damage)

Whats sanguineous discharge?

bloody & straw color mixed

Whats serosanguineous discharge?

clear or straw color

Whats serous exudate?

volume/time = mLs per hour/ 60 mins X drop rate

Whats the Iv drop rate formula?

gloves gown goggles/face shield mask

Whats the order to remove PPE?

X/ 0.25 x = mLs

Whats the piggyback formula for 15 mins?

X/0.5 x = mLs

Whats the piggyback formula for 30 mins?

X / 0.75 x = mLs

Whats the piggyback formula for 45 mins?

X/1 x = mLs

Whats the piggyback formula for 60 mins?

Volume # hours

Whats the pump rate formula?

Does the test really measure what its supposed to measure

Whats validity?

a commitment to tell the truth

Whats veracity?

high pitched can be heard on inspiration, expiration or both hard to get air out can cause barrel chest in COPD narrowing of bronchioles

Whats wheezing?

When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? a. The patient complains of a "pounding" headache. b. The patient becomes restless and agitated. c. The patient has not voided for over 10 hours. d. The patient has cramping abdominal pain.

c- concept map

When caring for a pt who has multiple health problems & related medical diagnoses, nurses can best perform nursing diagnoses & nursing interventions by developing a: a- critical pathway b- nursing care plan c- concept map d- diagnostic label

When caring for a young female Islamic client, the nurse notices the client does not answer questions during the assessment. When planning to educate her regarding her care. The nurse must understand that: A - Decision making tends to be male dominated B - Decision making is generally consultative between spouses C - Decision making tends to involve the entire family D - Decision making is generally left to the individual

When communicating w/ a pt who speaks a different language, the nurse understands best practice is to: a- speak slowly so the pt will understand b- make sure the family members are present c- use an interpreter for communication w/ pt d- allow the pt's daughter to translate the discussion

When communicating with a client who speaks a different language, it is most important to first attempt which of the following? A - Ask a family member to translate B - Seek assistance from a trained medical interpreter C - Use specific medical terminology to avoid mistakes D - Focus on the translation of information rather than nonverbal communication

c- data

When conducting quantitative research, the researcher collects information to support a hypothesis. This information would be identified as: a- the subject b- variables c- data d- the instrument

within 1 hour

When does a doc/HCP have to see a pt that is put in a restraint?

Starts at admission

When does discharge planning begin?

a- place the pt on their side w/ the head of the bed in a lowered position

When providing oral care for the unconscious pt, the nurse should a- place the pt on their side w/ the head of the bed in a lowered position b- skip brushing the teeth as the pt could aspirate c- swab the pt's lips & oral cavity w/ lemon glyercin swabs at least hourly d- place pt in an upright position & brush their teeth w/ a sponge brush

B C E

When working with an interpreter, which of the following principles should the nurse follow? Select all that apply. A - Expect the interpreter to translate statements word-for-word to eliminate misunderstandings B - Address any concerns regarding errors in interpretation C - Pace conversation to allow time for client responses D - Direct questions to the interpreter Ask the client for feedback at regular intervals

Which action demonstrates a break in sterile technique? 1) Remaining 1 foot away from nonsterile areas 2) Placing sterile items on the sterile field 3) Avoiding the border of the sterile drape 4) Reaching 1 foot over the sterile field

Which action should the nurse take before administering an opioid medication intravenously to a patient complaining of incisional pain? 1) Assess the patient's incision. 2) Clarify the order with the prescriber. 3) Assess the patient's respiratory status. 4) Monitor the patient's heart rate

Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain? 1) Assess the patient's incision. 2) Clarify the order with the prescriber. 3) Assess the patient's respiratory status. 4) Monitor the patient's heart rate.

Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? 1) Caution the patient to limit the number of times he presses the dosing button. 2) Ask another nurse to double-check the setup before patient use. 3) Instruct the patient to administer a dose only when experiencing pain. 4) Provide clear, simple instructions for dosing if the patient is cognitively impaired.

Which assessment question should the nurse ask to best understand how visual alterations are affecting the pt's self-care ability? a- have you stopped reading books or switched to books on audiotape? b- are you able to prepare a meal or write a check? c- how do you protect yourself from injury at work? d- how does your vision impairment make you feel?

Which change in hygiene practices may be necessary as the patient ages? 1) Brushing teeth twice a day 2) Bathing every other day 3) Decreasing moisturizer use 4) Increasing soap use

Which nursing diagnosis addresses psychological concerns for a pt w/ both hearing & visual sensory impairment? a- self-care deficit b- risk for falls c- social isolation d- impaired physical mobility

C D E

Which of the following actions performed by a nurse will increase the risk of liability? Select all that apply. a) Witnessing a client sign a consent for an ordered medical procedure b) Withholding a medication to clarify the ordered dosage c) Assisting a client on ordered bed rest to walk to the toilet d) Asking unlicensed assistive personnel to assess a client's wound e) Providing information to a unknown caller about a client's diagnosis and treatment

1, 3 & 4 (low-protein diet, lengthy surgical procedures & fever)

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1 & 2

Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1)Blood pressure (BP) was 132/80 mm Hg sitting and is 100/60 mm Hg upon standing 2) Rectal temperature is 97.9°F in the morning and 100.2°F in the evening 3) Heart rate was 76 while walking and 60 while sitting 4) Respiratory rate was 14 when standing and is 22 after walking 5) Blood pressure was 183/95 but decreased to 148/78 after taking a PRN blood pressure medicine

Which of the following incidents requires the nurse to complete an incident report? 1) Medication given 30 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration

d- a journal article about a study that used large, previously unpublished databases generated by the US census

Which of the following is an example of a primary source in a research study? a- a published commentary on the findings of another study b- a doctoral dissertation that critiques all research in the area of ADD c- A textbook of medical-surgical nursing d- a journal article about a study that used large, previously unpublished databases generated by the US census

Which of the following is required to deliver culturally congruent care? A) Learning about vast cultures B) Motivation and commitment to caring C) Influencing treatment and care of patients D) Acquiring specific knowledge, skills, and attitudes

A- hand washing

Which of the following is the first priority in preventing infections when providing care for a pt? a- handwashing b- wearing gloves c- use barrier b/t client's furniture & nurse's bag d- wear gown & goggles

Which of the following is the first step in developing cultural competence? A - Creating opportunities to interact with various cultural groups B - Examining one's own cultural background, values, and beliefs C - Learning about folk healing and alternative medicine from different cultures D - Learning assessment skills for different cultural groups

Which of the following sensory changes are normal w/ aging? a- impaired night vision b- difficulty hearing low pitch c- increase in taste discrimination d- heightened sense of smell

Which of the following statements most accurately describes cultural factors influence on health? A - Chronic condition rates differ by cultural/ethnic groups B - Most clients find religious rituals help them during illness C - There are limited ethnic variations in physiologic responses to treatments D - Silence during interactions usually means the client understands instructions

Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Repositioning the client away from the painful side 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications

Which represents a breach of the nursing Code of Ethics regarding the rights of clients in psychiatric care situations? a) The nurse discusses the client's care with out-of-town family members that the client has formally indicated are allowed to know about the client's hospital care. b) The nurse discusses the client's history and hospital course of treatment with a consulting health care provider (HCP). c) The nurse discusses with peers in the hospital cafeteria the progress of a well- known client being cared for at the hospital. d) The nurse discusses the client's care with the admission coordinator of a retirement home that the client plans to enter after discharge from the hospital.

A, b, D Identifying the phenomenon, research question, study & purpose & Design

Which research process steps may be noted in an article's abstract? Select all that apply a- identifying the phenomenon b- research question, study & purpose c- literature review d- design e- legal & ethical issues

c- the research design is systematic & subjective all the other choices are quantitative research

Which statement best describes qualitative research? a- data are collected from a large number of subjects b- data collected tend to be numeric c- the research design is systematic & subjective d- the research design is randomized & objective

Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills? a) It is important to facilitate the process of acculturation for people of different cultures. b) Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care. c) The code of ethics challenges nurses to practice in an ethical and caring way. d) There are many subcultures in our country, and it is important to know about these cultures and their practices.

3. If a person cannot turn himself in bed, someone should help them change position q4h.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Floating the heels can help decrease pressure. 3. If a person cannot turn himself in bed, someone should help them change position q4h. 4. Dry skin should be washed with only warm water (not hot) and lotion put on.

While performing a skin assessment on a pt who is immobile, you note a purplish black area on the pt's left heel. The skin is intact. On palpation the site feels heavy & spongy. You suspect this may be? a- stage 1 pressure injury b- deep tissue injury c- stage 4 pressure injury d- unstageable

to improve patient outcomes, improve cost effective care, improve nursing profession & create a path to new nursing knowledge

Why do we use evidence based practice?

A- because of new meds, medical supplies, treatments & illnesses

Why is it so important for critical care nurses to update their practice w/ evidence? a- b/c of new meds, medical supplies, treatments & illnesses b- b/c the way IV's are started & equipment in use hasn't changed c- b/c what the professional development specialists learned hasn't changed d- b/c nurse care hasn't changed since nursing school

You are a new nurse completing orientation in a busy intensive care unit. In preparing to administer medications, you find an order that is not clearly legible. You have heard experienced nurses state the physician does not like to be called. Which of the following is the best step for safe medication administration? A) Call the physician to clarify the order B) Seek assistance from your preceptor C) Refer to the medication manual before administering the med D) Use your best judgment and critical thinking to safely administer the dosage

a- appropriateness of the interventions & the correct application of the implementation process

You have finished w/ several nursing interventions. To evaluate interventions, you need to examine the: a- appropriateness of the interventions & the correct application of the implementation process b- nursing diagnoses to ensure that they are not medical diagnoses c- care planning process for errors in other health care team members' judgements d- interventions of each nurse to enable the nurse manager to correctly evaluate the performance

You're assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear: A. Pale, pink and moist B. Red and moist C. Dark or purple colored D. Dry and black

You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is: A. Formed B. Semisolid C. Semiliquid D. Watery

C [a = stage 4, B = stage 1 & D = unstageable]

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? a- there is full loss of skin tissue that can extend to the muscle, bone or tendon b- hallmark of a stage 3 pressure injury is that the skin will be intact but it won't blanch c- skin will not be intact & there will be full loss of skin tissue that can extend to the subcutaneous tissue d- black eschar may be present

A B D C

You're performing an abdominal assessment on a 50-year-old client who is clutching the right abdomen and grimacing. In which order do you proceed? A. Examine the abdomen for contour, shape, movement and discoloration B. Auscultate all four abdominal quadrants C. Palpate the right abdominal quadrants D. Palpate the left abdominal quadrants

b- soap & water

You're providing care to pt w/ CDIFF. After removing PPE, you would perform hand hygiene by: a- hand sanitizer b- soap & water c- soap & water only if hands are soiled but you can use hand sanitizer d- using either hand sanitizer or soap & water

B- "pts w/ airborne diseases such as the flu require a special room w/ negative air pressure" Flu = droplet not airborne

You're providing in-service on transmission-based precautions to group of nursing students. Which statement warrants re-education about the topic? a- I will make sure that any pt who is on droplet precaution wears a surgical mask when being transported b- pts w/ airborne diseases such as the flu require a special room w/ negative air pressure c- I will always wear a gown & gloves when entering a room of a pt on contact precautions d- if I provide care to pts w/ c-diff, noravirus & rotavirus infections, I will always wash my hands w/ soap & water not hand sanitizer.

A B D E

You're working on a medical surgical floor. You have the following pts below. Select all pts below that are at risk for a pressure injury a- 19 year old female who is a quadriplegic b- 35 year old male w/ BMI 13.6 that is incontinent of stool & has a right leg splint c-55 year old female w/ controlled diabetes & is ambulating 3 times a day d- 76 year old male w/ elevated ammonia level & is excessively sweaty e- 45 year old w/ Braden Scale score of 7

A) notify receiving department & put surgical mask on the patient

Your patient is being transported to special procedures for a PICC line placement. PT is on droplet precautions. What are your nursing actions to ensure proper transport of the pt? A- notify the receiving department & put surgical mask on pt b- put N95 mask on pt & notify the receiving department c- cancel transport & notify physician for further orders d- notify receiving department & put goggles, gown & mask on pt

c- "lets discuss how you feel about this situation?"

a 15-year-old male comes to the clinic seeking treatment for "a problem". The nursing history reveals the client may have a sexually transmitted infection (STI). Which is the most appropriate initial response by the nurse? a- I will need a list of all the people w/ whom you have had relations b- have you told your parents about this situation c- c- "lets discuss how you feel about this situation?" d- you will need to practice safe sex. Let's discuss how to use condoms

a nurse is providing discharge instructions for pt w/ diminished tactile sensation. Which of the following statements by pt indicates a need for further teaching? a- I'll need to be careful when washing dishes to avoid extreme temps b- I may be able to dress more easily w/ zippers & pullover sweaters c- my home care nurse may be able to help me become more independent d- I'll be so glad to get home to my hot shower

a nurse is using a caring approach w/ a pt to influence healthy lifestyle changes. The best statement by the nurse is: a- I would like you to perform this exercise once a day b- your physician has left orders for you to follow c- the lab tests reveal the need to reduce your daily percentage of fat grams d- adapting your diet & activity will lower your blood glucose levels

a nurse must make the decision to give a client a full or partial bed bath. Which criterion is most important for the basis of this decision? a- primary health-care providers order for the client's activity b- immediate need of the client c- time of the client's last bath d- the nurse's scheduling restraints & client load

A- independent thinking

a nurse who is newly employed at a hospital questions a standard of patient care that does not seem to follow evidence-based practice. Which critical thinking attitude is the nurse demonstrating? a- independent thinking b- intellectual humility c- intellectual courage d- fair-mindedness

b- data collection

a pt is admitted to the hospital w/ shortness of breath. As the nurse assesses this pt, the nurse is using the process of: a- evaluation b- data collection c- problem solution d- testing a hypothesis

b- the pt will breath unlabored at 14 - 18 breaths per minute by the end of the shift

a pt is suffering from shortness of breath. The correct goal statement would be written as: a- the pt will be comfortable by the morning b- the pt will breath unlabored at 14 - 18 breaths per minute by the end of the shift c- the pt will not complain of breathing problems within the next 8 hours d- the pt will have a respiratory rate of 14 - 18 breaths per minute

b- call the provider to come back & explain the procedure

after witnessing informed consent, an hour later the nurse hears the client state that they did not understand why they were having the procedure. What is the nurse's responsibility? a- explain the procedure in detail b- call the provider to come back & explain the procedure c- tell the client it is too late they should have asked sooner d- tell the client that the procedure is really minor so it doesn't matter

an RN reports to the oncoming RN that the client has a stage 2 pressure injury. What would the oncoming RN expect to see w/ this injury? a- intact skin b- presence of tunneling c- deep, crater-like appearance d- partial-thickness loss of the epidermis

an example of a secondary health prevention activity would be a- chemotherapy IV infusion b- hep B vaccine series c- gallbladder surgery d- flexible sigmoidoscopy at age 50

an older adult pt has been on complete bed rest for the past 2 weeks. Which of the following assessment data indicates the pt may be developing a complication of immobility? a- loss of appetite b- gum soreness c- difficulty swallowing d- left ankle joint stiffness

vegetarian accepts contraception, blood transfusion & organ transplant condemn abortion

buddism dietary & medical restrictions

c- planning

consultation occurs most often during which phase of the nursing process? a- assessment b- diagnosis c- planning d- evaluation

gloves & gown

contact precautions

TB varicella measles SARs

diseases for airborne precautions

c-diff (enteric) norovirus shigella herpes simplex MSAR impetigo scabies

diseases for contact precautions

influenza rhinovirus rubella scarlet fever sepsis

diseases for droplet precautions

what you are looking for = matching unit/amount in that unit (order dose)

dosage calculation

pt transport = mask, gown & eye protection ppe- mask, glove, gown & goggles

droplet precautions

a- stress incontinence

female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as a- stress incontinence b- urge incontinence c- functional incontinence d- unconscious incontinence

a- assess the pt & if unsure of the finding, ask a faculty member to assess the pt

for a student to avoid a data collection error the student should: a- assess the pt & if unsure of the finding, ask a faculty member to assess the pt b- review his or her own comfort level & competency w/ assessment skills c- ask another student to perform the assessment d- consider whether the diagnosis should be actual, potential, or risk

60 mg

gr 1 = ? mg

identify the pt w/ the greatest risk for developing protein-calorie malnutrition a- pt who has multiple sclerosis & is in a wheelchair b- pt weighing 300 lb who has entered the hospital for cardiac bypass surgery c- pt w/ a broken arm & femur from trauma who is running a fever of 101.5 F d- pt who is of Native American heritage

in caring for a pt w/ decreased mobility, the nurse understands which of the following is the most appropriate goal? a- perform passive range of motion exercises 2X daily b- maintain optimal functional ability c- ambulate 100 ft 3X daily d- increase activity by the time of discharge

halal food no pork women taken care by female staff

islam dietary & medical restrictions

no tea or coffee sacred garment only remove for hygiene, elimination, sex & surgery

mormons dietary & medical restrictions

c- decreased sensation

of the following factors, which would put a client at greatest risk for impaired skin integrity? a- medication, digoxin b- moisture c- decreased sensation d- dehydration

d- patient self- determination act

on admission to Hospital A, the pt indicates that he would like information about making a living will. The nurse informs the pt that the hospital does not have a process in place to facilitate this. Hospital A is not in compliance with the: a- Health insurance Portability & accountability act b- emergency medical treatment & active labor act c- Americans with disabilities act d- patient self- determination act

pt has had a stroke that has affected their ability to speak. Pt becomes extremely frustrated when trying to speak. Pt follows commands correctly but can't form words coherently. Which type of aphasia is the pt most likely experiencing? a- sensory b- receptive c- expressive d- combination

A B F

select all that apply What abnormal characteristics should you report after obtaining a urine sample? A) Moderate amount of sediment B) Cloudiness of urine C) Light amber color D) Slight musty odor E) Yellow color F) Blood tinged

A B

select all that apply What factors are necessary to determine whether a patient can be instructed to independently obtain a midstream urine specimen? A) If the patient is able to use toilet facilities independently B) If the patient is able to comprehend instructions C) If the patient is a non-toilet-trained child D) If the patient would be embarrassed easily E) If the client is unconscious

recommend vegetarian diet, avoid pork, shellfish & other non kosher foods

seventh day adventism dietary & medical restrictions

the nurse has received report on the following pts. She understands which pt takes highest priority? a- 32 year old postoperative day 1 that hasn't ambulated in hallway b- 44 year old admitted for left leg injury & pain rating of 4/10 on pain scale 0 - 10 c- 56 year old pt w/ head injury & Glasgow Coma Scale of 12 d- 72 year old admitted w/ right sided weakness & new onset of confusion

b- observe the client carefully for changes in behavior or vital signs

the nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should a- be aware that confused clients do not feel as much pain due to their confusion b- observe the client carefully for changes in behavior or vital signs c- ask the client's family how much pain the client normally has d- use only pain scales that feature numbers or "faces" the client can point to

3- it sounds like you are really upset

the nurse is assisting the client in caring for he ostomy. The client states, "oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is 1- I'm sure you will get used to taking care of it eventually 2- yes, it is pretty messy, so I'll take care of it for you today 3- it sounds like you are really upset 4- you sound very angry. should I call the chaplain for you?

the nurse is caring for a hospitalized pt who normally works the night shift at his job. The pt states, "I don't know what is wrong with me. I have been napping all day & can't seem to think clearly." The nurse's best response is a- you are sleep deprived, but that will resolve in a few days b- you are experiencing hypersomnia, so it will be important for you to walk in the hall more often c- there has been a disruption in your circadian rhythm. What can I do to help you sleep better at night? d- I will notify the doc & ask him to prescribe a hypnotic med to help you sleep

the nurse would utilize the Snellen chart for assessment of which pt? a- pt who is having difficulty remembering how to perform familiar tasks b- pt who turns the TV up as loud as possible c- pt who holds his newspaper 2 inches from his face d- pt who frequently reports the incorrect time from the clock across the room

1- literature review

the part of a literary article that provides a detailed background of the level of science & clinical background that exists on the topic is called? 1- literature review 2- purpose statement 3- abstract 4- results or conclusions

3- abstract

the part of the article that includes a brief summary of the article is called: 1- literature review 2- purpose statement 3- abstract 4- results or conclusions

the pt w/ multiple sclerosis can no longer walk or urinate on her own. She spends her day sewing quilts, reading & communicating via e-mail w/ a support organization. Which word describes this pt? a- healthy b- ill c- in poor health d- well

to maintain proper posture it is important to a- sleep on the softest mattress possible b- avoid arching shoulders forward when sitting c- keep your knees locked when standing upright d- keep your stomach muscles relaxed to prevent back spasms

diuretics

what are the treatments for crackles?

european americans

what group(s) are more future oriented?

native Americans & latinos

what group(s) are more present oriented?

not judging another culture's beliefs based off our own standard.

whats cultural relativity?

c- the client's living environment

which factor would be most likely to influence the hygiene practice of the homeless client? a- the client's degree of mental illness b- the client's cultural beliefs c- the client's living environment d- the client's knowledge level

NCLEX NUR 111 QUESTIONS & important info

Related study sets

ACC 211-801 CH 4

Accounting 189 Test #2

Managing and Troubleshooting Networks Chapter 10 - Network+ Cert

Types of life policies

Quiz 10

Chapter 6 Psych 172

insurance simulation exam

Chicano Studies

A&P 1 Chapter 9 Set 1

Project Management Quiz 8 (CH7)

practice qs

Chapter 11: DNA BiologyAssignment

POL2761

MB Exam I

Chapter 5 Membranes, Reading Questions Section 4-7 mastering bio

TD 4 Declaration of Independence

Computer Security

(BLAw chap 2 *1)CHT4 Business and the Constitution

A&P II: chapter 28- the reproductive system

MGMT exam 1