NUFT 204 Exam 1 Review Questions

Fill in the Blank. While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitaliza tion and three subsequent clinic visits that occurred in different provider's offices over the past 6 months. This type of feature is most common in a(n) __________________________.

Electronic Health Record

The nurse uses silence as a therapeutic communication tech- nique. What is the purpose of the nurse's silence? (Select all that apply.) 1. Prevent the nurse from saying the wrong thing 2. Prompt the patient to talk when he or she is ready 3. Allow the patient time to think and gain insight 4. Allow time for the patient to drift off to sleep 5. Determine if the patient would prefer to talk with another staff member

ans: 2,3

A new nurse is experiencing lateral violence at work. Which steps could the nurse take to address this problem? 1. Challenge the nurses in a public forum to embarrass them and change their behavior 2. Talk with the department secretary and ask if this has been a problem for other nurses 3. Talk with the preceptor or manager and ask for assistance in handling this issue 4. Say nothing and hope things get better

ans: 3

A patient who is Spanish-speaking does not appear to understand the nurse's information on wound care. Which action should the nurse take? 1. Arrange for a Spanish-speaking social worker to explain the procedure 2. Ask a fellow Spanish-speaking patient to help explain the procedure 3. Use a professional interpreter to provide wound care education in Spanish 4. Ask the patient to write down questions that he or she has for the nurse

ans: 3

A new nurse complains to her preceptor that she has no time for therapeutic communication with her patients. Which of the fol- lowing is the best strategy to help the nurse find more time for this communication? 1. Include communication while performing tasks such as chang- ing dressings and checking vital signs. 2. Ask the patient if you can talk during the last few minutes of visiting hours. 3. Ask Pastoral care to come back a little later in the day. 4. Remind the nurse to complete all her tasks and then set up remaining time for communication.

1

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) 1. Inadequate lighting 2. Throw rugs 3. Multiple medications 4. Doorway thresholds 5. Cords covered by carpets 6. Staircases with handrails

1,2,3,4,5

A nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) 1. Check the patient's peripheral pulse in the restrained extremity 2. Evaluate the patient's need for toileting 3. Offer the patient fluids if appropriate 4. Release both limbs at the same time to perform range of motion (ROM) 5. Inspect the skin under each restraint

1,2,3,5

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) 1. Check for needed adaptive equipment. 2. Exaggerate lip movements to help the patient lip read. 3. Give the patient time to respond to questions .4. Keep communication short and to the point. 5. Communicate only through written information.

1,3,4

Which factors influence a person's approach to death? (Select all that apply.) 1. Culture 2. Age 3. Spirituality 4. Personal beliefs 5. Previous experiences with death 6. Gender 7. Level of education 8. Degree of social support

1,3,4,5,8

Motivational interviewing (MI) is a technique that applies under- standing a patient's values and goals in helping the patient make behavior changes. What are other benefits of using MI techniques? (Select all that apply.) 1. Gaining an understanding of patient's motivations 2. Focusing on opportunities to avoid poor health choices 3. Recognizing patient's strengths and supporting their efforts 4. Providing assessment data that can be shared with families to promote change 5. Identifying differences in patient's health goals and current behaviors

1,3,5

Label each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]). 1. ______ Repositioned patient on right side. Encouraged patient to use patientcontrolled analgesia (PCA) device. 2. ______ "The pain increases every time I try to turn on my left side." 3. ______ Acute pain related to tissue injury from surgical incision. 4. ______ Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

1-P 2-S 3-A 4-O

A group of nurses is discussing the advantages of using comput erized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advan tage of using CPOE? 1. "CPOE reduces transcription errors." 2. "CPOE reduces the time needed for health care providers to write orders." 3. "CPOE eliminates verbal and telephone orders from health care providers." 4. "CPOE reduces the time nurses use to communicate with health care providers."

1. "CPOE reduces transcription errors."

The licensed practical nurse (LPN) provides you with the change- of-shift vital signs on four of your patients. Which patient do you need to assess first? 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, tempera- ture 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89%

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) 1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 3. Apply ice no more than 3 times a day. 4. Limit application of ice to no longer than 10 minutes. 5. Use a slow, circular steady massage.

1. Apply ice using firm pressure over skin. 2. Apply ice for 5 minutes or until numbness occurs. 5. Use a slow, circular steady massage.

A health care provider writes the following order for a patient who is opioidnaïve who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: 1. Calls the health care provider and questions the order 2. Applies the patch the third postoperative day 3. Applies the patch as soon as the patient reports pain 4. Places the patch as close to the hip dressing as possible

1. Calls the health care provider and questions the order

A nurse has been gathering physical assessment data on a patient and is now listening to the patient's concerns. The nurse sets a goal of care that incorporates the patient's desire to make treatment decisions. This is an example of the nurse engaged in which phase of the nurse-patient relationship? 1. Working phase 2. Preinteraction phase 3. Termination phase 4. Orientation phase

Ans: 1

A grieving patient complains of confusion, inability to concen- trate, and insomnia. What do these symptoms indicate? 1. These are normal symptoms of grief. 2. There is a need for pharmacological support for insomnia. 3. The patient is experiencing complicated grief. 4. These are common complaints of the admitted patient.

1. These are normal symptoms of grief.

What is the palliative care team's primary obligation for the patient with severe pain? 1. Providing postmortem care. 2. Teaching about grief stages. 3. Enhancing the patient's quality of life. 4. Supporting the family after the death.

3. Enhancing the patient's quality of life.

A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements

1. Cuff too small 5. Insufficient time between measurements

A patient has an indwelling urinary catheter. Why does an indwell- ing urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile.

1. It allows migration of organisms into the bladder. 3. It obstructs the normal flushing action of urine flow.

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? 1. Normal 2. Complicated 3. Chronic 4. Disenfranchised

1. Normal

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patientcontrolled analgesia (PCA) of morphine? (Select all that apply.) 1. Only the patient should push the button. 2. Do not use the PCA until the pain is severe. 3. The PCA system can set limits to prevent overdoses from occurring. 4. Notify the nurse when the button is pushed. 5. Do not push the button to go to sleep.

1. Only the patient should push the button. 3. The PCA system can set limits to prevent overdoses from occurring. 5. Do not push the button to go to sleep.

Which of the following patients are at most risk for tachypnea? (Select all that apply.) 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. Adult who has consumed alcoholic beverages 4. Adolescent waking from sleep 5. Three-pack-per-day smoker with pneumonia

1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 5. Three-pack-per-day smoker with pneumonia

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? 1. Patient's selfreport 2. Behaviors 3. Surrogate (wife) report 4. Vital sign changes

1. Patient's self report

At 12 noon the emergency department nurse hears that an explo- sion has occurred in a local manufacturing plant. Which action does the nurse take first? 1. Prepare for an influx of patients 2. Contact the American Red Cross 3. Determine how to resume normal operations 4. Evacuate patients per the disaster plan

1. Prepare for an influx of patients

To best assist a patient in the grieving process, which of the fol- lowing is most helpful to determine? 1. Previous experiences with grief and loss 2. Religious affiliation and denomination 3. Ethnic background and cultural practices 4. Current financial status.

1. Previous experiences with grief and loss

A 55-year-old female patient was in a motor vehicle accident and is admitted to a surgical unit after repair of a fractured left arm and left leg. She also has a laceration on her forehead. An intrave- nous (IV) line is infusing in the right antecubital fossa, and pneu- matic compression stockings are on the right lower leg. She is receiving oxygen via a simple face mask. Which sites do you instruct the nursing assistant to use for obtaining the patient's blood pressure and temperature? 1. Right antecubital and tympanic membrane 2. Right popliteal and rectal 3. Left antecubital and oral 4. Left popliteal and temporal artery

1. Right antecubital and tympanic membrane

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0to10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction

1. Transcutaneous electrical nerve stimulation (TENS) 3. Provide back massage 4. Reposition the patient

Which patient is at highest risk for tachycardia? 1. A healthy basketball player during warmup exercises 2. A patient admitted with hypothermia 3. A patient with a fever of 39.4° C (103° F) 4. A 90-year-old male taking beta blockers

3. A patient with a fever of 39.4° C (103° F)

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered mor phine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, label the documentation for each task with the time that it was completed. 1. ______ Morphine 2 mg IV given for pain rating of 8/10 2. ______ Dressing changed over midline abdominal incision using aseptic technique 3. ______ Ancef 1 g given IVPB over 30 minutes.

1= 15:45 2= 17:34 3= 20:00

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.) 1. Improve the nurse's status with the health team members 2. Reduce the risk of errors to the patient 3. Provide optimum level of patient care 4. Improve patient outcomes 5. Prevent issues that need to be reported to outside agencies

2,3,4

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? 1. "Only your family can read your medical record." 2. "You have the right to read your record." 3. "Patients are not allowed to read their records." 4. "Only health care workers have access to patient records."

2. "You have the right to read your record."

Which of the following is the best intervention to help a hospital- ized patient maintain some autonomy? 1. Use therapeutic techniques when communicating with the patient. 2. Allow the patient to determine timing and scheduling of interventions. 3. Encourage family to only visit for short periods of time. 4. Provide the patient with a private room close to the nurse's station.

2. Allow the patient to determine timing and scheduling of interventions.

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? 1. Denial 2. Anticipatory grief 3. Yearning and searching 4. Dysfunctional grief

2. Anticipatory grief

Which of the following signs or symptoms in a patient who is opioidnaïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? 1. Oxygen saturation of 95% 2. Difficulty arousing the patient 3. Respiratory rate of 10 breaths/min 4. Pain intensity rating of 5 on a scale of 0 to 10

2. Difficulty arousing the patient

A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions

2. Droplet precautions

Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed.

2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) 1. Palliative care and hospice are the same thing. 2. Palliative care is for any patient, any time, any disease, in any setting. 3. Palliative care strategies are primarily designed to treat the patient's illness. 4. Palliative care relieves the symptoms of illness and treatment. 5. Palliative care selects home health care services.

2. Palliative care is for any patient, any time, any disease, in any setting. 4. Palliative care relieves the symptoms of illness and treatment.

When providing postmortem care, which action is a priority for the nurse? 1. Locating the patient's clothing 2. Providing culturally and religiously sensitive care in body preparation 3. Transporting the body to the morgue as soon as possible 4. Providing postmortem care to protect the family of the deceased from having to view the body

2. Providing culturally and religiously sensitive care in body preparation

A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The nursing assistant reports his admitting vital signs to the nurse. Which measurements should the nurse reas- sess? (Select all that apply.) 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4° C (99.3° F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%

2. Radial pulse rate: 72 and irregular 4. Respiratory rate: 28 5. Oxygen saturation: 99%

The nursing assistive personnel (NAP) reports to you that the blood pressure (BP) of the patient in Question 11 is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) 1. Notify the health care provider immediately 2. Repeat the measurements on both arms using a stethoscope 3. Ask the patient if she has taken her blood pressure medications recently 4. Obtain blood pressure measurements on lower extremities 5. Verify that the correct cuff size was used during the measurements 6. Review the patient's record for her baseline vital signs 7. Compare right and left radial pulses for strength

2. Repeat the measurements on both arms using a stethoscope 6. Review the patient's record for her baseline vital signs

A patient presents in the clinic with dizziness and fatigue. The nursing assistant reports a slow but regular radial pulse of 44. What is your priority intervention? 1. Request that the nursing assistant repeat the pulse check 2. Call for a stat electrocardiogram (ECG) 3. Assess the patient's apical pulse and evidence of a pulse deficit 4. Prepare to administer cardiac-stimulating medications

3. Assess the patient's apical pulse and evidence of a pulse deficit

A patient with a 3day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? 1. No action is required by the nurse because the order is appropriate. 2. Request to have the order changed to around the clock (ATC) for the first 48 hours. 3. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. 4. Begin the hydrocodone/APAP when the patient shows nonver bal symptoms of pain.

2. Request to have the order changed to around the clock (ATC) for the first 48 hours.

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? 1. The nurse caring for the patient forgot to document on the pulmonary system. 2. The EMR uses a chartingbyexception format. 3. The computer shut down unexpectedly when the nurse was documenting the assessment. 4. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

2. The EMR uses a charting by exception format.

What does it mean when a patient is diagnosed with a multidrug- resistant organism in his or her surgical wound? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

2. The antibiotics the patient has received are not strong enough to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? 1. The drug 2. The time interval 3. The dose 4. The route

2. The time interval

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and informa tion that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? 1. Electronic health record 2. Clinical documentation 3. Clinical decision support system 4. Computerized physician order entry

3. Clinical decision support system

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1. Contact the nursing supervisor. 2. Restrict the family's visiting privileges. 3. Ask the family to stay with the patient if possible. 4. Inform the family of the risks associated with side-rail use. 5. Thank the family for being conscientious and put the four rails up. 6. Discuss alternatives that are appropriate for this patient with the family.

3,4,6

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? 1. "Even though you're continuing treatment, palliative care is something we might want to talk about." 2. "Palliative care is appropriate for people with any diagnosis." 3. "Only people who are dying can receive palliative care." 4. "Children are able to receive palliative care."

3. "Only people who are dying can receive palliative care."

The nurse observes a nursing student taking a blood pressure (BP) on a patient. The nurse notes that the student very slowly deflates the cuff in an attempt to hear the sounds. The patient's BP range over the past 24 hours is 132/64 to 126/72 mm Hg. Which of the following BP readings made by the student is most likely caused by an incorrect technique? 1. 96/40 mm Hg 2. 110/66 mm Hg 3. 130/90 mm Hg 4. 156/82 mm Hg

3. 130/90 mm Hg

A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3. Explain the reasons for isolation procedures and provide meaningful stimulation.

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: 1. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. 2. Documents

3. Gives a newly ordered medication before entering the order in the patient's medical record.

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? 1. HIPAA allows all hospital staff access to your medical record. 2. HIPAA limits the information that is documented in your medical record. 3. HIPAA provides you with greater protection of your personal health information. 4. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

3. HIPAA provides you with greater protection of your personal health information.

What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations

3. Hand hygiene practices

A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7° C (101.6° F) (0400), 36.6° C (97.9° F) (0800), 36.9° C (98.4° F) (1200), 37.6° C (99.6° F) (1600), and 38.3° C (100.9° F) (2000). How would you describe this pattern of tem- perature measurements? 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern

3. Intermittent fever pattern

As you are obtaining the oxygen saturation on a 19-year-old college student with severe asthma, you note that she has black nail polish on her nails. You remove the polish from one nail, and she asks you why her nail polish had to be removed. What is the best response? 1. Nail polish attracts microorganisms and contaminates the finger sensor. 2. Nail polish increases oxygen saturation. 3. Nail polish interferes with sensor function. 4. Nail polish creates excessive heat in sensor probe.

3. Nail polish interferes with sensor function.

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? 1. Spiritual Distress related to questioning God 2. Hopelessness related to terminal diagnosis 3. Pain related to disease process 4. Anticipatory Grief related to impending death

3. Pain related to disease process

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? 1. Rip the papers up into small pieces and place the pieces into a standard trash can 2. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit 3. Place papers with patient information in a secure canister marked for shredding 4. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

3. Place papers with patient information in a secure canister marked for shredding

A patient is being discharged home on an aroundtheclock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? 1. Opioid antagonists 2. Antiemetics 3. Stool softeners 4. Muscle relaxants

3. Stool softeners

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/ acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? 1. The patient's level of pain 2. The potential for addiction 3. The amount of daily acetaminophen 4. The risk for gastrointestinal bleeding

3. The amount of daily acetaminophen

Which of the following documentation entries is most accurate? 1. "Patient walked up and down hallway with assistance, tolerated well." 2. "Patient up, out of bed, walked down hallway and back to room, tolerated well." 3. "Patient up, walked 50 feet and back down hallway with assis tance from nurse. Spouse also accompanied patient during the walk." 4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

4. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this obser vation of the patient? 1. "The patient has a defiant attitude and is demanding test results." 2. "The patient appears to be upset with the nurse because he wants his test results immediately." 3. "The patient is demanding and is complaining about the doctor." 4. "The patient stated feelings of frustration from the lack of information received regarding test results."

4. "The patient stated feelings of frustration from the lack of information received regarding test results."

A patient has been admitted for a cerebrovascular accident (stroke). She cannot move her right arm, and she has a right-sided facial droop. She is able to eat with her dentures in place and swallow safely. The nursing assistive personnel (NAP) reports to you that the patient will not keep the oral thermometer probe in her mouth. What direction do you provide to the NAP? 1. Direct the NAP to hold the thermometer in place with her gloved hand 2. Direct the NAP to switch the thermometer probe to the left sublingual pocket 3. Direct the NAP to obtain a right tympanic temperature 4. Direct the NAP to use a temporal artery thermometer from right to left

4. Direct the NAP to use a temporal artery thermometer from right to left

A patient with chronic low back pain who took an opioid around theclock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: 1. Opioid toxicity. 2. Opioid tolerance. 3. Opioid addiction. 4. Opioid withdrawal.

4. Opioid withdrawal.

A 52-year-old woman is admitted with dyspnea and discomfort in her left chest with deep breaths. She has smoked for 35 years and recently lost over 10 lbs. Her vital signs on admission are: HR 112, BP 138/82, RR 22, tympanic temperature 36.8° C (98.2° F), and oxygen saturation 94%. She is receiving oxygen at 2 L via a nasal cannula. Which vital sign reflects a positive outcome of the oxygen therapy? 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 112 3. Respiratory rate: 24 4. Oxygen saturation: 96% 5. Blood pressure: 134/78

4. Oxygen saturation: 96%

A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contami- nated equipment or material.

4. Perform hand hygiene after care and/or handling contami- nated equipment or material.

Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

The nursing assessment of a 78-year-old woman reveals ortho- static hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? 1. Activity Intolerance 2. Impaired Bed Mobility 3. Acute Pain 4. Risk for Falls

4. Risk for Falls

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? 1. Using silence 2. Asking, "Why are you crying today?" 3. Using therapeutic touch 4. Stating, "I see that you're crying."

4. Stating, "I see that you're crying."

A parent calls the pediatrician's office to ask about directions for using a car seat. Which of the following is the most correct set of instructions the nurse gives to this parent? 1. Only infants and toddlers need to ride in the back seat. 2. All toddlers can move to a forward facing car seat when they reach age 2. 3. Toddlers must reach age 2 and the height/weight requirement before they ride forward facing. 4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

4. Toddlers must reach age 2 or the height or weight requirement before they ride forward facing.

A patient has been newly admitted to a medicine unit with a history of diabetes and advanced heart failure. The nurse is assess- ing the patient's fall risks. Place the following steps for measuring the "Timed Get-up and Go Test" (TUG) in the correct order: 1. Have patient rise from straight-back chair without using arms for support. 2. Begin timing. 3. Tell patient to walk 10 feet as quickly and safely as possible to a line you marked on the floor, turn around, walk back, and sit down. 4. Check time elapsed. 5. Look for unsteadiness in patient's gait. 6. Have patient return to chair and sit down without using arms for support.

ANS; 3,1,2,5,6,4

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihy- pertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impul- sive. He has moderate left-sided weakness that requires the assis- tance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.) 1. Smokes a pack a day 2. Used a cane to walk at home 3. Takes antihypertensive and diuretics 4. History of recent fall 5. Neglect, spatial and perceptual abilities, impulsive 6. Requires assistance with activity, unsteady gait 7. IV line, urinary catheter

ANS 3,4,5,6,7

The nursing assessment of an 80-year-old patient who demon- strates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: 1. Place a bed alarm device on the bed. 2. Place the patient in a belt restraint. 3. Provide one-on-one observation of the patient. 4. Apply wrist restraints.

ANS: 1

A nursing student is reviewing a process recording with the instructor. The student engaged the patient in a discussion about availability of family members to provide support at home once the patient is discharged. The student reviews with the instructor whether the comments used encouraged openness and allowed the patient to "tell his story." This is an example of which step of the nursing process? 1. Planning 2. Assessment 3. Intervention 4. Evaluation

ANS; 4

A nurse is educating parents to look for clues in teenagers for possible substance abuse. Which environmental and psychosocial clues should the nurse include? (Select all that apply.) 1. Blood spots on clothing 2. Long-sleeved shirts in warm weather 3. Changes in relationships 4. Wearing dark glasses indoors 5. Increased computer use

ANSWER: 1,2,3,4

What is your role as a nurse during a fire? (Select all that apply.) 1. Help to evacuate patients 2. Shut off medical gases 3. Use a fire extinguisher 4. Single carry patients out 5. Direct ambulatory patients

ANS: 1,2,3,5

The nurse is transferring a patient to a longterm, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) 1. The patient's name, age, and admitting diagnoses 2. The discussion of any allergies to food and medications that the patient has 3. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" 4. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol 5. Description of any unresolved problems and current interven tions in place

ANS: 1,2,4,5

A nurse knows that the people most at risk for accidental hypo- thermia are: (Select all that apply.) 1. People who are homeless. 2. People with respiratory conditions. 3. People with cardiovascular conditions. 4. The very old. 5. People with kidney disorders.

ANS: 1,3,4

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) 1. Documents a medication given by another nursing student. 2. Includes the date and time of the entry into the medical record. 3. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. 4. Leaves a slip of paper with her user name and password in the patient's room. 5. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

ANS: 1,4

You are caring for a patient who frequently tries to remove his intravenous catheter and feeding tube. You have an order from the health care provider to apply a wrist restraint. Place the steps for applying a wrist restraint in the correct order. 1. Be sure that patient is comfortable with arm in anatomic alignment. 2. Wrap wrist with soft part of restraint toward skin and secure snugly. 3. Identify patient using two identifiers. 4. Introduce self and ask patient about his feelings of being restrained. 5. Assess condition of skin where restraint will be placed.

ANSWER: 3,4,1,5,2

The nurse is caring for a patient who is having a seizure. Which of the following measures will protect the patient and the nurse from injury? (Select all that apply.) 1. If patient is standing, attempt to get him or her back in bed. 2. With patient on floor, clear surrounding area of furniture or equipment. 3. If possible, keep patient lying supine. 4. Do not restrain patient; hold limbs loosely if they are flailing. 5. Never force apart a patient's clenched teeth.

ANS: 2,4,5

You are conducting an education class at a local senior center on safe-driving tips for seniors. Which of the following should you include? (Select all that apply.) 1. Drive shorter distances 2. Drive only during daylight hours 3. Use the side and rearview mirrors carefully 4. Keep a window rolled down while driving if has trouble hearing 5. Look behind toward the blind spot 6. Stop driving at age 75

ANSWER; 1,2,3,4,5

A patient is evaluated in the emergency department after causing an automobile accident while being under the influence of alcohol. While assessing the patient, which statement would be the most therapeutic? 1. "Why did you drive after you had been drinking?" 2. "We have multiple patients to see tonight as a result of this accident." 3. "Tell me what happened before, during, and after the automo- bile accident tonight." 4. "It will be okay. No one was seriously hurt in the accident."

Ans: 3

A nurse is assigned to care for a patient for the first time and states, "I don't know a lot about your culture and want to learn how to better meet your health care needs." Which therapeutic commu- nication technique did the nurse use in this situation? 1. Validation 2. Empathy 3. Sarcasm 4. Humility

Ans: 4

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication. 1. "She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5 PM yester- day. She complains of a poor appetite." 2. "The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 3. "Would you like to make a change in antibiotics, or could we give her a nutritional supplement before her medication?" 4. "The patient started complaining of nausea yesterday evening and has vomited several times during the night."

Ans: 4S, 1B, 2A, 3R

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? 1. "Avoid rushing when documenting an entry in the medical record." 2. "Use correction fluid to remove the entry." 3. "Draw a single line through the statement and initial it." 4. Enter only objective and factual information about a patient in the medical record.

Enter only objective and factual information about a patient in the medical record.

When planning care for the dying patient, which interventions promote the patient's dignity? (Select all that apply.) 1. Providing respect 2. Viewing patients as a whole 3. Providing symptom management 4. Showing interest 5. Being present 6. Using a preferred name

ans: 1,2,4,5,6

Which strategies should a nurse use to facilitate a safe transition of care during a patient's transfer from the hospital to a skilled nursing facility? (Select all that apply.) 1. Collaboration between staff members from sending and receiving departments 2. Requiring that the patient visit the facility before a transfer is arranged 3. Using a standardized transfer policy and transfer tool 4. Arranging all patient transfers during the same time each day 5. Relying on family members to share information with the new facility

ans: 1,3

What are the physical changes that occur as death approaches? (Select all that apply.) 1. Unresponsiveness 2. Erythema 3. Mottling 4. Restlessness 5. Increased urine output 6. Weakness 7. Incontinence

ans: 1,3,4,6,7

A nurse is talking with a young-adult patient about the purpose of a new medication. The nurse says, "I want to be clear. Can you tell me in your words the purpose of this medicine?" This exchange is an example of which element of the transactional communica- tion process? 1. Message 2. Obtaining feedback 3. Channel 4. Referent

ans: 2

A nurse has the responsibility of managing a deceased patient's postmortem care. What is the proper order for postmortem care? 1. Bathe the body of the deceased. 2. Collect any needed specimens. 3. Remove all tubes and indwelling lines. 4. Position the body for family viewing. 5. Speak to the family members about their possible participation. 6. Ensure that the request for organ/tissue donation and/or autopsy was completed. 7. Notify support person (e.g., spiritual care provider, bereave- ment specialist) for the family. 8. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. 9. Elevate the head of the bed.

ans: 6,9,2,5,7,3,1,4,8

A patient who has been isolated for Clostridium difficile (C. diffi- cile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body.

answer- 1,2,3

The infection control nurse has asked the staff to work on reduc- ing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intrave- nous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea

answer- 1,2,3

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contami- nated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

answer- 1,2,4

Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

answer- 1,3,5,4,2

When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory proce- dure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter.

answer- 2,4,5

A patient is prescribed morphine patientcontrolled analgesia (PCA). Arrange the following steps for administering PCA in the correct order. 1. Program computerized PCA pump to deliver prescribed medi cation dose and lockout interval. 2. Check label of medication 3 times: when removed from storage, when brought to bedside, when preparing for assembly. 3. Administer loading dose of analgesia as prescribed. 4. Attach drug reservoir to infusion device, prime tubing, and attach needleless adapter to end of tubing. 5. Identify patient using two identifiers. 6. Insert and secure needleless adapter into injection port nearest patient.

answer- 2,5,1,4,6,3

A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appro- priate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing.

answer- 4,2,1,3

Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves

answer-1,2,5

The nursing assistive personnel (NAP) informs you that the elec- tronic blood pressure machine on the patient who has recently returned from surgery following removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place your care activities in priority order. 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pres- sure cuff.

answer: 4,1,3,2,5