NUR 322: Exam 2
4. Which of the following guidelines must a nurse use for taking verbal or telephone orders? (Select all that apply). 1. Follow the health care agency guidelines regarding authorized staff who may receive and record verbal or telephone orders. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.
Answer: 1, 2, 3, 4, 5. - These are all acceptable guidelines for taking verbal and telephone orders in a health care setting. All of the stated guidelines should be used by the nurse.
3. An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What actions should the nurse take to help the older adult patient? (Select all that apply.) 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.
Answer: 1, 2, 5. - Larger print and a dispensing system can ensure safe medication administration in older adults. Medication pamphlets in larger print are also available. The use of teach-back ensures that the patient understands the medications and increases safety.
10. After receiving an IM injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.
Answer: 1, 3, 4. - Assessing the injection site may reveal a site reaction or induration from the injection. The health care provider needs to be notified in case there is an adverse effect from the injection. The nurse must always document adverse effects so the site and the patient can be monitored.
7. Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie bottom and then top 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. - Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator
7. A nurse is administering an MDI with a spacer to a patient with COPD. Place the steps of the procedure in the correct order. 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2 to 5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.
Answer: 2, 3, 6, 1, 4, 5, 8, 7. - Obtains baseline respiratory assessment before medication. Ensures optimal delivery of medication using a metered-dose inhaler (MDI)
6. Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) 1. The front and sides of the sterile gown are considered sterile from the waist up. 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. After cleansing the hands with antiseptic rub, apply clean disposable gloves.
Answer: 2, 3. - Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing such as gowns, masks, eyewear, and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer 1-inch border not considered sterile. Surgical asepsis requires the application of sterile (not clean) gloves.
2. A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions
Answer: 2. - Because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, Droplet Precautions are most appropriate.
9. Place the steps of administering an intradermal injection in the correct order. 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab.
Answer: 6, 4, 5, 3, 1, 2. - This is the correct sequence of steps to administer an intradermal injection
7. A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse's priority interventions include which of the following? (Select all that apply.) 1. Conducting a home-safety assessment and identifying hazards in the patient's living environment 2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching 4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eyes 5. Alerting other nurses and health care providers about patient's visual status during hand-off reports
Answer: 3, 4, 5. - Safety is a top concern when setting priorities for patients who experience eye trauma. Patients with eye trauma may experience serious visual impairments. Patients need to be oriented to the environment and necessary objects placed in front of them to reduce anxiety and prevent further injury. Communicate about the patient's visual impairment to other staff who will be caring for the patient
7. A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.
Answer: 3. Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result.
9. The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance
Answer: 4. - These symptoms are consistent with lactose intolerance, and they occur with ingestion of dairy products.
5. Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.
Answer: 5, 8, 7, 2, 6, 3, 4, 1. - This order of tasks describes the correct way to change an ostomy pouch.
8. What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks. 2. Initiate a bowel or habit training program to promote continence. 3. Help the patient go to the toilet once every hour. 4. Use sanitary pads in the patient's underwear.
Answer: 2. - Patients who are cognitively impaired often forget how to respond to the urge to defecate and benefit from a structured program of bowel retraining.
5. A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? 1. Tell the patient when you are approaching the chair. 2. Walk at a relaxed pace. 3. Guide the patient's hand to your arm, resting just above the elbow. 4. Position yourself one-half step in front of the patient. 5. Position the patient's hand on the back of the chair.
Answer: 3, 4, 2, 1, 5. - These steps ensure safety when guiding a patient with impaired vision to walk and sit in a chair. In addition, they help to provide patient education and independence in carrying out activities of daily living (ADLs).
1. Which nursing actions does the nurse take when placing a bedpan under a patient who is immobilized? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have the patient sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when ready to have the bedpan removed.
Answer: 2, 5. - Elevating the head of the bed allows the patient the most normal and comfortable position for defecation on a bedpan. Sitting on a bedpan for a prolonged time is uncomfortable and exerts pressure on the ischial bony prominences, so it is important for the patient to have privacy but to be able to let the nurse know when finished using the bedpan.
9. Which nursing intervention decreases the risk for CAUTI? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water
Answer: 2. - Evidence-based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag. This will occur when the drainage bag is hung below the level of the bladder.
2. A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety.
Answer: 2. - Factors that often lead to depression include presence of a chronic disease or a recent change or life event (such as loss of a spouse, friend, or beloved pet). Patients are alert but easily distracted in conversation
3. A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Normal aging. 2. Delirium. 3. Depression. 4. Worsening dementia.
Answer: 2. - Hallmark characteristics of delirium are acute confusion, hallucinations, and agitation. These symptoms are not part of the normal aging process. As dementia worsens, there is a gradual rather than sudden change in memory, usually not accompanied by hallucinations. Depression does not present with acute confusion and agitation.
7. A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. The patient lives with her son, is very thin and unkempt, has a Stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess the patient's cognitive status.
Answer: 2. - Such assessment findings may lead you to suspect elder mistreatment, but the nurse needs more information directly from the patient before calling social services or the adult protective services or telling the patient she cannot return home. The nurse will best get this information by asking the son to leave so that she can privately ask the patient direct questions. If the son refuses to leave, this will be another indication that elder mistreatment may be occurring. Cognitive testing will be important but is not the priority.
10. The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse? 1. Vesicular breath sounds in the lung bases 2. Temperature 38.5o C (101.4o F) 3. Incision pain rating of 6 out of 10 4. Blood glucose of 164 mg/dL
Answer: 2. - Temperature is a sign of infection. The temperature of the patient is outside the normal range and indicative of low-grade fever. The nurse should be concerned that the patient is developing an infection; the most likely location to assess would be the incision. Vesicular breath sounds are normal in the bases of the lungs. The pain rating is moderate and can be treated with pain medications. Although the glucose is elevated as expected in a postoperative patient, it is not in a critical value range for a postoperative patient.
10. The nurse is inserting a urinary catheter for a female patient, and after the catheter has been inserted 3 inches, no urine is returned. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther.
Answer: 2. - The catheter may be in the vagina; leave the catheter in the vagina as a landmark indicating where not to insert and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for catheter-associated urinary tract infection (CAUTI).
1. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? 1. Logging on to AMDS or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADMS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside.
Answer: 2. - This is the second check for accuracy. The second check for accuracy occurs when you check the label of the medication against the MAR before leaving the medication preparation area. The first check occurs when you check label of the medication against the MAR when removing the medication from the unit dose or automated medication dispensing systems (AMDS. The third check for accuracy occurs at the patient's bedside when you again compare the MAR or computer printout with the names of medications on medication labels and the patient name.
8. A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated for 30 to 60 minutes after the medications are given
Answer: 3, 4, 5, 6. - An enteral tube syringe is necessary to avoid dangerous misconnections and accidentally administering the medications through another tube. Flushing the tubing after medication administration clears the tubing of any residual medication and ensures that the tube remains patent. If gastric residuals are high, then the absorption of the enteral tube medication is reduced. Elevating the head of the bed helps to reduce the risk for aspiration. Verification of tube placement is essential before administering anything via a nasogastric tube. Medications are given separately to avoid any drug-to-drug interactions, which could clog the feeding tube.
3. An older-adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply.) 1. Talk to the patient at a distance so she can read your lips. 2. Keep your arms at your side; speak directly into the patient's left ear. 3. Face the patient when speaking; demonstrate ideas you wish to convey. 4. Position the patient so that the light is on her face when speaking. 5. Verify that the information that has been given has been clearly understood.
Answer: 3, 5. - To facilitate communication, face the patient when speaking, speak more slowly and in a normal tone, talk toward the patient's better or normal ear, articulate clearly, and demonstrate ideas you wish to convey. You should also position yourself so the light is on your face when you speak and verify that the information that has been given has been clearly understood.
2. What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.
Answer: 3. - Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or tension on the catheter. Advancing the catheter until urine flows and then inserting it ¼ inch more is not unique to the male patient.
3. A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but the nurse recognizes that this is a normal response to isolation. Which is the nurse's 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.
Answer: 3. - By providing a rationale for the isolation, the patient can better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when the patient is alone in the room.
3. Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible UI. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.
Answer: 3. - To adequately assess bladder function after a catheter is removed, voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a urinary tract infection.
7. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.
Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9.
2. The health care provider has written the following orders. Which order(s) does the nurse need to clarify before administering the medication? (Select all that apply.) Provide a rationale for your answers and rewrite the incorrect order(s) to follow the ISMP current medication order safety guidelines. 1. Timoptic.25% solution 1 drop OD BID 2. Metoprolol 12.50 mg QD 3. Insulin Glargine 6 u SC twice a day 4. Enalapril 2.5 mg. PO 3 times a day, hold for systolic blood pressure <100
Answer: 1, 2, 3, 4. - The nurse needs to clarify all the orders. Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dosage could be mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6 u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4, and SC could be mistaken as SL. Enalapril 2.5 mg. PO 3 times a day, hold for systolic blood pressure ,100 has a period after mg, which could be mistaken as the number 1, and the , sign could be mistaken as greater than. The correctly written orders are: Timoptic 0.25% solution 1 drop right eye BID Metoprolol 12.5 mg QD PO Insulin glargine 6 units subcutaneous twice a day Enalapril 2.5 mg PO 3 times a day, hold for systolic blood pressure less than 100
4. Which skills does the nurse teach a patient with a new colostomy before discharge from the health care agency? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately
Answer: 1, 2, 3, 5. - The patient must be able to do these tasks to successfully manage the colostomy when going home. Irrigation is not done routinely for a colostomy.
1. A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the 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 rather than the alcohol-based hand sanitizer." 3. "Everyone coming into the room must wear a gown and gloves." 4. "While I am in Contact Precautions, I cannot leave the room." 5. "C. difficile dies quickly once outside the body."
Answer: 1, 2, 3. - Clostridium difficile is transmitted through the oral-fecal route and spread through contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile. The organism develops a hard spore, which can live for long periods on surfaces, making it extremely hard to eradicate. If a patient with C. difficile is continent of stool and first cleans hands and changes gown, the patient may leave the room.
5. The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses' 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 intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. Decreasing a patient's environmental stimuli to decrease nausea
Answer: 1, 2, 3. - Nausea is not typically associated with transmission of infection, and loose stools are a common side effect with antimicrobials. All the other interventions break the cycle of infection transmission.
9. 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. Routine 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 contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.
Answer: 1, 2, 4. - Proper cleaning and disinfection are processes that occur prior to sterilization. Routine environmental cleaning is an example of medical asepsis, which helps break the chain of infection. Cleaning is always done from least contaminated to most contaminated to decrease the risk of further infection and contamination.
9. A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." After determining that the patient's hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply.) 1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 3. Demonstrate how to wash the earmold and microphone with hot water. 4. Discuss the importance of having wax buildup in the ear canal removed. 5. Recommend a chemical cleaner to remove difficult buildup.
Answer: 1, 2, 4. - The earmold should be wiped with warm water and a mild soap. The microphone should not be allowed to get wet. Chemical cleaners should not be used. For difficult buildup the brush that was included with the aid should be used to sweep away debris.
6. A nurse is teaching a patient about the warning signs of possible colorectal cancer according to the American Cancer Society guidelines. Which statements reflect that the patient understands the teaching? (Select all that apply.) 1. "I need to let my doctor know if my bowel habits start to change." 2. "Blood in the stool is one warning sign I need to look for." 3. "Muscle aches are common in people with colorectal cancer." 4. "It is not normal to see food particles in the stool." 5. "Some people with colorectal cancer have unexplained abdominal or back pain."
Answer: 1, 2, 5. - According to the American Cancer Society current guidelines, persons with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms, but if colon cancer is present, early diagnosis is important.
4. Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves
Answer: 1, 2, 5. - Chickenpox is an airborne organism that can travel great distances, so it is important that the air breathed by the nurse is filtered and that hands and clothes are covered, as required for Airborne Precautions.
5. A nurse sees a 76-year-old woman in the outpatient clinic. The patient states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (Select all that apply.) 1. Refer her to an ophthalmologist. 2. Suggest large-print books and playing cards. 3. Reassure her that the visual changes are part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety.
Answer: 1, 2, 5. - This patient most likely has cataracts and should be referred to an ophthalmologist. While common, cataracts are not considered to be part of normal aging. In the meantime, using large-print books or playing cards and reducing home safety hazards would be beneficial. Lower-wattage light bulbs would not be helpful.
2. A home care nurse is planning care for a patient with a visual impairment. Which strategies does the nurse plan to implement? (Select all that apply.) 1. Use of fluorescent lighting 2. Use of warm incandescent lighting 3. Use of yellow or amber lenses to decrease glare 4. Use of adjustable blinds, sheer curtains, or draperies 5. Use of indirect lighting to reduce glare
Answer: 2, 3, 4. - Interventions to enhance vision include the use of warm, incandescent lighting; yellow or amber lenses to decrease glare; and adjustable blinds, sheer curtains, or draperies to allow for the adjustment of natural light. Fluorescent lighting can contribute to indirect and direct glare.
1. A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.
Answer: 2, 3, 5. Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person's home rather than a hospital.
8. A nurse is participating in a health and wellness event at the local community center. A woman approaches with her father and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs) by asking which of the following questions? (Select all that apply.) 1. Tell me if you are still driving. 2. Describe any problems you have in sitting or getting up from your toilet. 3. Tell me how often you take a bath during the week and how you bathe. 4. Estimate for me the amount of time you spend exercising each day. 5. Tell me how you do your grocery shopping.
Answer: 2, 3. - Activities of daily living are self-care tasks that measure function and are markers for the ability to live independently. Although driving, shopping, and daily exercise are important to quality of life and health maintenance, they are not ADLs. Shopping and driving are IADLs.
4. A patient with a three-way indwelling urinary catheter and CBI complains of lower abdominal pain and distention after surgery. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.
Answer: 2, 3. - An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irrigant solution infused. If the system is not draining urine and irrigant, the irrigant should be stopped immediately; the catheter may be occluded, and the bladder distended. Pain medication should not be administered until after assessment is completed.
8. Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal.
Answer: 2, 3. - By allowing the balloon to drain by gravity, it is possible to avoid the development of creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size of the syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal.
2. During the administration of a warm tap-water enema, a patient starts to have cramping abdominal pain that he rates a 6 out of 10. What nursing action should the nurse take first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.
Answer: 1. - When a patient complains of pain during an enema, you need to stop the instillation and conduct an assessment before discontinuing or resuming the procedure.
3. Which instructions does the nurse include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.
Answer: 1, 5, 6. - These are the steps a patient needs to take to resolve chronic problems with constipation before considering regular laxative or enema use.
10. A nurse is caring for a 76-year-old female patient in the home setting. She just lost her husband from COVID-19 and has four children who live nearby. The patient was an educator and retired only 2 years ago. The nurse applies knowledge of developmental changes and the nature of loss in older adults when assessing which of the following situations? (Select all that apply.) 1. The nature of her relationships with her adult children 2. The total number of medications the patient is taking, including over-the-counter medications 3. The patient's perception of the need for caregiving assistance from the family with activities her husband performed 4. The impact of her husband's death on her monthly income 5. The patient's current physical functional status
Answer: 1, 3, 4, 5. - With the loss of the patient's husband, her relationship with her adult children can change as a result. Redefining relationships with one's children after such a loss is challenging, especially if the children are involved in any decision making or if they are now needed to take on responsibilities the patient's husband (their father) once performed. The total number of medications is a part of the nursing assessment but not in relationship to the patient's loss. Instead it is important to know the patient's economic situation; has there been a change in income with the loss of her husband that might affect the purchase of medications or her ability to keep her home? Aging changes one's functional status and often can result in loss of quality of life.
6. What should the nurse teach a young woman with a history of UTIs about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercises (Kegel) daily.
Answer: 1, 3, 4. - Maintaining regular bowel elimination prevents the rectum from filling with stool, which can irritate the bladder. Adequate hydration will ensure that the bladder is regularly flushed and will help prevent a UTI. Cotton undergarments are recommended. Pelvic muscle exercises promote pelvic health but do not necessarily prevent UTIs.
1. A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.) 1. Encourage him to participate in activities he can do in his room such as reading and doing crossword puzzles. 2. Move him to a room away from the nurses' station. 3. Turn on the lights and open the room blinds. 4. Sit down when talking with him and listen to his feelings and perceptions. 5. Provide auditory stimulation for the patient by keeping the television on continuously.
Answer: 1, 3, 4. - Patients who are isolated in a health care setting are at risk for sensory deprivation because they are unable to enjoy normal interactions with others. To help them adjust to their environment, promote meaningful stimulation. You can do this best by sitting down when communicating with them and encouraging them to participate in activities that provide stimulation
1. A patient is scheduled to have an intravenous pyelogram (IVP) tomorrow morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast medium is given.
Answer: 1, 4, 5. - An IVP involves intravenous injection of an iodine based contrast medium. Patients who have had a previous hypersensitivity reaction to contrast media are at high risk for another reaction. Informed consent is required. The patient may experience facial flushing during injection of the contrast medium. There is no need to have a full bladder as with a pelvic ultrasound examination or to save any urine for testing. There is no instrumentation of the urinary tract as with cystoscopy.
6. A patient with progressive vision impairments had to surrender his driver's license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.) 1. Sharing information about senior transportation services 2. Reassuring the patient that loneliness is a normal part of aging 3. Maintaining distance while talking to avoid overstimulating the patient 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends
Answer: 1, 4, 5. - Loneliness is not a normal part of aging. Principles for reducing loneliness include providing information about local social groups and recommending alterations in living arrangements if physical isolation occurs. Access to senior transportation services is important, because transportation challenges can lead to social isolation.
5. Which aspects of the patient's care related to the administration of heparin can the nurse delegate to the nursing AP? (Select all that apply): 1. Notify the nurse if there are any signs of bleeding. 2. Assess the vital signs for possible symptoms of bleeding. 3. Assess bleeding sites and apply appropriate pressure to the sites. 4. Notify the nurse if there is blood noted in the patient's urine. 5. Notify the nurse if there is oozing from any puncture sites.
Answer: 1, 4, 5. - The nurse cannot delegate administration of heparin but can direct the assistive personnel (AP) to notify the nurse of any signs of bleeding, such as blood in the urine. Assessment cannot be delegated to the AP; it is a nursing responsibility. The nurse can direct the AP to notify if there are any changes in vital signs that may indicate bleeding, such as increased heart rate or decreased blood pressure. The nurse can direct the AP to notify if there is any blood oozing from any puncture or IV sites.
6. A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for their grandchildren as needed, and belongs to numerous church committees. What are the major psychosocial concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination on whether the wife will need to start working 4. How the wife may now expect assistance with household tasks and with babysitting the grandchildren 5. The age the patient chose to retire
Answer: 1, 4. - The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new home responsibilities and family expectations of the retired person. This patient is unlikely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time, nor is the age of the patient.
4. A pt is going through preop screening & prep for his surgery. He & wife are anxious. He will be undergoing a colon resection for cancer & will have a permanent colostomy. The nurse knows the pts age & developmental status will affect how the assessment is conducted. The rn wants to provide data that will be useful to the nurses in the hospital & applies clinical judgment appropriately through which of the following: (Select all that apply.) 1. Rn notes the physical changes of decreased bowel sounds, dry mouth, and reduced skin elasticity are physical changes likely related to the cancer. 2. Pt has difficult remembering current meds, the rn asks the wife for info 3. The rn anticipates the effect of the colostomy on fxning & asks the pt how he perceives life w/ a colostomy. 4. While gathering the history of the pts illness, the nurse anticipates him having the classic signs of fatigue & unexplained weight loss.
Answer: 2, 3. - Memory deficits, if present, can affect the accuracy and completeness of an assessment. Information contributed by a family member is sometimes necessary to supplement an older adult's recollection of medication adherence. Older adults' concepts of health generally depend on personal perceptions of functional ability. The symptoms of decreased bowel sounds, dry mouth, and reduced skin elasticity are likely not related to colon cancer but are normal physical changes of aging. Classic signs of a disease are sometimes absent, blunted, or atypical in older adults. All older adults, whether healthy or frail, need to express their need for intimacy and sexual feelings
4. A patient is returning to an assisted-living apartment following a diagnosis of declining vision/progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step up into her apartment. Her children are planning to be available to their mother for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.) 1. Walk one-half step behind and slightly to her side. 2. Have her grasp your arm just above the elbow and walk at a comfortable pace. 3. Stand next to your mother at the top and bottom of stairs. 4. Stand one step ahead of your mother at the top of the stairs. 5. Place yourself alongside your mother and hold onto her waist.
Answer: 2, 3. - To help with ambulation of a person with a visual impairment, offer an elbow or arm. Instruct the patient to grasp your arm just above the elbow. If necessary, physically assist the person by guiding the person's hand to your arm or elbow. When assisting a person to ascend or descend stairs, stand next to the person.
5. After abdominal surgery, the patient is on the surgical unit with an indwelling urinary catheter placed. What aspects of care for this patient can be delegated to the assistive personnel (AP)? (Select all that apply.) 1. Assessing the patient for any postoperative issues with the indwelling catheter 2. Assisting the nurse with patient positioning and maintaining privacy during catheter care 3. Teaching the patient signs and symptoms of a UTI 4. Reporting to the nurse any patient discomfort or fever 5. Reporting any abnormal color, odor, or amount of urine in the drainage bag
Answer: 2, 4, 5. - The AP may assist the nurse with patient positioning, focus lighting for the procedure, maintain privacy, empty urine from collection bag, and help with perineal care. The AP may report post-procedure patient discomfort or fever to the nurse or any abnormal color, odor, or amount of urine in drainage bag and if the catheter is leaking or causes pain. The AP may not assess, teach, or evaluate aspects of patient care.
8. An older adult with pneumonia is admitted from a skilled nursing home to a medical unit. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.) 1. Slow, cautious behavioral style 2. Inattention and neglect, especially to the left side 3. Cloudy or opaque areas in part of the lens or the entire lens 4. Visual spatial alterations such as loss of half of a visual field 5. Loss of sensation and motor function on the right side of the body
Answer: 2, 4. - A stroke in the right hemisphere of the brain produces symptoms on the left side, which may include visual spatial alterations (such as loss of half of a visual field) or inattention and neglect, especially to the left side, and a quick, inquisitive behavioral style. Additionally the patient may have a loss of sensation and motor function on the left side of the body. Cloudy or opaque areas in part of the lens or the entire lens indicate cataracts
8. A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (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.
Answer: 2, 4. - An MDRO is a single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available.
6. The nurse is administering an IV push med to a patient who has a compatible IV fluid running through IV tubing. Place the following steps in the appropriate order. 1. Release tubing & inject med w/in amount of time recommended by agency policy, pharmacist, or med reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injxn port should accept a needleless syringe. Use IV filter if required by med reference or agency policy. 3. After injecting med, release tubing, withdraw syringe, & recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injxn port. 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injxn port. Pull back gently on syringe plunger to aspirate blood return.
Answer: 2, 5, 4, 6, 1, 3. - These are the correct steps to administer an IV push medication in an existing line with compatible fluid running.
9. A daughter is beginning to assume caregiver responsibility for her 90-year-old widowed father. Her father has HTN, coronary artery disease, and T2DM. Home health services are set for once a week. During the first visit, the daughter expresses concern about all the meds that her father has been prescribed by different doctors and that he has obtained from different pharmacies. The daughter states that her father cannot really tell her what each med is for or when he should take them. From this initial information the nurse suspects polypharmacy. What med assessment data are needed? (Select all that apply.) 1. Review all med prescriptions 2. Match med prescriptions with the patient's med bottles or unit-dose blister packs 3. Identify involvement of the caregiver in helping with med administration 4. Identify and delete duplicate meds 5. Obtain a listing of any over-the-counter meds
Answer:1, 2, 3, 5. - Because there are multiple medication prescribers and multiple pharmacies, it is important to review all prescriptions and match these with actual patient medications to identify any duplicate medications or medication actions. Involving a family caregiver is desirable; this can help prevent missed or duplicate doses and help in identifying possible adverse drug effects (ADEs) in a timely manner. Over-the-counter medications can also interfere with prescribed medications and are part of a medication history. It is not the nurse's role to delete duplicate medications. The nurse needs to identify duplicate medications and notify the health care provider, who is responsible for deleting duplicate medications.
