NUR204 exam 2

Miriam is excited to go home. Which of the following are key elements of discharge planning? Select all that apply. 1. Include her husband during instructions. 2. Arise from bed slowly to prevent or reduce dizziness. 3. Remove loose rugs and obstacles that may cause problems. 4. Stop using the walker when she's feeling strong enough. 5. Walk around the block several times a day independently.

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The nurse, Peter, knows that Mariam is at a higher risk for injury as a result of her immobility. Which assessment changes indicate a potential complication of immobility? Select all that apply. 1. Crackles in both lung bases 2. Edema of the feet 3. Reddened areas on the coccyx 4. Increased appetite 5. Diarrhea

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Her first walk in the hallway went well with the assistance of two staff members. Which statements should the nurse include upon returning Miriam to bed? Select all that apply. 1. "Do not try to get up by yourself." 2. "Perform active range-of-motion [AROM] activities hourly when in bed." 3. "That was good; we'll try again before discharge." 4. "Tell me about the severity of the pain you are having now." 5. "I'll bring the bedpan if you need it."

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As the days slowly pass, Mariam begins to develop psychological effects of immobility. What should the nurse be assessing for? Select all that apply. 1. Apathy toward self-care 2. Depression 3. Sleep disturbances 4. Restlessness 5. Disorientation

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As Mariam is walking to her exercise class, she steps off the curb and falls. She is taken to the emergency room and diagnosed with a fractured hip. She must be on bedrest and in traction for a week before surgery is scheduled. During that time, the pain is significant and she requires a large amount of pain medicine. Which factors contribute to her immobility? Select all that apply. 1. Age 2. Injury 3. Nutritional status 4. Abuse of body 5. Stress

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Peter develops an immobility plan of care for Mariam. What should be included? Select all that apply. 1. Position to allow for lung expansion 2. Massage calves and legs each shift 3. Encourage visitors 4. Eat a healthy balanced diet 5. Turn every 2 hours

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Upon discharge, Miriam is instructed to continue using a walker until the follow-up visit with her surgeon in 2 weeks. What instructions need to be included with the use of the walker? 1. Advance the walker far ahead of your body and walk toward it. 2. Slide the walker with each step. 3. Move your weaker leg forward as your walker moves forward. 4. Stand well behind the back legs. 5. Size does not matter; any size walker will work.

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Mariam has returned from surgery and is prescribed to begin increasing activity. Peter is prepared to help her get up for the first time. What is the most important action before beginning? 1. Obtain a walker 2. Obtain a gait belt 3. Remove all obstacles 4. Obtain additional assistance 5. Determine level of motivation

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Which of the following clients is most at risk for losing his or her balance? 1. A woman who is 9 months pregnant walking down a flight of stairs 2. A 16-year-old skate boarding down a 15-degree slope 3. A 45-year-old taking hypertensive medication 4. A 4-year-old riding a tricycle

ANS: 1 Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Impaired balance is a major threat to physical safety and contributes to a fear of falling and self-imposed restrictions on activity. Although all the options represent a risk, the situation of the pregnant woman places her

The nurse caring for a 73-year-old female client who has been hospitalized with a stroke instructs the client's daughter to continue to do passive range-of-motion exercises with her mother on her affected side to prevent contractures. The nurse explains to the daughter that this is very important in an immobile older adult client because contractures can form in as little as: 1. 8 hours 2. 24 hours 3. 1 week 4. 1 month

ANS: 1 Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot obtain full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in clients who are permanently curled in a fetal position. Early prevention of contractures is key; they can begin to form after only 8 hours of immobility in the older adult client.

The nurse understands that using metabolic functioning, measures of height, weight, and skinfold thickness, to evaluate muscle atrophy in an immobilized client is known as: 1. Anthropometric measurements 2. Anhydrous measurements 3. Balke test 4. Calorimetry

ANS: 1 When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Anhydrous means without water, the Balke test determines maximum oxygen utilization, and calorimetry is the determination of heat loss or gain.

The nurse caring for a 78-year-old male client recovering from hip replacement surgery is assessing for signs of improvement of the client's activity tolerance. The nurse determined a baseline for ongoing assessments by: 1. Determining how much time it takes the client to recover from an activity 2. Assessing how much the client can do at one time 3. Determining the level of pain experienced by the client during the activity 4. Asking the client how much the client feels like doing

ANS: 1 When the client experiences decreased activity tolerance, carefully assess how much time the client needs to recover. Decreasing recovery time indicates improving activity tolerance. Pain should not be an assessment of activity tolerance. Asking the client how much he feels like doing before an activity will not tell the nurse if he is improving over time. The client may be able to do more (or less) than he thinks he is capable of doing before an activity.

The nurse is providing ancillary personnel with instructions regarding the performance of passive range-of-motion (ROM) exercises for a client experiencing paralysis from the waist down (paraplegia) as a result of an automobile accident. Which of the following statements made by the ancillary personnel reflects the greatest insight regarding the frequency with which the intervention should be provided for this client? 1. "I will do a whole body range of motion as I complete her daily bath." 2. "Bath time, bedtime, after lunch, and at least once more; she can pick when." 3. "It works well with her bath and when she is being prepared for bed at night." 4. "I'll ask her when she wants me to exercise her joints in addition to bath time."

ANS: 2 If the client is unable to move part or all of the body, perform passive ROM exercises for all immobilized joints while bathing the client and at least 2 or 3 more times a day

The nurse chooses to use a mechanical lift to move an obese immobile client. The nurse recognizes that the positive outcomes for both the client and the staff resulting from this intervention will be: (Select all that apply.) 1. Less of the client's body will be dragged along the sheets during the transfer 2. There will be less chance of injuring the skin on the client's elbows and buttocks 3. The staff involved in the transfer will have less likelihood of self-injury 4. The staff will have a greater degree of control over the move 5. The client will feel physically safer during the transfer 6. The move will be accomplished more quickly

ANS: 1, 2, 3, 4 Mechanical lifts raise the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the client's delicate skin; it also protects the nurse and other staff from injury. There is no guarantee that the move will be quicker or that the client will feel safer.

Which of the following factors has an impact on the severity of physical impairment a client will experience from a period of immobility? (Select all that apply.) 1. The client's age 2. Prior overall health 3. Length of immobility 4. The degree of immobility 5. Situation requiring the inactivity 6. Client's mental attitude about the limitations

ANS: 1, 2, 3, 4 The severity of the impairment depends on the client's overall health, degree and length of immobility, and age. The resulting effects are not dictated by situation or attitude

The nurse recognizes that facilitating correct body alignment for a dependent client may well result in which of the following positive client outcomes? (Select all that apply.) 1. A comfortable night's sleep 2. Minimized activity intolerance 3. Muscle tone that promotes ambulation 4. Reduction of falls caused by general weakness 5. Minimal strain placed on the spinal column 6. Increased socialization, resulting in peace of mind

ANS: 1, 2, 3, 4, 5 Correct body alignment reduces strain on musculoskeletal structures, aids in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy. Although a client experiencing the benefits of proper body alignment and thus experiencing the positive outcomes may well experience increased peace of mind, there is not a clear connection between the two

A 16-year-old has had a full leg cast in place for 2 months, and it is being removed today. Which of the following assessment findings would be expected following the removal of the cast? (Select all that apply.) 1. Popliteal pulse equal in both legs 2. Slight footdrop noted on affected leg 3. Swelling noted at ankle on affected leg 4. Weight bearing less stable on affected leg 5. Calf circumference greater in unaffected leg 6. Greater range of motion of knee of unaffected le

ANS: 1, 4, 5, 6 Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Pulses should be equal, and there should not be swelling or footdrop on either foot.

A client who experienced a myocardial infarction has been placed on bed rest. The nurse caring for the client recognizes that the inactivity will result in certain assessment findings that include: (Select all that apply.) 1. Lethargy 2. Confusion 3. Depression 4. Poor appetite 5. Hypoactive bowel sounds 6. Decrease in baseline respiratory rate

ANS: 1, 4, 5, 6 Immobility disrupts normal metabolic functioning; decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. Cognitive and psychological alterations are not directly caused by the inactivity

A staff member experienced a shoulder injury while assisting with a client transfer. The nurse manager's most therapeutic response to this situation is to: 1. Thoroughly review the accident report filed by the injured personnel to determine the factors that contributed to the injury 2. Have a nonpunitive meeting with all the involved staff to discuss correcting the factors that resulted in the injury 3. Require that mechanical lifts be used in the transfer of all clients incapable of assisting with the transfer 4. Implement new policies and procedures to correct the factors that resulted in the injury

ANS: 2 An "after-action review" allows the health care team to apply knowledge about safe client moving to the situation to identify safety factors contributing to the problem and make suggestions for the implementation of strategies to minimize risk to both client and staff.

Which of the following statements made by ancillary staff reflects the most informed knowledge regarding the benefit of having a client assist with his or her own activities of daily living (ADLs) to that client's activity tolerance? 1. "The more he does for himself, the more he will be able to do for himself." 2. "He doesn't like washing and dressing himself, but it makes him stronger." 3. "Doing for himself makes him tired, but in the long run he has more energy and strength when he does." 4. "By washing and dressing himself he is building muscle strength that lets him actually walk a little better."

ANS: 4 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The remaining options do not explain the reason for the additional activity tolerance as does the answer

The nurse assesses that the client has torticollis and that this may adversely influence the client's mobility. This individual has a(n): 1. Exaggeration of the lumbar spine curvature 2. Increased convexity of the thoracic spine 3. Abnormal anteroposterior and lateral curvature of the spine 4. Contracture of the sternocleidomastoid muscle with a head incline

ANS: 4 Torticollis is inclining of the head to the affected side, in which the sternocleidomastoid muscle is contracted. Lordosis is an exaggeration of the lumbar spine curvature. Kyphosis is an increased convexity in the curvature of the thoracic spine. Kyphoscoliosis is an abnormal anteroposterior and lateral curvature of the spine.

Which of the following is the most important to consider when assisting the client in passive range-of-motion exercises? 1. Flex the joint to the point of discomfort. 2. Work from the proximal joints to the distal joints. 3. Quickly work through the range of motion. 4. Support the distal joints while performing range-of-motion exercises

ANS: 4 While performing range-of-motion exercises, support should be provided for the distal joints. The joint should be flexed to the point of resistance, not to the point of discomfort. When performing range-of-motion exercises, begin at distal joints and work toward proximal joints. Joints should be moved slowly through their range of motion. Quick movement could cause injury

When caring for an elderly patient who presents with acute confusion of sudden onset, which test would the nurse expect to be ordered? a. Urine culture and sensitivity testing b. Mini-Mental State Examination (MMSE) c. Swallow evaluation d. Magnetic resonance imaging (MRI) with contrast

Answer: a A major cause of acute confusion in the elderly is infections, including urinary tract infections and pneumonia. Urine culture and sensitivity testing will detect bacteria in the urine and determine proper antibiotic treatment. A MMSE is a valuable tool to assess the progression of dementia. Swallow evaluation is done in patients who are suspected of having a weak or absent gag reflex. MRI with contrast might be done in a patient with confusion after infection has been ruled out.

What nursing action would be most effective in preventing flaccidity in a hospitalized patient? a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy

Answer: a Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing are important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently.

During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons? a. Persistent aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scoliosis

Answer: a Aspiration pneumonia results from abnormal entry of material from the mouth and stomach into the trachea and lungs. Patients should be evaluated for whether they have a decreased gag reflex or decreased level of consciousness. The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these findings. A physical therapist may be consulted if scoliosis is hampering the patient's respirations.

Which nursing action is appropriate for a patient with sensory overload? a. Dimming the lights b. Performing care a little at a time c. Leaving the patient's door open d. Rushing to get care done quickly

Answer: a Dimming the lights decreases sensory stimuli which alleviates sensory overload. Constant disruption adds to the overload, as does leaving the door open and rushing while in the room. A calm, quiet atmosphere diminishes the overload.

Which nursing diagnosis is most appropriate for a patient with expressive aphasia? a. Impaired Verbal Communication b. Acute Confusion c. Self-Care Deficit d. Impaired Mobility

Answer: a Expressive aphasia occurs when people are not able to express themselves with words. They might be able to understand what is being said but not able to respond appropriately. Therefore, Impaired Verbal Communication is most appropriate. The nursing diagnosis of Acute Confusion is appropriate for patients who are not oriented to person, place, time, or situation. The diagnosis of Self-Care Deficit would apply to a patient who cannot independently take care of activities of daily living (ADLs). Patients with limitations of movement may have a nursing diagnosis of Impaired Mobility.

Which cue during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone c. Decreased cardiac workload d. Orthostatic hypertension

Answer: a Joint contractures may begin within hours of immobility and cause irreparable damage to joint flexibility. Muscle tone decreases and cardiac workload increases with immobility. Pooling of blood in the lower extremities and quickly changing position may cause a rapid drop, rather than increase, in blood pressure, known as orthostatic hypotension.

1. Which action should be taken when attempting to decrease falls in the hospital setting? a. Lower the height of the bed and the bottom two side rails before leaving the room. b. Ask patients on first encounter to use the bathroom and every 4 hours thereafter. c. Instruct patients to use the call light only if they think they need help getting out of bed. d. Encourage patients to not take any prescribed medicine that could cause drowsiness or light headedness.

Answer: a Keeping the bed in the lowest position and lowering the bottom side rails decreases the chance of a fall. Hourly rounding for toileting is recommended to improve patient safety. Patients should always use a call light to get up even if they do not think they need it. Patients should take prescribed medications but may need assistance with ambulation.

When caring for a hearing-impaired patient, use of which action by the nurse would facilitate communication? a. Speaking clearly with distinct words b. Talking slowly to facilitate understanding c. Sitting behind the patient to decrease distractions d. Standing near the patient's affected ear to balance sound

Answer: a Speaking clearly without shouting facilitates communication with the hearing-impaired patient by giving each word separate emphasis. Talking distinctly, but not too slowly, and allowing the patient to see facial expressions and read lips, with the use of hearing aids if prescribed, are good communication techniques. Speaking into the ear with the better hearing is recommended.

A nurse is providing patient education on the prevention of osteoporosis. Which important fact should the nurse include in the teaching care plan? a. Calcium should be taken with vitamin D to increase calcium absorption. b. African American women are more prone to developing osteoporosis than are white women. c. Increased phosphorus metabolism may lead to bone fragility. d. Anaerobic exercise is more advantageous than weight-bearing exercise in preventing osteoporosis

Answer: a Vitamin D is required for calcium metabolism. White women are more prone to osteoporosis than African American women. Phosphorus deficiency may lead to malformation of bones. Weight-bearing exercise is more beneficial than anaerobic exercise in the prevention of osteoporosis.

5. The nurse is caring for a patient requiring parenteral anticoagulant therapy. Which of the following actions should the nurse take to maximize patient safety? (Select all that apply.) a. Double-check order and dosage with another RN. b. Administer medication using a smart IV infusion pump. c. Administer heparin only through a central venous catheter. d. Monitor glucose every 6 hours. e. Assess and document IV site every 8 hours.

Answer: a, b Double-checking the order and dose with another RN can prevent errors. Using an IV smart pump to administer anticoagulants increases correct dose administration. Heparin can be administered through a peripheral line. Glucose is not a focus of anticoagulant therapy. IV access requires more frequent monitoring than every 8 hours.

. The nurse implements the necessary safety precautions in an environment for a patient by doing which of the following? (Select all that apply.) a. Place bed in lowest position with brakes locked. b. Put both upper side rails up while patients are in bed. c. Move personal belongings within reach. d. Place bedside table between patient and the bathroom to use as a resting area. e. Ensure that all patients have bedside commode access.

Answer: a, b, c The safest bed position is lowest to the ground and secure (brakes intact) with the upper two side rails elevated. Raising all four side rails is restrictive and should not be used. Having personal belongings within reach minimizes patients moving about to get items. The bedside table has wheels and is not stable to use for resting. It creates an obstacle for the patient to navigate on the way to the bathroom and would be better placed on the opposite side of the bed from the bathroom. Some patients are able to walk to the bathroom; therefore, they do not require a bedside commode.

A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? (Select all that apply.) a. Alternative therapies b. Nicotine replacements c. Support groups d. Switching to e-cigarettes e. Counseling f. Decreasing the number of cigarettes smoked by half g. Educating about the risks of smoking

Answer: a, b, c, e, g Providing the patient with alternative therapy—such as meditation or relaxation techniques, nicotine replacement therapy, support groups, and counseling—are all tools to help a person quit smoking. Education about the risks of smoking gives the patient factual information about the long-term effects. Changing to e-cigarettes and decreasing the amount of cigarettes by half does not eliminate inhalation of nicotine and other harmful substances.

8. A patient is being discharged and several previous medications are being discontinued. The patient asks the nurse what she should do with unused medications. The nurse demonstrates knowledge of proper disposal of medications by which of the following? (Select all that apply.) a. Encouraging the patient to use a drug take-back location if available b. Telling the patient to check the label and, if approved, flush the medication down the toilet c. Encouraging the patient to donate the unused medication to a local hospital for use d. Teaching the patient to add coffee grounds to the medication, put in a sealed bag, and dispose in the trash. e. Checking to see whether the patient's family members could benefit from the medication.

Answer: a, b, d Drug take-back locations are the recommended disposal method for unused and expired medications. If a medication can be flushed down the toilet, this is the next recommended way to discard medication. Since some may not be able to be flush, they should be mixed with an undesirable substance, placed in a sealed bag, and then disposed of. Medications are not meant to be shared; thus, they should not be sent to a health care facility or given to a family member.

Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and activities of daily living (ADLs) c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation

Answer: a, b, d Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals.

Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

Answer: a, b, d, e Asking questions and providing time for the patient to answer is essential to helping determine what is occurring. Pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient's religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient.

Which set of cues is most concerning in a patient with deep vein thrombosis (DVT) in the left calf? a. High blood pressure and low heart rate b. Coughing up blood and chest pain c. Low oral intake and urine output d. Bruising on the upper arm and torso

Answer: b The patient who is coughing up blood and has chest pain has the most concerning cues. A pulmonary embolism (PE) is suspected when a patient has sudden shortness of breath, chest pain, dizziness, irregular heartbeat or palpitations, low blood pressure or is coughing up blood. High blood pressure and low heart rate are the opposite of that seen in PE. Fluid intake is important in the prevention of venous thrombolytic events but is not the most concerning cue. Bruising might be related to anticoagulant therapy but is not the most concerning cue.

2. The nurse demonstrates proper use of a fire extinguisher by taking which action first? a. Sweep from side to side b. Pull the pin c. Squeeze the handles together d. Aim and approach the fire

Answer: b The pin must be pulled to break the seal and activate the fire extinguisher. When using a fire extinguisher, remembering the PASS acronym (i.e., pull, aim, squeeze, and sweep) ensures proper technique.

The nurse is caring for a patient who has a blood pressure of 184/110. An hour after administering an antihypertensive medication, the nurse returns to recheck the blood pressure, only to find the patient in the chair pale, sweaty, and feeling faint. Which is the expected explanation for the nurse's observations? a. The blood pressure is 184/110; the medication has not had an effect. b. The blood pressure is 118/76; the sudden drop has caused the signs. c. The blood pressure is 174/96; the medication has made the patient sick. d. The blood pressure is 130/82; the symptoms are from another cause.

Answer: b The symptoms are indicative of a sudden drop in the blood pressure; an alteration in dose or medication may be needed.

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase from 16 to 28 breaths/min during hospitalization.

Answer: b The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is related to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.

3. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows d. Hips e. Coccyx

Answer: b, c, d The patient's ears, elbows, and hips are in contact with the bed surface in the side-lying position. Breakdown on the sternum would be a potential risk if the patient were in prone position. The coccyx experiences the most pressure when a patient is sitting or in the supine position.

The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? (Select all that apply.) a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning. c. Suction intermittently for no more than 10 to 15 seconds. d. Flush the artificial airway with 5 mL of normal saline to loosen secretions e. Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning. f. Document time, amount, and characteristics of secretions.

Answer: b, c, e, f Assess heart rate, respiratory rate, oxygen saturation, and lung sounds before suctioning to provide a baseline for detecting changes in the patient's condition. Reassess after suctioning to determine whether suctioning was beneficial to the patient. Oxygen is removed during the suctioning procedure, and the amount of time spent suctioning needs to be limited to 10 to 15 seconds. In some cases, the nurse provides extra oxygen before and during suctioning procedures, and decreasing the oxygen is contraindicated, therefore it would not be appropriate to decrease the flow rate. Documentation ensures that changes are noticed and that other members of the interprofessional team are aware of the patient's condition. Evidence-based practice shows that flushing with sterile NSS has no benefit because saline does not mix with secretions and the procedure may have negative effects for the patient.

The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.) a. Always wear socks when walking to protect your feet when ambulating. b. Remove rugs that can slip; use rubber mats instead. c. Use your walker or cane even if only moving short distances. d. Use lightweight, easily moveable chairs to assist with mobility. e. Put frequently used items in easy-to-reach places. f. Use handrails when available.

Answer: b, c, e, f Hard-soled shoes with a back or nonskid slippers should be worn instead of socks. Chairs should be sturdy with arms and not move for increased safety. Interventions to decrease falls include replacing rugs with rubber mats that will not skid or slip, using ambulatory devices and handrails, and placing frequently used items within easy reach.

A visually impaired diabetic patient states that he has lost the call light. What is the next action the nurse should take? a. Clip the call light closer to the patient. b. Tell the patient that the call light is clipped to the bed. c. Describe the call light location; then, take the patient's hand and guide it to that location. d. Instruct the patient to verbally call for a staff member because "someone is always nearby."

Answer: c Always leave the call light within easy reach of the patient. Use of the patient's senses of touch and hearing enables the patient to locate the call light easier. Simply telling the patient that the call light is clipped to the bed is not adequate because the patient will not know where on the bed to look. Verbally calling for the nurse is not acceptable because the nurse and other staff members might be out of hearing range.

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels

Answer: c Chronically elevated level of carbon dioxide in the chemoreceptors become tolerant of high levels. The carbon dioxide ceases to be the patient's trigger to breathe; therefore, what drives the patient to breathe is the hypoxic (low oxygen) drive. A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.

. The nurse places a patient with a high fever on a cooling blanket. How is heat loss achieved with this treatment? a. Radiation b. Convection c. Conduction d. Evaporation

Answer: c Conduction is the transfer of heat from a warm object (the patient) to a cooler object (the cooling blanket) during direct contact. Radiation is heat loss from one surface to another without direct contact. Convection is the loss of heat from cool air flowing over a warm body. Evaporation is the conversion of a liquid to a vapor, such as when perspiration evaporates.

Which goal statement is appropriate for a patient with the nursing diagnosis of Acute Confusion? a. Patient will remember nurse's name. b. Nurse will remind patient of his or her name each shift. c. Patient will state name and date with each nursing encounter. d. Nurse will remind patient of name and date with each nursing encounter.

Answer: c Goals are always patient centered and measurable and have a specified time frame. A patient goal would not include a nursing behavior. A confused patient would not be expected to remember different nurses' names but would be assessed for person, place, and time orientation with each encounter.

7. The nurse would understand the need for further safety education when a parent makes which of the following statements? a. "I secure my 8-month-old in a rear-facing car seat in the back seat." b. "My 10-year-old is angry that I still make him use a booster seat and he is not permitted to ride in the front seat." c. "My 2-month-old sleeps the longest when I put him in his crib on his stomach." d. "All of our household cleaners are stored in the upper cabinets in my home."

Answer: c Infants should be placed on their backs to sleep to prevent sudden infant death syndrome. The other statements all agree with safety recommendations and show an understanding of correct behavior.

It is 6 a.m. and the unlicensed assistive personnel reports to the nurse that the patient has a temperature of 96.7° F (35.9° C) tympanic. Which factor explains this reading? a. The patient's room is cold. b. The patient was drinking cold water. c. The patient is exhibiting a normal circadian rhythm. d. The patient just completed a warm shower.

Answer: c Normal circadian rhythms cause a lower temperature in the early morning and higher temperature in the late afternoon. A cool room would initially cause compensatory mechanisms, such as shivering and a feeling of being cold. Cold water could affect temperature if an oral thermometer was used. A warm shower would not cause a decrease in temperature unless there was a delay in drying the skin and dressing.

An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse.

Answer: cAccording to safe patient handling algorithms, a full-body sling with more than one caregiver is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand-and-pivot technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative.

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a flow rate of 5 L/min c. Simple mask at a flow rate of 6 L/min d. Nonrebreather mask at a flow rate of 5 L/min

Answer: d A nonrebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a nonrebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min.

The nurse is performing an initial assessment of a patient with a severe infection at hospital admission. Vital signs for the patient indicate hypotension and tachycardia. Which data would support this evaluation? a. Pulse 78, blood pressure 140/88 b. Pulse 86, blood pressure 120/76 c. Pulse 100, blood pressure 118/68 d. Pulse 114, blood pressure 88/56

Answer: d A pulse over 100 is tachycardia; a blood pressure less than or equal to 90/60 is hypotension. All of the other measurements of pulse are within normal limits for an adult, and the blood pressures are within normal limits, except 140/88 mm Hg, which is hypertensive.

The nurse is caring for a patient with decreased sensation in the lower extremities. Which precaution does the nurse advise the patient to take? a. Use heat to warm hands during cold weather. b. Go barefoot at home to prevent blisters from shoes. c. Soak feet in cold water daily to decrease swelling. d. Test the bath water temperature to prevent burning injuries.

Answer: d Because the patient may not be able to feel the temperature of the water, using a thermometer will prevent burns. The use of heat and cold is contraindicated in patients with tactile deficits because they would not be able to feel whether the therapy was too hot or cold. The patient should wear good-fitting shoes around the house to prevent foot injury.

The nurse is reviewing vital signs obtained as part of a community health fair. Which patient would be referred for follow-up based on the patient's vital signs? Patient Temperature Pulse Blood Pressure Pulse oximetry on room air 1 98.9° F (37.1° C) 84 bpm 128/74 98% 2 97.5° F (36.3° C) 92 bpm 116/78 95% 3 99.1° F (37.2° C) 78 bpm 108/70 97% 4 98.2° F (36.7° C) 94 bpm 136/86 95% a. Patient 1 b. Patient 2 c. Patient 3 d. Patient 4

Answer: d Cue recognition identifies relevant information for a patient. The vital signs for patient 4 indicates a blood pressure above 130/80, which indicates hypertension stage 1 and the need for follow-up for monitoring and interventions to lower the systolic and diastolic pressures. This patient should be referred for additional readings. The other readings are within normal limits, although all patients should be considered for health promotion teaching regarding cardiac health, especially the patient with a blood pressure of 128/80 mm Hg, which is in the elevated category.

. The nurse is admitting a stable patient for a minor outpatient procedure. Which site would the nurse most commonly use to assess pulse rate? a. carotid pulse b. popliteal site c. brachial artery d. radial artery

Answer: d For a minor procedure or in the absence of other known pathology, the nurse may assess the pulse at the radial artery pulse point (Location D). The radial site is the most easily accessible and most commonly used site for routine monitoring of pulse rate for a stable patient. The brachial artery (Location C) can be used for infants and young children in emergency situations and is used to palpate and auscultate blood pressure. A carotid pulse (Location A) is used when a peripheral pulse cannot be felt. The popliteal site (Location B) is used as an alternate site when an upper extremity is not available or when assessing circulation to lower extremities.

4. What actions should be taken when caring for an 80-year-old postoperative patient with a history of Parkinson's disease? a. Ensure that all four side rails are elevated. b. Instruct family that they cannot leave the room. c. Place wrists in soft restraints to protect invasive lines. d. Include hourly rounding in the plan of care.

Answer: d Hourly rounding prevents patient falls and addresses patient care needs. Four side rails are considered a restraint. Restraints are used only if other measures to keep the patient safe have been tried and failed. It is the nurse's responsibility to care for the patient; families are not required to be with patients at all times.

Which recommendation in the home-going instructions is appropriate for a patient with damage to the chemoreceptors of the upper nasal passages? a. Arranging for lighted signals on doorbells and telephones b. Obtaining a thermometer for testing bath water temperature c. Installing amplification devices on televisions, doorbells, and telephones d. Scheduling yearly safety checks of gas hot water heaters and furnaces

Answer: d Patients with damage to the chemoreceptors of the nasal passages may not be able to smell noxious fumes from household appliances. Lighted signals and amplification are interventions for a person with auditory deficits. Testing the bath water temperature is important for patients with tactile deficits.

A nurse is assessing a patient in restraints. The nurse observes correct use of restraints by checking which of the following? a. Restraint is tied in a secure knot. b. Restraint is secured to the bedrail. c. Restraint allows for 3 to 4 fingers width between restraint and patient's wrist. d. Restraint is secured to the bedframe.

Answer: d Restraints should be secured to a part of the bed that moves with the patient. The bedframe allows for a secure area to attach. The restraint should always be tied in a quick release knot that can be easily untied in an emergency. The recommendation is for two finger widths of space between the restraint and the patient's extremity.

The unlicensed assistive personnel reports a patient's vital signs to the nurse: temperature of 37.3° C (99.2° F ) oral, pulse of 88 bpm and regular, respirations of 18 BPM and regular, blood pressure of 178/112 mm Hg, and oxygen saturation of 96%. Based on these cues, which vital sign should the nurse be most concerned about? a. Temperature b. Pulse c. Respirations d. Blood pressure

Answer: d The blood pressure is well above the expected normal of less than 120/80 mm Hg and requires immediate follow-up evaluation by the nurse. The temperature is within the normal range of 95.9° to 99.5° F for an oral reading. The pulse rate is within the normal range of 60 to 100 bpm. Respirations are within the normal range of 12 to 20 BPM. The oxygen saturation is within the normal range of 95% to 100%.

Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum

Answer: dInjury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions (such as vomiting). The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain.

From the nurse's understanding, which statements regarding temperature and heat production in the body are accurate? (Select all that apply.) a. Heat generates energy for cellular functions. b. Hormones, such as thyroid hormones, decrease metabolism and heat production. c. Exercise decreases heat production through muscular activity. d. Expected temperature readings vary by the route selected for measurement. e. Women tend to have more fluctuations in temperature than do men.

Answers: a, d, e Heat is a by-product of metabolism that supplies energy for cellular functions; there are expected alterations in temperature readings depending on the route used—for example, the rectal temperature is higher than the oral temperature; because of hormonal influences, women tend to have more temperature fluctuations than men. Thyroid hormone increases metabolism and temperature. Muscular activity from exercise increases temperature.

Which nursing interventions would be necessary in caring for a patient with cognitive alterations who is hospitalized? (Select all that apply.) a. Apply wrist restraints for combativeness. b. Place a clock in the room for orientation. c. Keep floor free of clutter for safety. d. Identify staff with each interaction. e. Play loud music for distraction.

Answers: b, c, d Reality orientation is important for patients with cognitive alterations. Keeping the floor free of clutter prevents falls. All staff members should wear a readily visible name tag and state their name and what they are going to do. Soft music and dim lights will create a less distracting environment for the patient. Restraints may cause increased confusion and agitation and are used in special circumstances only.

A client is admitted to the hospital with chronic obstructive pulmonary disease (COPD). He is receiving supplemental oxygen via nasal cannula. Which position will best assist his breathing? A.Fowler's B.Sims' C.Lateral Supine

a

Identify which of the following vital signs are within the expected range for a 40 year old. Select all that apply a. T 98F b. BP 110/70 c. P 140 d. T 39C e. P 50 f. R 18

a b f

An older adult client suffered left-sided paralysis from a stroke. Which are the best actions for this client? Select all that apply. A.Monitor for constipation. B.Encourage an even gait when walking in place. C.Assess the extremities for swelling and muscle atrophy. D.Encourage taking deep breaths frequently to hyperinflate the lungs. E.Teach the use of a two-point crutch technique for ambulation.

a c d

Which of the following are accurate for pulse measurement? Select all that apply. a. brachial artery is used for children in emergency situations b. bilateral carotid pulses are measured simultaneously c. the most definitive site is the radial pulse d. peripheral circulation can be evaluated by checking the posterior tibial arteries e. a pulse deficit is measured by two nurses f. measurement should wait for 10 minutes if the patient has just exercised

a d e f

1.While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that: A.Teenagers need to practice safe sex. B.A 3-year-old can safely sit in the front seat of the car. C.Children need to wear safety equipment when bike riding. D.Children need to learn to swim even if they do not have a pool.

b

2.A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A.Raise all four side rails when darkness falls. B.Use an electronic bed monitoring device. C.Place the patient in a room close to the nursing station. Use a loose-fitting vest-type jacket restraint.

b

A client is being transferred from the bed to a stretcher for surgery using a transfer board. What should be the nurse's first action? A.Lower the stretcher below the level of the bed. B.Explain the procedure to the client. C.Place the client in the prone position. D.Place the bed in the lowest position.

b

A nurse is caring for a 25-year-old client who is quadriplegic. Which treatment would be a priority to decrease the risk of joint contracture and promote joint mobility? A.Active ROM B.Passive ROM C.Turning every 2 hours Applying a trochanter roll

b

29. Indicate the accurate statements related to body tem-perature. Select all that apply. a. Body temperature decreases with exercise. b. The temperature for most people is highest around 6 p.m. c. Infants are least susceptible to environmental temperature extremes. d. Smoking can cause a drop in the temperature of the skin and mucous membranes. e. Epinephrine decreases heat production and body temperature.

b d

Which of the following are signs of hyperthermia (fever)? select all that apply. a. bradypnea b. malaise c. pale skin d. shivering e. decreased muscle coordination f. tachycardia

b d f

3.A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as: A.A poisoning accident. B.An equipment-related accident. C.A procedure-related accident. D.An accident related to time management.

c

A teenage client was hospitalized 3 weeks ago after a motor vehicle accident in which he crushed his pelvis. He remains on bedrest. His parents tell the nurse, "Our son is just staring off into space and won't talk to us. He doesn't want to listen to his music or watch television. That is so unlike him." What is the nurse's best response? A."I will inform his doctor and see whether we can get your son started on an antidepressant medication." B."He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse." C."Your son had a major injury, and his immobility might be causing him to feel isolated and depressed." D."He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to do."

c

The nurse teaches an elderly client with right-sided weakness how to use a cane. Which of the following behaviors, if demonstrated by the client to the nurse, indicates that the teaching was effective? A. The client holds the cane with his right hand, moves the cane forward followed by the right leg, and then moves the left leg.B. The client holds the cane with his right hand, moves the cane forward followed by his left leg and then moves the right leg.C. The client holds the cane with his left hand, moves the cane forward followed by the right leg, and then the left leg.D. The client holds the cane with his left hand, moves the cane forward followed by his left leg, and then moves the right leg.

c

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to: A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the patient to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature.

d

A 16-year-old had a full leg cast for 4 months, and it is being removed today. Which of the following statements made by the client shows the most informed understanding of the effects of immobilization of a muscle on its strength and stamina? 1. "I'm hoping to be back at soccer practice in 3 weeks." 2. "Walking and riding my bike will help regain the muscle." 3. "I'll practice the strengthening routine the physical therapist taught me, so I can play baseball in the spring." 4. "There was a good bit of muscle and strength loss, but I'll work at getting it back

ANS: 3 Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. Appropriate general exercise and specific exercise of the atrophied muscle will increase both muscle tone and overall stamina. Although the remaining options are not incorrect, the answer shows the greatest insight because it provides both a plan and a time line for recovery.

A 78-year-old inactive client diagnosed with acute renal failure is at risk for which of the following skeletal maladies? 1. Rickets 2. Osteomyelitis 3. Pathological fractures of long bones 4. Compression fractures of the spinal colum

ANS: 3 Immobility causes the release of calcium into the circulation, where normally the kidneys excrete the excess calcium. If the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium reabsorption continues as the client remains on bed rest or continues to be immobile. Bed rest is not a direct causative factor for the other options

Which of the following statements regarding physical activity and its effect on activity tolerance made by a client shows the most informed knowledge regarding the connection between the two? 1. "I know I need to walk more if I want to get stronger." 2. "I don't like walking, but I do it because I know it will make me stronger." 3. "I try to walk a little farther each afternoon so I can dance at my grandson's wedding." 4. "I walk with my son three evenings a week because it's good for his weight and for my bones.

ANS: 3 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. The better the muscle tone, the more stamina the client will experience. The remaining options do not state the connection between activity and stamina as well as the answer.

The nurse is discussing joint mobility exercises with a client who experienced a stroke and now has left-sided weakness. Which of the following statements made by the client reflects the greatest insight regarding the best method for him to maintain mobility of the joints on his left side? 1. "My wife knows how to do those exercises for the joints on my left side." 2. "Physical therapy really exercises my left side when I go there every afternoon." 3. "I'll remind the staff to exercise my left side when they come to help me with my bath and getting dressed." 4. "I will do those passive range of motion exercises you taught me to my left side at least 3 times a day."

ANS: 4 If one extremity is paralyzed, teach the client to put each joint independently through its ROM.

The nurse understands that a pressure ulcer is an impairment of the skin as a result of prolonged ischemia. One of the easiest ways to prevent a pressure ulcer from occurring in an immobile client is to: 1. Keep the skin dry 2. Provide range of motion every shift 3. Use lift equipment when transferring a client 4. Turn the client a minimum of every 2 hours

ANS: 4 Implement a comprehensive skin care program to prevent skin breakdown in all clients, from neonates to older adults. Effective skin care programs include accurate and consistent assessment and documentation as well as interventions to protect the skin (e.g., turn the client at least every 2 hours). Keeping the skin dry is very important in preventing skin breakdown, range-of-motion exercises will help prevent contractures from occurring, lift equipment will help decrease harm to both clients and staff, but turning the client will best help prevent pressure ulcers

A client recovering from hip surgery tells the nurse that she wants to get better so she can walk down the aisle to her seat at her granddaughter's wedding. Which of the following nursing interventions will have the greatest impact on achieving that goal? 1. Informing physical therapists that the client has expressed that goal 2. Reminding the ancillary staff to offer to walk with the client after her bath 3. Regularly praising the client for the efforts she is making to reach her goal 4. Walking with the client to and from the dining room where she eats her meal

ANS: 4 Muscle tone helps maintain functional positions such as sitting or standing without excess muscle fatigue and is maintained through continual use of muscles. ADLs require muscle action and help maintain muscle tone. When a client is immobile or on prolonged bed rest, activity level, activity tolerance, and muscle tone decrease. The better the muscle tone, the more stamina the client will experience. Although all the interventions are appropriate, actually walking with the client will have the greatest impact on her ability to achieve the goal

The nurse caring for a 38-year-old female client with multiple fractures in the trauma intensive care unit knows that this client is at high risk for pulmonary complications such as atelectasis from her immobility. One of the interventions that the nurse can do to help prevent this from occurring is to: 1. Keep the PaO2 level at or above 94% 2. Instruct the client to deep breathe and cough every hour while awake 3. Turn the client every 2 hours 4. Keep the client on the ventilator as long as possible

ANS: 2 In atelectasis, secretions block a bronchiole or a bronchus, and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. At some point in the development of these complications, there is a proportional decline in the client's ability to cough productively. Turning the client is an excellent way to help prevent the accumulation of mucus in the dependent regions of the airways causing hypostatic pneumonia. Mucus is an excellent place for bacteria to grow. Keeping a client on a ventilator longer than necessary has the potential to cause multiple other complications and is not the best choice.

An infant born via cesarean section because of a breech presentation is diagnosed with bilateral congenital hip dysplasia. The primary nursing intervention directed toward this diagnosis is: 1. Assessing the infant frequently to determine abduction of the thighs 2. Maintaining the infant in the position of continuous abduction of both hips 3. Educating the parents about the importance of positioning the infant so that the head of the femurs are in alignment with the hip sockets 4. Providing pain management so that the infant is comfortable in the therapeutic position required

ANS: 2 Maintenance of continuous abduction of the thigh so that the head of the femur presses into the center of the acetabulum is critical in the care and treatment of this infant. Although the other options are appropriate, they are not primary interventions in this scenario.

Prevention of plantar flexion (footdrop) through the application of high-topped shoes is a primary intervention for which of the following mobility-impaired clients? 1. A 54-year-old diagnosed with osteoarthritis in all lower extremity joints 2. A 25-year-old with a fractured pelvis as a result of a motorcycle accident 3. A 78-year-old who has experienced left-sided paralysis resulting from a cerebral vascular accident (CVA) 4. A 15-year-old who has been comatose for 2 years as a result of a head injury sustained from a fall off a roof

ANS: 2 The client who has suffered a CVA with resulting left-sided paralysis (hemiplegia) is at risk for footdrop. In two of the options, the client would not damage the nerve necessary to cause the condition, and the remaining option is not the correct answer because there is little chance this client will ever be capable of mobility

The nurse and a nursing assistive personnel (NAP) are going to move an older adult client up in bed. Before moving the client, the nurse explains to the NAP that they will need to lift the client off the bed with an assistive device instead of using the drawsheet. The most important reason for using the assistive device is: 1. To avoid frightening the client 2. To avoid shearing the client's skin 3. To avoid getting "written up" for not following lift procedures 4. Because the nurse is tired

ANS: 2 The greater the surface area of the object that is moved, the greater the friction. A larger object produces greater resistance to movement. To decrease surface area and reduce friction when clients are unable to assist with moving up in bed, nurses use an ergonomic assistive device, such as a full body sling. It mechanically lifts the client off the surface of the bed, thereby preventing friction, tearing, or shearing of the client's delicate skin. The client may also be frightened by the use of the equipment. It is important to explain what will be going on and what the client can expect to experience when using any piece. Lift policies are put in place to protect both clients and staff; however, the nurse should not be as concerned with being "written up" as with protecting himself or herself, the NAP, and the client from harm. The most important reason for using the lift equipment is to protect the client and staff from harm

The nurse is caring for a 48-year-old male client who was involved in a motor vehicle accident and had a fractured pelvis, a ruptured spleen, and multiple contusions. The client has been in the hospital for 5 days on bed rest. The nurse knows that this client is at risk for venous thrombus formation because of prolonged bed rest, potential damage to vessel walls during surgery, and the platelets he received in the trauma unit. These three factors are also known as: 1. Trigeminy 2. Virchow's triad 3. Trigone 4. Hutchinson's triad

ANS: 2 There are three factors that contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity. These three factors are sometimes referred to as Virchow's triad

The nurse recognizes that a client who is inactive is at a risk for decreased muscle mass as a result of increased muscle atrophy and: 1. Decrease metabolic rate 2. Catabolic tissue breakdown 3. Inactivity-induced depression 4. Anorexia caused by decreased peristalsis

ANS: 2 Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown).

Which of the following statements made by a nurse caring for a client who experienced a myocardial infarction 8 hours ago shows the greatest insight as to the purpose for keeping the client on bed rest? 1. "This has been exhausting; she needs a period of uninterrupted rest." 2. "The pain she experienced is exhausting; it's imperative that she rest." 3. "Keeping her on bed rest decreases the need her body has for oxygen" 4. "She needs complete rest; she is really very ill, especially her heart.

ANS: 3 Although all of the options are correct, the primary reason for bed rest in this scenario is to minimize the need for oxygen to both the heart and the body in general

It has been determined that all of the following clients are at risk for falling. Which one requires the nurse's priority for ambulation? 1. A 16-year-old with a sprained ankle being discharged from the emergency department 2. A 54-year-old who has taken the initial dose of an antihypertensive medication 3. A 45-year-old postoperative client up for the first time since knee surgery 4. An 81-year-old who is asthmatic and had a hip replaced 18 months ago

ANS: 3 Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility also affect balance. Although all the options represent a potential risk for falling, the postoperative client has both prolonged immobility and physical injury (surgery) and so is at greatest risk

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient's room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (Select all that apply.) a. Place patient in upright position. b. Call respiratory therapy. c. Increase oxygen to 7 L/min per nasal cannula. d. Assess vital signs e. Listen to lung sounds. f. Administer metoprolol.

Answer: a, b, d, e When a person is having difficulty breathing, placing the individual in an upright position (Fowler or semi-Fowler) helps to increase the effectiveness of breathing by placing less pressure on the chest from the bed. The nurse would put the patient in an upright position to improve breathing. Respiratory therapy should come to assess the patient, to administer a second breathing treatment, and evaluate oxygen requirements depending on the facility. It is important to assess vital signs and lung sounds to determine what has changed with the patient since the last assessment. Do not administer oxygen through a simple nasal cannula at greater than 6 L/min. Medications are given only per order from the primary care provider.

Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital signs? a. Complaining of feeling "chilled" after a shower b. Complaining of pressure in the chest c. Completing ambulation of 100 feet after a stroke d. Complaining of hunger while NPO (nothing by mouth)

Answer: b Chest pressure is a classic sign of a heart attack—vital signs should be checked immediately. Vital signs may be monitored before, during, or after activity, but this is not the most critical need. Unless the vital signs have changed drastically, not having baseline values before ambulation makes it hard to interpret vital signs after activity. Hunger is not a critical indicator for the need for obtaining vital signs.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest? a. A ratio of 1 : 2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine

Answer: b Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity, causing the anteroposterior diameter of the chest to increase. The chest diameter ratio of 1:2 is the normal finding for a person who does not have hyperinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD.

The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels

Answer: b Cyanosis occurs due to hypoxemia, which is a low level of oxygen in the blood. Hemoglobin that is not saturated with oxygen causes a bluish discoloration of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.

Which statement by the patient with vertigo lets the nurse know that the patient has understood the home-going instructions? a. "I will buy a visual signal for my smoke detectors." b. "I will have grab bars installed in my bathtub." c. "I will change positions quickly to avoid vertigo." d. "I will get a home phone with amplified sound."

Answer: b Grab bars provide stability for the patient with vertigo. Patients with vertigo should change positions slowly to avoid worsening of the spinning sensation. Visual signals and amplified sound are used in the home of the patient with hearing deficits.

. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 12 inches forward and then swinging both legs forward

Answer: b Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The patient can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and the swing-to gait is not appropriate for this patient.

Which of the following interventions by the nurse addresses a National Patient Safety Goal as indicated by The Joint Commission? a. Take a picture of the patient upon admission to verify patient identity. b. Answer patient call alarms in a timely manner. c. Provide patients a permanent marker to label all of their medications. d. Use hand sanitizer as the best option for hand hygiene.

Answer: b One of the patient safety goals focuses on reducing harm associated with clinical alarm systems. A nurse responding to a patient alarm in a timely manner indicates that the alarm can be heard and the patient condition is being assessed. Patients should be identified by scanning barcodes or comparing the patient's stated name and birthdate to information on the patient's wristband or health record. Patients are encouraged to leave medications in labeled bottles. Handwashing remains the most effective hand hygiene technique.

The nurse understands that which statement is correct regarding respiratory rates? a. Infants have a lower respiratory rate than adults. b. Healthy adults breathe between 12 and 20 times a minute. c. A compensatory response to a fever is to breathe at a slower rate. d. An increase in intracranial pressure results in an increased respiratory rate.

Answer: b The normal respiratory rate for a healthy adult is 12 to 20 BPM. Infants have a higher respiratory rate than adults. A fever increases the metabolic rate and results in a higher rate. Intracranial pressure decreases the respiratory rate.

After application of sequential compression devices (SCDs) on a patient, what assessment finding is essential for the nurse to include in documentation? a. Warmth of bilateral upper extremities b. Lower extremity circulatory status c. Circumoral cyanosis d. Altered bowel sounds

Answer: b The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or altered bowel sounds.