NUR3632 Foundations Exam 2 Study

A nurse caring for patients with bowel alterations formulates a nursing diagnosis for a patient with a new ileostomy. Which diagnosis is most appropriate? Disturbed Body Image Constipation Delayed Growth and Development Excess Fluid Volume

. a. An ileostomy may cause disturbed body image due to the invasive nature of the procedure and the presence of the stoma. Constipation does not normally occur with an ileostomy because the drainage is liquid. Growth and development are not generally affected by the formation of an ileostomy. Excess fluid volume is unlikely to occur because the drainage is liquid and probably continual.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80-150 mm Hg).

a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis (Roman, 2005).

A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. A patient diagnosed with peritonitis A patient who is on prolonged bedrest A patient who has diarrhea A patient who has gastroenteritis A patient who has an early bowel obstruction A patient who has paralytic ileus caused by surgery

a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes (Jensen, 2011)—signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction

A nurse is caring for a patient who has a nasogastric tube in place for gastric decompression. Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction? Select all that apply. Draw up 30 mL of saline solution into the syringe. Unclamp the suction tubing near the connection site to instill solution. Place the tip of the syringe in the tube to gently insert saline solution. Place syringe in the blue air vent of a Salem sump or double-lumen tube. After instilling irrigant, hold the end of the NG tube over an irrigation tray. Observe for return flow of NG drainage into an available container.

a, c, e, f. The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline solution (or amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.

. A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? 2, 4, 1, 3 3, 1, 4, 2 2, 4, 3, 1 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A nurse is caring for a postpartum patient who has stitches in the perineum from an episotomy (surgically planned incision to prevent vaginal tears). Which medication would the nurse most likely administer to this patient? A stool softener (Colace) An osmotic laxative (Miralax) A bulk-forming laxative (Metamucil) An emollient laxative (mineral oil)

a. Although all the choices are laxatives that would soften the stool and make it easier to expel, a stool softener, such as Colace, is the one recommended for a patient who must avoid straining. In this case, it would help to prevent disturbing the stitches in the perineum.

A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? Have the patient follow a clear liquid diet 24 to 48 hours before the test. Have the patient take Dulcolax and ingest a gallon of bowel cleaner on day 1. Prepare the patient for the use of general anesthesia during the test. Explain that barium contrast mixture will be given to drink before the test.

a. Preparation for a colonoscopy includes a clear liquid diet 24 to 48 hours before the test along with a 2-day bowel prep of a strong cathartic and Dulcolax on day 1 and enema on day 2 of the test, or a 1-day bowel prep that consists of ingestion of a gallon of bowel cleanser in a short period of time. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the folks responsible for these errors and see if we can replace them." This is an example of: Quality by inspection Quality by punishment Quality by surveillance Quality by opportunity

a. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity (d) focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Answers b and c are distractors.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the student's best response? Tell the RN that he or she lacks the technical competencies to change the dressing independently. Assemble the equipment for the procedure and follow the steps in the procedure manual. Ask another student nurse to work collaboratively with him or her to change the dressing. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies his identity by: Asking the patient his name Reading the patient's name on the sign over the bed Asking the patient's roommate to verify his name Asking, "Are you Mr. Brown?"

a. The nurse should ask the patient to state his name. A sign over the patient's bed may not always be current. The roommate is an unsafe source of information. The patient may not hear his name but may reply in the affirmative anyway (e.g., a person with a hearing deficit).

A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.

a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.

An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. Performing the initial patient assessments Making patient beds Giving patients bed baths Administering patient medications Ambulating patients Assisting patients with meals

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. A patient who is taking narcotics for pain A patient who is taking laxatives A patient who is taking diuretics A patient who is dehydrated A patient who is taking amoxicillin for an infection A patient taking over-the-counter antacids

b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate (Augmentin), laxatives, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.

A nurse is irrigating the colostomy of a patient and is unable to get the irrigation solution to flow. What would be the nurse's next action in this situation? Assist the patient to a prone position on a waterproof pad and try again. Check the clamp on the tubing to make sure that the tubing is open. Quickly pull the cone from the stoma and check for bleeding. Remove the equipment and call the primary care provider.

b. If irrigation solution is not flowing, the nurse should first check the clamp on the tubing to make sure the tubing is open. Next, the nurse should gently manipulate the cone in the stoma and check for a blockage of stool. If there is a blockage, the nurse should remove the cone from the stoma, clean the area, and gently reinsert. Alternately, the nurse could assist the patient to a side-lying or sitting position in bed, place a waterproof pad under the irrigation sleeve, and place the drainage end of the sleeve in a bedpan.

A medication order reads: "K-Dur, 20 mEq po b.i.d." When and how does the nurse correctly give this drug? Daily at bedtime by subcutaneous route Every other day by mouth Twice a day by the oral route Once a week by transdermal patch

c. The abbreviation "b.i.d." refers to twice-a-day administration. po (by mouth) refers to administration by the oral route.

A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient complains of severe cramping. What would be the appropriate nursing intervention in this situation? Elevate the head of the bed 30 degrees and reposition the rectal tube. Place the patient in a supine position and modify the amount of solution. Lower the solution container and check the temperature and flow rate. Remove the rectal tube and notify the primary care provider.

c. If the patient complains of severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur.

A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? Reassure the patient that this is a normal finding with a new ostomy. Notify the primary care provider that the stoma is prolapsed. Have the patient rest for 30 minutes to see if the prolapse resolves. Remove the appliance and redo the procedure using a larger appliance.

c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the physician. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse discovers that she made a medication error. What should be the nurse's first response? Record the error on the medication sheet. Notify the physician regarding course of action. Check the patient's condition to note any possible effect of the error. Complete an incident report, explaining how the mistake was made.

c. The nurse's first responsibility is the patient—careful observation is necessary to assess for any effect of the medication error. The other nursing actions are pertinent, but only after checking the patient's welfare.

A patient has a fecal impaction. The nurse correctly administers an oil-retention enema by: Administering a large volume of solution (500-1,000 mL) Mixing milk and molasses in equal parts for an enema Instructing the patient to retain the enema for at least 30 minutes Administering the enema while the patient is sitting on the toilet

c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.

A nurse is performing digital removal of stool on a 74-year old female patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then she vomits. What should be the nurse's next action? Reassure the patient that this is a normal reaction to the procedure. Stop the procedure, prepare to administer CPR, and notify the physician. Stop the procedure, assess vital signs, and notify the physician. Stop the procedure, wait five minutes, and then resume the procedure.

c. When a patient complains of dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the physician. The vagal nerve may have been stimulated.

A nurse is writing an evaluative statement for a patient who is trying to lower her cholesterol through diet and exercise. Which evaluative statement is written correctly? "Outcome not met." "1/21/15—Patient reports no change in diet." "Outcome not met. Patient reports no change in diet or activity level." "1/21/15—Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. Answers a, b, and c are incomplete statements.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? The nurse collects data to identify health problems. The nurse collects data to identify patient strengths. The nurse collects data to justify terminating the plan of care. The nurse collects data to measure outcome achievement.

d, The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the plan of care, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. "I will be careful not to shake up the canister before using it." "I will hold the canister upside-down when using it." "I will inhale the medication through my nose." "I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale.

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

A nurse prepares to assist a patient with her newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. "When you inspect the stoma, it should be dark purple-blue." "The size of the stoma will stabilize within 2 weeks." "Keep the skin around the stoma site clean and moist." "The stool from an ileostomy is normally liquid." "You should eat dark green vegetables to control the odor of the stool." "You may have a tendency to develop food blockages."

d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.

A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The physician ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? c, b, d, a d, c, a, b a, b, d, c b, a, d, c

d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.

A nurse is teaching a patient with frequent constipation how to implement a bowel-training program. What is a recommended teaching point? Using a diet that is low in bulk Decreasing fluid intake to 1,000 mL Administering an enema once a day to stimulate peristalsis Allowing ample time for evacuation

d. For a bowel-training program to be effective, the patient must have ample time for evacuation (usually 20-30 minutes). Fluid intake is increased to 2,500 to 3,000 mL, food high in bulk is recommended as part of the program, and a daily enema is not administered in a bowel-training program. A cathartic suppository may be used 30 minutes before the patient's usual defecation time to stimulate peristalsis.

While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating: Thrombophlebitis Atelectasis Infection Hemorrhage

d. Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Manifestations of atelectasis include decreased lung sounds over the affected area, dyspnea, cyanosis, crackles, restlessness, and apprehension. Signs of infection include elevated white blood count and fever.

A student health nurse is counseling a female college student who wants to lose 20 pounds. The nurse develops a plan to increase the student's activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 pounds, the student has lost only 1 pound. Which is the best nursing response? Congratulate the student and continue the plan of care. Terminate the plan of care since it is not working. Try giving the student more time to reach the targeted outcome. Modify the plan of care after discussing possible reasons for the student's partial success.

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the plan of care. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the plan of care since the student has not met her targeted outcome. The student may need more than time to reach her outcome, which makes (c) the wrong response.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? Reposition the extremity and raise the height of the IV pole. Apply pressure to the dressing on the IV. Pull the catheter out slightly and reinsert it. Put on gloves; remove the catheter; apply pressure with a sterile pad.

d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings? Gently push down on the needle and flush it a second time. Stop flushing and remove the needle; notify the primary care provider. Ask the patient to perform a Valsalva maneuver; change the patient position. Close the clamp; wait 3 minutes, try flushing the port again.

. c. If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or raise or lower the head of the bed. If these measures do not work, the nurse should remove the needle and reaccess the device with a new needle.

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? Quickly position the patient on his or her side. Put on disposable gloves and remove the oral airway. Check that the airway is the appropriate size for the patient. Put on sterile gloves and suction the airway.

. a. When a patient vomits upon insertion of an oropharyngeal airway, the nurse should immediately position the patient on his or her side to prevent aspiration, remove the oral airway, and suction the mouth if needed.

. When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? The oxygen must be humidified. The rate will be no more than 2 to 3 L/min or less. Arterial blood gases will be drawn every 4 hours to assess flow rate. The rate will be 6 L/min or more.

. b. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? High Fowler's position Left side with pillow under chest wall Lying position/half on abdomen and half on side Trendelenberg position

. b. For postural drainage, the nurse should place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung, use high Fowler's position to drain the apical sections of the upper lobes of the lungs, place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs, and place the patient in the Trendelenburg position to drain the lower lobes of the lungs.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? Explaining the mechanisms involved in transporting fluids to and from intracellular compartments Keeping fluids readily available for the patient Emphasizing the long-term outcome of increasing fluids when the patient returns home Planning to offer most daily fluids in the evening

. b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? Inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin.

. b. Regular or short-acting insulin should never be contaminated with NPH or any insulin modified with added protein. Placing air in the NPH vial first without allowing the needle to contact the solution ensures that the regular insulin will not be contaminated.

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. Manage patient's pain.

. d. This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. Place your answer on the line provided below.

Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. Extracellular fluid volume deficit Protein deficit Metabolic alkalosis Sodium deficit Plasma-to-interstitial fluid shift Metabolic acidosis

a, b, d, e. Patients with fluid loss due to ascites are at risk for extracellular fluid volume deficit, protein deficit, sodium deficit, and plasma-interstitial fluid shift.

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed. Some people experience the same response with a placebo as with the active drug used in studies. People with liver disease metabolize drugs more quickly than people with normal liver functioning. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects. Oral medications should not be given with food as the food may delay the absorption of the medications. Circadian rhythms and cycles may influence drug action.

a, b, d, f. Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patient's expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patient's environment may also influence the patient's response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drug needed to reach a therapeutic level. The presence of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhanced absorption if taken with certain foods.

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of this surgical team member? Select all that apply. Maintaining sterile technique Draping and handling instruments and supplies Identifying and assessing the patient on admission Integrating case management Preparing the skin at the surgical site Providing exposure of the operative area

a, b. The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instruments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the operating room and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient.

A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. "Try to drink at least six to eight glasses of water each day." "Try to limit your fluid intake to one quart of water daily." "Limit sugar, salt, and alcohol in your diet." "Report side effects of medications you are taking, especially diarrhea." "Temporarily increase foods containing caffeine for their diuretic effect." "Weigh yourself daily and report any changes in your weight."

a, c, d, f. Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. Dyspnea Hypotension Small pulse pressure Decreased respiratory rate Pallor Increased pulse rate

a, c, e, f. If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. Basing patient care on continuous healing relationships Customizing care to reflect the competencies of the staff Using evidence-based decision making Having a charge nurse as the source of control Using safety as a system priority Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. Monitoring patient status every hour Using intuition to troubleshoot patient problems Turning a patient on bed rest every 2 hours Becoming a nurse mentor to a student nurse Administering pain medication ordered by the physician Becoming involved in community nursing events

a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent.

A nurse is teaching an adolescent patient how to use a meter-dosed inhaler to control his asthma. What are appropriate guidelines for this procedure? Select all that apply. Remove the mouthpiece cover and shake the inhaler well. Take shallow breaths when breathing through the spacer. Depress the canister releasing one puff into the spacer and inhale slowly and deeply. After inhaling, exhale quickly through pursed lips. Wait 1 to 5 minutes as prescribed before administering the next puff. Gargle and rinse with salt water after using the MDI.

a, c, e. The correct procedure for using a meter-dosed inhaler is: remove the mouthpiece cover and shake the inhaler well; breathe normally through the spacer; depress the canister releasing one puff into the spacer and inhale slowly and deeply; after inhaling, hold breath for 5 to 10 seconds, or as long as possible, and then exhale slowly through pursed lips; wait 1 to 5 minutes as prescribed before administering the next puff; and gargle and rinse with tap water after using the MDI.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. 5% dextrose in water (D5W) 0.9% NaCl (normal saline) Lactated Ringer's solution 0.33% NaCl (¹∕³-strength normal saline) 0.45% NaCl (½-strength normal saline) 10% dextrose in water (D10W)

a, d, e. 5% dextrose in water (D5W), 0.33% NaCl (¹∕³-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 10% dextrose in water (D10W) is used in peripheral parenteral nutrition (PPN).

A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. Diazepam is given to alleviate anxiety. Ranitidine is given to facilitate patient sedation. Atropine is given to decrease oral secretions. Morphine is given to depress respiratory function. Cimetidine is given to prevent laryngospasm. Fentanyl citrate-droperidol is given to facilitate a sense of calm.

a, c, f. Sedatives, such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate (Robinul) are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar) are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed.

. A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. The nurse uses a binary decision tree for stepwise assessment and intervention. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

a, d, f. Distribution occurs after a drug has been absorbed into the bloodstream and the drug is distributed throughout the body, becoming available to body fluids and body tissues. Some drugs move from the intestinal lumen to the liver by way of the portal vein and do not go directly into the systemic circulation following oral absorption. This is called the first-pass effect, or hepatic first pass. Excretion is the process of removing a drug or its metabolites (products of metabolism) from the body. Absorption is the process by which a drug is transferred from its site of entry into the body to the bloodstream. Metabolism, or biotransformation, is the change of a drug from its original form to a new form. The liver is the primary site for drug metabolism. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug excretion.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. The nurse carefully removes the bandages from a burn victim's arm. The nurse assesses a patient to check nutritional status. The nurse formulates a nursing diagnosis for a patient with epilepsy. The nurse turns a patient in bed every 2 hours to prevent pressure ulcers. The nurse checks a patient's insurance coverage at the initial interview. The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient appreciates or values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? Cognitive Psychomotor Affective Physical changes

c. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? Checking the amount of oxygen in the cylinder before using it Using a cylinder for a patient transfer that indicates available oxygen is 500 psi Placing the oxygen cylinder on the stretcher next to the patient Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

a. The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." "Is this an actual or a possible diagnosis?" "This is a medical, not a nursing problem."

a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues.

a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system? Respiratory system Circulatory system Digestive system Nervous system

a. A thoracic incision makes it more painful for the patient to take deep breaths or cough. Shallow respirations and ineffective coughing increase the risk for respiratory complications.

A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? Anticoagulants Antacids Laxatives Sedatives

a. Anticoagulant drug therapy would increase the risk for hemorrhage during surgery

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? Cognitive Psychomotor Affective Physical changes

a. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nurse is administering an oral medication to a patient via a gastric tube. The nurse observes the medication enter the tube, and then the tube becomes clogged. What would be the appropriate initial action of the nurse in this situation? Attempt to dislodge the medication with a 10-mL syringe. Notify the primary care provider. Remove the tube and replace it with another tube. Flush the tube with 60 mL of water.

a. If medication becomes clogged in a gastric tube, the nurse should attach a 10-mL syringe on the end of the tube and pull back and lightly apply pressure to the plunger in a repetitive motion to attempt to dislodge the medication. If the medication does not move through the tube, the nurse should notify the primary care provider, who may request the tube be replaced.

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? Perform the focused assessment. This is an independent nurse-initiated intervention. Request an order from Jill's physician since this is a physician-initiated intervention. Request an order from Jill's physician since this is a collaborative intervention. Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse-initiated intervention, thus the nurse does not need an order from the physician or the nutritionist.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. The nurse formulates nursing diagnoses. The nurse identifies expected patient outcomes. The nurse selects evidence-based nursing interventions. The nurse explains the nursing care plan to the patient. The nurse assesses the patient's mental status. The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. Thoracentesis Spirometry Pulse oximetry Peak expiratory flow rate Diffusion capacity Maximal respiratory pressure

b, c, d. Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. Bronchial pneumonia Impaired gas exchange Ineffective airway clearance Potential complication: sepsis Infection related to pneumonia Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A nurse sits down with a patient and prioritizes existing diagnoses. A nurse assesses a woman for postpartum depression during routine care. A nurse plans interventions for a patient who is diagnosed with epilepsy. A busy nurse takes time to speak to a patient who received bad news. A nurse reassesses a patient whose PRN pain medication is not working. A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

A nurse has been asked to witness a patient signature on an informed consent form for surgery. For which of these patients would the document be valid? Select all that apply. A 92-year-old patient who is severely confused A 45-year-old patient who is oriented and alert A 10-year-old patient who is oriented and alert A 36-year-old patient who has had a narcotic premedication A 45-year-old mentally ill patient who has been ruled incompetent

b, f. A consent form is not legal if the patient signing the form is confused, sedated, unconscious, or a minor.

1. A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. The nurse uses the nursing interview to collect patient data. The nurse analyzes data collected in the nursing assessment. The nurse develops a care plan for the patient. The nurse points out the patient's strengths. The nurse assesses the patient's mental status. The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?," "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" (5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression (1) and (3) (2) and (4) (1), (2), and (3) All of the above

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement.

A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? Actual Risk Possible Wellness

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? Actual Possible Risk Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care? Administer pain medication. Reassess the patient. Prepare the equipment. Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications.

A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? Hunger Impaired wound healing Hemorrhage Gas pains

b. Fatty tissue is less vascular and, therefore, less resistant to infection and more prone to delayed wound healing.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? 1 2 3 4

b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage.

A patient tells the nurse she is having pain in her right lower leg. How does the nurse assess for the presence of thrombophlebitis? By palpating the skin over the tibia and fibula By documenting daily calf circumference measurements By recording vital signs obtained four times a day By noting difficulty with ambulation

b. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference on a regular basis.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? Encourage foods and fluids with high sodium content. Administer oral K supplements as ordered. Caution the patient about eating foods high in potassium content. Discuss calcium-losing aspects of nicotine and alcohol use.

b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? Take and record vital signs every shift. Turn, cough, and deep breathe every 4 hours. Encourage increased intake of oral fluids. Assess bowel sounds daily.

b. Reduced vital capacity in older adults increases the risk for respiratory complications, including pneumonia and atelectasis. Having the patient turn, cough, and deep breathe every 4 hours maintains respiratory function and helps to prevent complications.

Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure? Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention A complete list of reimbursable charges for each nursing intervention

b. The Nursing Interventions Classification Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? Kidneys Lungs Adrenal glands Blood vessels

b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

Ms. Hall has an order for hydromorphone (Dilaudid), 2 mg, intravenously, q 4 hours PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to Dilaudid. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? Administer the medication; the doctor is responsible for medication administration. Call Dr. Long and ask that she change the medication. Ask the supervisor to administer the medication. Ask the pharmacist to provide a medication to take the place of Dilaudid.

b. The nurse is responsible for any medications he or she gives and must contact the doctor to inform her of the patient's allergy to the drug. The nurse should not give the medication and might speak with the supervisor only if uncomfortable with the physician's answer once she is notified. The nurse is legally unable to order a replacement medication, as is the pharmacist.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? The age of the patient The size of the endotracheal tube The type of secretions to be suctioned The height and weight of the patient

b. The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? Offer the patient 60 mL fluid every 2 hours while awake. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15 At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day.

b. The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware."

A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? "You have a wonderful doctor." "Let's talk about how you are feeling." "Everyone wakes up from surgery!" "Don't worry, you will be just fine."

b. This answer allows the patient to talk about his feelings and fears, and is therapeutic.

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: Quality assurance Quality improvement Process evaluation Outcome evaluation

b. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no end points. Its goal is improving quality rather than assuring quality. Answers c and d are types of quality-assurance programs.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? No problem Possible problem Actual nursing diagnosis Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A physician orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? A single dose during the postoperative period Doses administered as needed for pain relief One dose administered immediately Doses routinely administered as a standing order

b. When the prescriber writes a PRN order ("as needed") for medication, the patient receives medication when it is requested or required. With a single or one-time order, the directive is carried out only once, at a time specified by the prescriber. A stat order is a single order carried out immediately. A standing order (or routine order) is carried out as specified until it is canceled by another order.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient's head forward. Hold the mask tightly over the patient's nose and mouth. Pull the patient's jaw backward. Compress the bag twice the normal respiratory rate for the patient.

b. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16-20 breaths/min in adults).

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? Risk for Impaired Skin Integrity Related to prescribed bedrest As evidenced by As evidenced by reddened areas of skin on the heels and back

b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. A nurse consults with a psychiatrist for a patient who abuses pain killers. A nurse checks the skin of bedridden patients for skin breakdown. A nurse orders a kosher meal for an orthodox Jewish patient. A nurse records the I&O of a patient as prescribed by his physician. A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.

The nurse is administering a medication to a patient via a nasogastric tube. Which are accurate guidelines related to this procedure? Select all that apply. Crush the enteric-coated pill for mixing in a liquid. Flush open the tube with 60 mL of very warm water. Check for proper placement of the nasogastric tube. Give each medication separately and flush with water between each drug. Lower the head of the bed to prevent reflux. Adjust the amount of water used if patient's fluid intake is restricted.

c, d, f. The nurse should use the recommended procedure for checking tube placement prior to administering medications. The nurse should also give each medication separately and flush with water between each drug and adjust the amount of water used if fluids are restricted. Enteric-coated medications should not be crushed, the tube should be flushed with 15 to 30 mL of water, and the head of the bed should be elevated to prevent reflux.

A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. Loss of consciousness Relaxation of skeletal muscles Reduction or loss of reflex action Localized loss of sensation Prolonged pain relief after other anesthesia wears off Infiltrates the underlying tissues in an operative area

c, d. A localized loss of sensation and possible loss of reflexes occurs with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema

c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? Decreased Cardiac Output related to difficulty breathing Impaired Gas Exchange related to use of bronchodilators Fatigue related to impaired oxygen transport system Ineffective Airway Clearance related to fatigue

c. Fatigue related to an impaired oxygen transport system is an example of a nursing diagnosis with alteration in oxygenation as the etiology or cause of other problems. Ineffective Airway Clearance, Decreased Cardiac Output and Impaired Gas Exchange are examples of nursing diagnoses indicating alterations in oxygenation as the problem.

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? Readminister the medication and notify the primary care provider. Readminister the pill in a liquid form if possible. Assess the vomit, looking for the pill. Notify the primary care provider.

c. If a patient vomits immediately after swallowing an oral pill, the nurse should assess the vomit for the pill or fragments of it. The nurse should then notify the primary care provider to see if another dosage should be adm

3. When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

. A nurse uses the following classic elements of evaluation when caring for patients. Which item below places them in their correct sequence? (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting one's judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what one is looking for when evaluating, e.g., expected patient outcomes) 1, 2, 3, 4, 5 3, 2, 1, 4, 5 5, 2, 1, 3, 4 2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate, e.g., expected patient outcomes), (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the RN? Allow the UAPs to do the admission assessment and report the findings to the RN. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. Contact his or her labor representative and complain about this practice.

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? Instruct assistant to notify the primary care provider. Assess the patient's vital signs. Remove the tape, adjust the depth to ordered depth and reapply the tape. No action is required as depth will adjust automatically.

c. The tube depth should be maintained at the same level unless otherwise ordered by the physician. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. The nurse knows that this type of surgery belongs in what category? Minor, diagnostic Minor, elective Major, emergency Major, palliative

c. This surgery would involve a major body organ, has the potential for postoperative complications, requires hospitalization, and must be done immediately to save the patient's life. Elective surgery is a procedure that is preplanned by essentially healthy people. Diagnostic surgery is performed to confirm a diagnosis. Palliative surgery is not curative, rather it is done to relieve or reduce the intensity of an illness.

A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? "You know your personal situation better than I do, so I will respect your wishes." "If you don't accept these services, your baby's health will suffer." "Let's take a look at the plan again and see if we can adjust it to fit your needs." "I'm going to assign your case to a social worker who can explain the services better."

c. When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? Aspirate before giving and gently massage after the injection. Do not aspirate; massage the site for 1 minute. Do not aspirate before or massage after the injection. Massage the site of the injection; aspiration is not necessary but will do no harm.

c. When giving heparin subcutaneously, the nurse should not aspirate or massage, so as not to cause trauma or bleeding in the tissues.

A nurse is reconstituting powdered medication in a vial. Which action is a recommended step in this process? The nurse draws up the proper amount of powered medication into the syringe. The nurse inserts the needle through the rubber stopper of the diluent vial. The nurse gently agitates the powdered medication vial to mix the powder and diluent completely. The nurse draws up the prescribed amount of medication while holding the syringe horizontally at eye lev

c. When reconstituting powdered medication in a vial, the nurse should draw up the appropriate amount of diluent into the syringe, insert the needle through the center of the self-sealing stopper on the powdered medication vial, inject the diluent into the powdered medication vial, remove the needle from the vial and replace the cap, and gently agitate the vial to mix the powdered medication and diluent completely. The nurse should then draw up the prescribed amount of medication while holding the syringe vertically and at eye level.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to 2.5″). By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills. c is an outcome describing a physical change in the patient.

A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. Schedule the testing and meal planning first and complete hygiene as time permits. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? Recording intake and output Testing skin turgor Reviewing the complete blood count Measuring weight daily

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility (1) and (2) (3) and (4) (1), (2), and (3) All of the above

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation? Promote respiratory function Maintain functional abilities Provide diversional activities Increase venous return

d. Leg exercises in the postoperative period increase venous return. As a result, the patient has a decreased risk for thrombophlebitis and emboli.

A medication order reads: "Hydromorphone, 2 mg IV every 3 to 4 hours PRN pain." The prefilled cartridge is available with a label reading "Hydromorphone 2 mg/1 mL." The cartridge contains 1.2 mL of hydromorphone. Which nursing action is correct? Give all the medication in the cartridge because it expanded when it was mixed. Call the pharmacy and request the proper dose. Refuse to give the medication. Dispose of 0.2 mL correctly before administering the drug.

d. Many cartridges are overfilled, and some of the medication needs to be discarded. Always check the volume needed to provide the correct dose with the volume in the syringe. Giving the excess medication in the cartridge may result in adverse effects for the patient. For this dose, it is not necessary to call the pharmacy or refuse to give the medication, provided the order is written correctly.

A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? Collaborative problem Interdisciplinary problem Medical problem Nursing problem

d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? "The pump allows the patient to be completely free of pain during the postoperative period." "The pump allows the patient to take unlimited amounts of medication as needed." "The pump allows the patient to choose the type of medication given postoperatively." "The pump allows the patient to self-administer limited doses of pain medication."

d. PCA infusion pumps allow patients to self-administer doses of pain-relieving medication within physician-prescribed time and dose limits. Patients activate the delivery of the medication by pressing a button on a cord connected to the pump or a button directly on the pump.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the physician. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline.

d. When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? The patient vomits during suctioning. The secretions appear to be stomach contents. The catheter touches an unsterile surface. Epistaxis is noted with continued suctioning.

d. When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A nurse is teaching a man scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? Lecture Discussion Audiovisuals Written instructions

d. Written instructions are most effective in providing information for same-day surgery.