Nursing Fundamentals

Which of the following is a requirement of the Omnibus Reconciliation Act of 1986? A) The families of dying or death patients must be approached about organ and tissue donation B) The medical examiner must be notified C) The physician cannot approach the family about organ donation, this must be done by a representative of an organ donation organization D) The physician must notify the donor organization in a timely manner

ANSEWR: A Explanation: - All hospitals are mandated to establish protocols for identifying potential tissue and organ donors - The donor organization does not have to be notified by the physician, the primary nurse can do this also - The physician can approach the family about organ and tissue donation, but ideally, this is done by a representative of the donor organization - The medical examiner does not have to be notified unless she is directly involved in the patients case

A nurse is preparing to administer total parenteral nutrition (TPN) to a toddler. However, the patient does not have central access, which requires the nurse to administer the TPN via peripheral I.V. What is the maximum safe glucose concentration that can be administered through a peripheral I.V.? A) 10% glucose B) 15% glucose C) 17% glucose D) 20% glucose

ANSWER: A Explanation: - 10% glucose concentration is the maximum amount considered safe for peripheral veins. Any amount over 10% should be administered through a central venous catheter

A patient is prescribed lactated Ringer's solution, 2500 ml over 24 hours. The nurse sets the infusion rate at 125 ml/hour. The infusion will be complete in: A) 20 hours B) 22 hours C) 24 hours D) 36 hours

ANSWER: A Explanation: - 2500 ml divided by the hourly rate, 125 ml/hr - 2500/125 = 20 hours

A new nurse is reviewing her patient assignments for the day. Which patient should the nurse assess first? A) A newly admitted patient with acute flank pain and hematuria B) A patient having urinary retention related to BPH C) A patient undergoing hemodialysis later today D) A patient who underwent a renal biopsy two days ago

ANSWER: A Explanation: - A new admission should be assessed first because little is known about the patient and he or she may be unstable - A renal biopsy is a low-risk procedure. After two days without complications, the patient should be stable and not a priority - A patient receiving hemodialysis should be assessed before the treatment. In this case, the treatment is scheduled for later in the day. Therefore, assessing the patient is a low priority - Urinary retention related to BPH is common among older men and odes not require immediate attention from the nurse

A patient is receiving isotonic I.V. fluids at a rate of 150 ml/hour. Which of the following would increase a need for more I.V. fluids? A) Amber urine B) Jugular vein distention C) Peripheral edema D) Serum potassium of 3.4 mEq

ANSWER: A Explanation: - Amber or dark urine is highly concentrated and may signal dehydration. The patient needs additional fluids - Jugular vein distention and peripheral edema would indicate fluid overload - A serum potassium of 3.4 mEq/L is only slightly low and does not require additional fluids. However, the administration of potassium chloride may be required

After administering sulfate 3 hours ago, the patient complains of rapid onset pain rated at 8 out of 10. The nurse would consider this to be: A) Breakthrough pain B) Inflammatory pain C) Neuropathic pain D) Referred pain

ANSWER: A Explanation: - Breakthrough pain comes on suddenly, lasts for short periods, and is not relieved by the patient's normal pain management - Referred pain is felt at distance from the stimulus - Neuropathic pain is caused by damage to a nerve, but is felt in the area that nerve intervals - Inflammatory pain is caused by the stretch or distention of sensitive tissue

A 40-year-old male sustained a pleura effusion. The chest x-ray shows that accumulation of fluid is present in the left lower lobe of the lung. The physician decides to insert a chest tube to drain the fluid. Where is the insertion site? A) Lower left lateral chest wall B) Lower mid lateral chest wall C) Upper left anterior thorax D) Upper right anterior thorax

ANSWER: A Explanation: - Chest tubes used to drain fluid or blood are usually placed at the lateral chest wall, near the fourth to sixth intercostal space - Since air rises, the chest tubes for a pneumothorax are ofter placed at the upper anterior thorax

An 8-year-old has full thickness burns on 34% of his total body surface area. Someone calls the unit claiming to be the patient's mother and asks for information about the patient's prognosis. How should the nurse respond? A) "I'm sorry, I cannot give out information over the phone" B) "Let me transfer you to the physician" C) "Your son has suffered massive burns, please come to the hospital as soon as possible" D) "Your son may not survive"

ANSWER: A Explanation: - For confidentiality reasons, the nurse is prohibited from discussing patient information over the phone to an unknown person - "Your son has suffered massive burns" and "your son may not survive" breaches patient confidentiality - "Let m transfer you to the physician" does not address the caller's concerns. Also, the physician cannot provide confidential information to an unknown caller

After combining two intravenous medications into a single vial, how should the nurse mix the two solutions? A) Gently roll the vial B) Invert the vial C) Let stand for 2 minutes D) Shake the vial

ANSWER: A Explanation: - Gently rolling the medication between the palms of your hands will ensure adequate mixing without breaking down the medication - Shaking the vial can cause the medication to break down, changing its action - Inverting the vial or letting it stand for two minutes will not adequately mix the two solutions

An orthopedic nurse receives a phone call from a good friend of the patient. The friend asks how the patient's hip surgery went. How should the nurse respond? A) "I cannot give out that information" B) "Please call back later when I have more time to discuss the surgery" C) "The surgery went as planned, you can ask the physician for more details" D) "There were some complications, but the patient is stable"

ANSWER: A Explanation: - Giving out information over the phone to an unknown person is in violation of HIPPA regulations - The nurse should politely inform the person that the patient's privacy must be maintained

A nurse is preparing to administer I.V. fluids that raise serum osmolarity and pull fluid into the intravascular space. Which fluid should the nurse administer? A) Hypertonic B) Hypotonic C) Isotonic D) Supratonic

ANSWER: A Explanation: - Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity and pull fluid into the vascular space by diffusion (due to the concentration gradient) - Isotonic solution has equal osmolarity compared to serum. This would not create a concentration gradient and not pull fluids into or out of the vascular space - Hypotonic solution contains less solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity and pull fluid out of the vascular space by diffusion (due to the concentration gradient) - Supertonic solution does not exist

A 23-year-old patient sustained a cervical spinal cord injury from a motorcycle accident. A tracheostomy is made to facilitate long-term ventilation. In performing tracheostomy care, the nurse would take the highest consideration on which of the following? A) Deflate the cuff prior to meals B) Secure the tracheostomy ties tightly to prevent slippage and loosening C) Suction only half the length of the tracheostomy tube D) The tracheostomy dressing should be changed every other day

ANSWER: A Explanation: - If the patient is allowed to eat, the cuff should be deflated prior to and 1 hour after meals to reduce the risk of aspiration - The full length of the tracheostomy tube should be suctioned to remove secretions and ensure a patent airway - Dressings are changed every day to prevent infection - Tracheostomy ties should not be too tight, this could cause pressure on the jugular veins

When administering lipid emulsions via piggyback to a patient requiring total parenteral nutrition, the nurse remembers to: A) Add the solution below the infusion filter B) Use an infusion filter C) Use polyethylene-lined tubing D) Use vented I.V. tubing

ANSWER: A Explanation: - Lipid emulsions should be administered below the infusion filter because lipids cannot pass through infusion filters without breaking down - Vented tubing is not needed for lipid emulsions - Special I.V. tubing is not needed

A physician orders morphine, 1 mL I.V., every 4 hours. Which of the following is true regarding this medication order? A) The dose should be clarified B) The frequency should be clarified C) The order is correctly written D) The route should be clarified

ANSWER: A Explanation: - Morphine should be ordered in milligrams because it is available in different concentrations. 1 mL could contain different amounts of the medication - The frequency and route are correctly written

A 19-year-old suicidal patient feel backward over a stair rail to the floor and is not breathing. After calling for assistance, the nurse should: A) Confirm pulselessness and start wth 30 chest compressions B) Determine absence of breathing and give 15 chest compressions C) Perform rescue breathing by doing a jaw thrust maneuver and administer two breaths D) Perform rescue breathing by doing chin tilt maneuver and administer two breaths

ANSWER: A Explanation: - New BLS guidelines emphasize C-A-B (compressions, airway, breathing). Early chest compressions provide perfusion to vital organs until defibrillation can be provided - With a suspected spinal cord injury, do not hyperextend the neck to open the airway, use th jaw thrust maneuver instead - Immobilize the patient in the position found until further medial help arrives

A patient complains of chest pain and diaphoresis. The nurse administers oxygen and a nitroglycerin tablet, as ordered by the physician. The nurse then continues her routine without notifying the physician of the patient's condition. The patient then suffers from a myocardial infarction, leaving the nurse liable for which charge? A) Failure to assess, monitor, and communicate B) Failure to consult C) Failure to protect from harm D) Failure to react in a timely manner

ANSWER: A Explanation: - Nurses have a duty to communicate with the physician if the patient's situation changes. In this case, the nurse failed to communicate the patient's chest pain with the physician and the patient suffered a negative outcome as a result - This failure has resulted in negligence, or the failure to exercise the care that a reasonably prudent person would in similar circumstances - Protect from harm requires the nurse to protect patients in a vulnerable state that cannot distinguish harmful situations from harmless - Failure to react and failure to consult are made-up terms

During a disaster, the charge nurse must make room for multiple admissions by discharging patients that are ready. After the nurse selects potential patients for discharge, what should she do next? A) Assess each patient, then contact the physician and ask for discharge orders B) Call the physician and request his presence C) Contact the physician and obtain discharge orders D) Immediately start discharging the stable patient

ANSWER: A Explanation: - Once the nurse has identified potential discharges, she must then assess the patients to confirm readiness for discharge. The physician can then be notified - The nurse cannot discharge patients without physician orders - During a disaster situation, there is no time to wait for the physician to come and assess the patients

Which of the following tasks can be delegated to a nursing assistant? A) Ambulating a stable patient B) Irrigating a nasogastric tube C) Nasotracheal suctioning of a stable patient D) Setting up patient-controlled analgesia

ANSWER: A Explanation: - The nurse can safely delegate the ambulation of a stable patient to the nursing assistant - Irrigating a nasogastric tube, nasotracheal suctioning, and patient-controlled analgesia cannot be safely delegate to a nursing assistant

A nurse has been informed by the charge nurse that she will be getting a new admission from the emergency room. The nurse is already caring for 5 patients, one who had surgery 3 hours ago and another patient going to surgery later today. What should the nurse do to best manage her assignment? A) Advocate to the charge nurse that additional staff is required to ensure patient safety B) Ask the nursing assistant to take over the care of one of the patients C) Call the physician and ask that the patient be sent to a different unit D) Refuse to accept anymore patients

ANSWER: A Explanation: - The nurse should advocate for patient safety when patient census is too high for adequate nursing care - The nurse cannot refuse to admit a sick patient - Taking over the care of a patient is out of the scope of practice of a nursing assistant - The nurse should not request that the physician sends the patient to a different floor because the patient has specific needs that require properly trained nurses

After administering a subcutaneous injection, the nurse should: A) Discard the uncapped needle into a sharps container B) Recap the needle and discard it into a sharps container C) Recap the needle and discard it into the trash D) Recap the needle and save it for the next administration

ANSWER: A Explanation: - The nurse should never recap a used needle to protect from accidental needle sticks. A sharps container should be used for all needles to protect the hospital staff from accidental needle sticks - The nurse should never reuse a needle for multiple administrations

A patient is prescribed vitamin K, 5 mg IM. Which of the following factors affects drug absorption when using the intramuscular route? A) Blood flow B) Fat tissue C) Muscle strength D) Subcutaneous tissue thickness

ANSWER: A Explanation: - The primary determinant of IM drug absorption is blood flow to the insertion site - Fat and subcutaneous tissue do not affect absorption because the medication should be administered into the muscle tissue - Muscle strength does not affect medication absorption

The nurse enters a patient's room and finds her in the bathroom with lacerations to the wrists. The patient is surrounded by broken glass and blood and appears calm. What should the nurse do next? A) Call for help and then, in a calm voice, ask the patient to walk with the nurse to the treatment room B) Call for help, because the patient may need to be restrained C) Kneel at her side to assess her injuries D) Move the glass away from the patient to provide a safe environment

ANSWER: A Explanation: - The safety of the nurses and patient is the first priority. The patient cannot be safely assessed in this situation. Remaining calm, the nurse should call for help and then request that the patient leave the area to move to a treatment room to be assessed. If she does not agree, another staff person can provide assistance by removing the broken glass, but only after the first nurse confirms that the patient is not a threat to the staff Incorrect options: - Restraining the patient before assessing her is not appropriate - Going to the patient's side to assess her is unwise. The patient may be frightened or defensive, and my have broken glass in her hand that could be used as a weapon - Moving the glass should be done only after the nurse confirms that the environment is safe

When administering a heparin injection, the nurse minimizes pain by choosing what insertion site? A) Lateral abdomen B) Medial abdomen C) Posterior upper arm D) Superior buttocks

ANSWER: A Explanation: - To minimize pain for the patient, administer a heparin injection on the right or left side of the abdomen, at least 2 inches from the umbilicus

The nurse is preparing to administer one unit of packed red blood cells. The nurse should include which of the following interventions? A) Administer the infusion through a 20G I.V. catheter or larger B) Administer the infusion through a 24G I.V. catheter C) Initiate an infusion of 5% dextrose in normal saline before starting the blood D) Stay with the patient for 5 minutes after initiating the infusion

ANSWER: A Explanation: - When administering blood products, the nurse should use a 20G catheter or larger to prevent hemolysis - Normal saline is the only fluid compatible with blood products - The nurse should stay with the patient for the first 20 minutes because this is the time hemolytic reactions are most likely to occur

A medical-surgical unit is implementing a floor stock system for medications. Which of the following is an advantage of a floor stock system? A) Can administer new medications orders more quickly B) Minimizes telephone order errors C) Quick pharmacist input D) Reduces calculation errors

ANSWER: A Explanation: - With a floor stock system, the nurse has immediate access to medications and can therefore administer new medication orders quickly - The floor stock system does not provide pharmacist input quickly, nor does it reduce errors from calculations, transcriptions, or telephone orders

After a fire has erupted in a patient's room, the nurse rescues the patients in the immediate area. What should the nurse do next? A) Activate the fire alarm B) Close all doors and windows C) Evacuate the building D) Extinguish the fire

ANSWER: A Explanation: R.A.C.E. - Rescue patients in immediate danger - Alarm - Confine the fire - Extinguish the fire if small or Evacuate if the fire is too large

A newly diagnosed diabetic asks the nurse how much a unit of insulin is equal to. The nurse responds by explaining that a unit of insulin: A) Is a measure of effect, not a measure of weight, volume, or mass B) Is a measure of volume in the imperial system C) Is a measure of volume in the metric system D) Is a measure of weight in the metric system

ANSWER: A Explanation: - A unit is a measure of effect, not a measure of volume or weight such as grams. Units can be used for many different drugs, but they have no relationship to each other in quantity (one unit of insulin is not the same weight or volume as one unit of heparin)

A nursing student is preparing a IM injection and asks her preceptor what gauge of needle to use. The preceptor replies: A) 22 gauge B) 27 gauge C) 28 gauge D) 29 gauge

ANSWER: A Explanation: - Many intramuscular injections are a thick oil-base. IM injections should be administered using a 18-25 gauge needle

Due to an outbreak of E. coli in the community, a public health nurse instructs parents about measures to prevent further occurrence, which should include: (Select all that apply) A) Avoid swimming in standing water B) Cooking all meat thoroughly C) Drinking purified water D) Sanitizing kitchen surfaces twice daily

ANSWER: A, B, C Explanation: - E. coli originates in the intestinal tract of animals. It can grow in meat that is half-cooked. Parents should be aware of the health hazards associated with not cooking meats thoroughly - Drinking bottled water will help prevent the outbreak of E. coli from contaminated water - Although E. coli can spread to the surfaces from raw meat, cleaning these surfaces twice a day is not necessary - Swimming in any non-treated water can increase the risk of E. coli transmission, including standing water and running water

While preparing to administer medication, the nurse safely verifies the patient's identity by: (Select all that apply) A) Asking the parent or legal guardian to identify the patient B) Asking the patient her name C) Asking the patient's date of birth D) Checking the identification band E) Checking the patient's room number

ANSWER: A, B, C, D Explanation: - Checking the patient's identification band is the safest option because the identification band is placed on the patient's limb during admission and should not removed. Most State regulations make ID bands a requirement for short-term care - When the patient is a minor, asking the parent or legal guardian to identify the patient is acceptable in addition to comparing the ID band with the medical information record - Nursing homes are not required by law to use ID bands, but must have in place procedures for patient identification - Nurses must check at least two identification methods, which may include verifying the date of birth or confirming the patient's name. The patient's room is not an acceptable way of confirming patient identity

A living will includes which of the following information? (Select all that apply) A) Documentation requirements B) How and when the living will takes effect C) How the patient's valuables are distributed among the family D) Immunity from liability for following the living will E) Which family member will inherit the patient's home

ANSWER: A, B, D Explanation: - The living will includes what circumstances are needed for the living will to be executed, documentation requirements, health care worker immunity from liability, & witness requirements - Distribution of the patient's possessions is not included in the living will

A nurse documenting the intake and output of her patients, The nurse would consider which of the following insensible fluid loss? (Select all that apply) A) Expired air B) Liquid stool C) Sweat D) Urine output E) Wound drainage

ANSWER: A, C Explanation: - Insensible fluid loss occurs throughout the day without our awareness. This includes fluid loss through the skin and lungs - Sensible fluid loss is fluid loss that we are aware of, such as urination, GI tract loss, and would drainage

The nurse is assessing her patient for pain. The nurse recognizes the pain as chronic because of the presence of: (Select all that apply) A) Decreased concentration B) Diaphoresis C) Poor sleep and chronic fatigue D) Social withdrawal E) Tachycardia

ANSWER: A, C, D Explanation: - Acute pain is often accompanied by tachycardia, increased or decreased blood pressure, diaphoresis, tachypnea, and focusing on the pain - Chronic pain is often accompanied by depression, social withdrawal, change in appetite, restricted activity, decreased concentration, and poor sleep

When a small fire is discovered on the unit, the nurse rescues any patients in immediate danger and activates the alarm. What actions does the nurse perform next? A) Close all doors B) Evacuate the building C) Extinguish the fire D) Keep clients and visitors inside rooms E) Turn off the unit oxygen gas valve

ANSWER: A, D, E Explanation: - According to the RACE mnemonic, after the nurse rescues clients in immediate danger and activates the alarm, the nurse should ensure client safety and confine the fire by closing all doors, keeping clients in rooms, and turning off any main oxygen valves. This limits fire spread - If you are involved in a fire, remember R.A.C.E. to help you respond safely and correctly - R = RESCUE anyone in immediate danger from the fire if it does not endanger your life - A = ALARM: activate a pull station alarm box - C = CONFINE the fire by closing all doors and windows and shutting off main oxygen gas supply. Provisions should be made to supply clients with portable oxygen when needed - E = EXTINGUISH the fire with a fire extinguisher, or EVACUATE the area if the fire is too large for a fire extinguisher - If you have to escape through smoke, crawl on your hands and knees where air will be cleaner. Test all doors in our escape path for heat prior to opening them. Always test doors with the back of your hand - To use fire extinguishers correct, remember the P.A.S.S. acronym: P = PULL the pin on the fire extinguisher A = AIM the extinguisher nozzle at the base of the fire S = SQUEEZE or press the handle S = SWEEP from side to side until the fire appears to be out

The nurse is preparing to administer potassium chloride, 20 mEq in 100 ml solution over 2 hours. The I.V. tubing has a drop factor of 15 get/ml. What is the drip rate? A) 10 gtt/minute B) 13 gtt/minute C) 15 gtt/minute D) 20 gtt/minute

ANSWER: B Explanation: - 100 ml/120 minutes x 15 gtt/ml = 12.5 gtt/minute. A half drip is impossible, so rounded up, the answer is 13 gtt/minute

The physician orders morphine sulfate, 4 mg I.V., for a patient with post operative pain. The vial concentration is 10 mg/ml. What is the correct volume to administer? A) 0.04 ml B) 0.4 ml C) 1 ml D) 4 ml

ANSWER: B Explanation: - 4mg/x = 10mg/1 ml - x = 4mg/10mg = 0.4 ml

A nurse is preparing a blood transfusion for an anemic toddler. Which of the following blood transfusion matches would cause a hemolytic reaction? A) A-negative blood to an A-positive patient B) A-positive blood to an AB-negative patient C) B-positive blood to a B-positive patient D) O-negative blood to a B-negative patient

ANSWER: B Explanation: - A hemolytic reaction occurs with a Rh or ABO compatibility - The Rhesus factor is the presence of proteins on the cell, which is what the body reacts to. Rh negative blood can donate to Rh positive blood if it's the same type, because there are no proteins - O-negative is the universal donor, because it does not have A or B properties, and A and B blood types do not have O antibodies - AB patients can receive both A & B blood types, as long as there is a Rh compatibility

A patient has been diagnosed with renal failure and has spent the last week in the hospital. The patient's employer calls the unit and asks for the patient's diagnosis for insurance purposes. How can the nurse best respond? A) "He has kidney disease" B) "I cannot give out information regarding any patient" C) "Of course! Insurance companies can be such a pain!" D) "Please submit your request in writing"

ANSWER: B Explanation: - A nurse cannot release any information to unauthorized people. - The request does not need to bee submitted in writing, the patient needs to authorize the release of information or tell the employer himself.

Which of the following is the best example of a patient-centered goal? A) Eat sufficient amounts of food B) Get out of bed, walk to the nurses station and back to bed before Monday C) Self administer I.V. medication D) Walk up and down the hallway

ANSWER: B Explanation: - A patient-centered goal needs to be SMART (Specific, Measurable, Attainable, Reasonable, and Time-oriented) - Walking around the hospital is not specific enough or measurable - Eating a sufficient amount of food is not specific enough - Self-administering I.V. medications is not appropriate or attainable

A nurse administering blood products should keep the infusion time under: A) 2 hours B) 4 hours C) 6 hours D) 8 hours

ANSWER: B Explanation: - Blood transfusions should not last longer than 4 hours due to the increased risk of sepsis - Infusing blood products under 2 hours may be too fast for patients with cardiovascular compromise due to the risk of fluid overload

A physician not involved in the patient's care asks to see the results of his HbA1C. How should the nurse respond? A) "Ask the clerk for that information" B) "I can't give you that information." C) "It is 8.5" D) "You can look it up in the computer."

ANSWER: B Explanation: - HIPPA regulations prohibit those not directly involved in patient care from accessing patient information.

The nurse is caring for a patient with a chest tube. During her rounds, the nurse considers that the chest tube is working properly if she observes: A) Continuous bubbling in the water-seal chamber B) Intermittent bubbling in the water-seal chamber C) No bubbling appears in the suction chamber D) Tidaling is absent in the water-seal chamber

ANSWER: B Explanation: - Intermittent bubbling is expected in the water-seal chamber. If bubbling is increased or becomes rapid, it may indicate an air leak in the closed drainage system. Rapid bubbling may also indicate a considerable loss of air due to a tear or incision in the pleura - Fluid in the water-seal chamber must fluctuate during respiration. This is called tidaling. When tidaling stops, the chest tube might be kinked or obstructed. - Fluid in the suction chamber should bubble gently. If there is no bubbling, check to see if the suction tubing is connected and the suction source turned on.

After shift change on a cardiovascular unit, the new nurse is looking over her assignments to determine the order in which they should be assessed. Which patients should be assessed last? A) A new post-op patient B) A patient with chronic knee pain C) A patient with difficulty breathing D) A patient with new onset chest pain

ANSWER: B Explanation: - Knee pain known to be chronic is not urgent or emergent - Post-op patients require more frequent monitoring and care - The remaining two answer choices describe potentially life threatening situations

A newly diagnosed type 1 diabetic requires education on insulin administration. Why should the nurse instruct the patient to rotate insulin injection sites? A) To improve drug distribution B) To prevent lipodystrophy C) To prevent pain D) To reduce drug duration

ANSWER: B Explanation: - Lipodystrophy can cause unpredictable insulin absorption. It can be avoided by rotating injection sites - Lipodystrophy occurs when the body continuously pulls insulin from the subcutaneous fat causing an atrophy of the fat at the injection site. This creates divots in the skin which are irreversible - Rotating injection sites does not change drug duration or distribution, and it will not prevent pain

Who is authorized to give consent for a 5-year-old in forster care? A) The court B) The foster parent C) The primary nurse D) The social worker

ANSWER: B Explanation: - Parents or legal guardians are authorized to give consent or a child. Foster parents are considered legal guardians

A 59-year-old female is complaining that she lacks enough sleep ever since she got admitted to the hospital. The nurse notes that the patient is restless, frequently yawns and has teary eyes. In order to promote rest and sleep, the nurse will: A) Cluster activities during the daytime to limit patient interaction at night time B) Talk and plan with the patient about the nursing care to be done at night and schedule it C) Tell the patient that the hospital routine may disrupt her sleeping patterns, but should not be worried since sleep medications will be provided D) Tell the patient that this is a normal experience in the hospital

ANSWER: B Explanation: - Planned and scheduled nursing care minimizes interruptions during hours of sleep - Although it is true that most patients experience sleep pattern disturbance while in the hospital, it is still important to discuss and plan activities to promote rest and sleep - Sleep medications can be given as per patient's request but may have side effects - Clustering nursing care activities does not promote relaxation

A patient with a potassium level of 2.9 mEq/L is prescribed potassium chloride, 40 mEq I.V. The patient only has a peripheral I.V. The nurse should administer this medication: A) In the central venous line only B) Over 4 hours C) Over 5 minutes D) With I.V. lidocaine to reduce irritation

ANSWER: B Explanation: - Potassium chloride should be administered at a rate of 10 mEq per hour when using a peripheral I.V. (20 mEq per hour with a central line) to reduce injection site irritation - Potassium administered at a rate exceeding 40 mEq per hour may result in lethal arrhythmias - Central venous access is not needed, but preferred - Lidocaine should only be given I.V. to treat lethal ventricular arrhythmias

A patient with a nasogastric (NG) tube has medications ordered in tablet form. How should the nurse administer the medications? A) Contact the pharmacy and request a liquid form B) Crush the tablets, dissolve them in water, then administer through the NG tube C) Cut the tablet in half and administer them through the NG tube D) Liquefy the tablets by heating them

ANSWER: B Explanation: - Tablets (except for extended/sustained release) can be crushed and mixed with water in order to be administered through an NG tube - Requesting a liquid form is not necessary - Cutting the tablets in half will clog the NG tube - Heating the medication may alter its action

While working on pediatric-oncology unit, a nurse notices the nursing assistant is slurring her words and smells of alcohol. After confronting the nursing assistant, she promises to never do it again and asks the nurse to keep it a secret. What should the nurse do next? A) Assign the nursing assistant to non-patient care, such as paper work or stocking supplies B) Report the incident to the supervisor C) Send the nursing assistant home for the day and tell the staff she wasn't feeling well D) Take the nursing assistant to the emergency department to be treated for alcohol overdose

ANSWER: B Explanation: - The nurse should report the nursing assistant to the supervisor immediately. An intoxicated employee can be a danger to both the patients and the staff - The nursing assistant is not in critical condition and does not need to be treated for alcohol overdose - Although sending the nursing assistant home is appropriate, lying about the situation is inappropriate and dangerous - Intoxicated staff members should not remain at work, even doing non-patient care

A patient with severe metabolic abnormalities is prescribed a peripherally inserted central catheter (PICC). The nurse tells the patient that an informed consent is required. The patient asks why a consent is needed. The best response is: A) "The Joint Commission requires it" B) "The consent ensures that you make an informed decision based on the indications, risks, and alternatives" C) "We need consent unless it is an emergency" D) "You need to understand how dangerous this procedure is"

ANSWER: B Explanation: - This answers the patient's question accurate and appropriately - "The Joint Commission requires it" does not give any explanation of JCAHO requirements - "We ned consent unless it is an emergency" does not answer the patient's question - "You need to understand how dangerous this procedure is" is an inaccurate statement

A physician order reads "furosemide, 40 mg intravenously daily, times 4 days" Which type of medication order is this? A) Protocol order B) Standard written order C) Standing order D) Stat order

ANSWER: B Explanation: - This is a standard written order Incorrect options: - A stat order is given immediately during an urgent situation, and it might say, "Ativan 2 mg IM, for agitation, times 1 does, NOW" - A standing order, or protocol, establishes guidelines for administering medications for a set of symptoms of diseases

A nurse is caring for a patient using guided imagery to help relieve pain. The patient rates his pain a 2, down from a 6. Which of the following best describes guided imagery? A) Closure of the eyes and focusing on respiration B) Focusing on a relaxing mental picture C) Repetition of a single word D) Taking slow, deep breaths

ANSWER: B Explanation: - Using mental images, both pleasant and relaxing, can be used to reduce stress, anxiety, and pain - The other options describe forms of meditation

When preparing an I.V. medication from an ampule, the nurse should remember to: A) Never hold the ampule upside down B) Place the gauze around the neck of the ampule C) Snap the ampule neck toward your body D) Wipe the ampule with an alcohol swab

ANSWER: B Explanation: - When preparing medication from an ampule, the nurse should place a glaze around the neck to protect her hands from broken glass - Wiping the ampule with an alcohol swab is unnecessary because the needle should never touch the outside of the ampule - After removing the neck of the ampule, the nurse can draw up the medication with the ampule upside down without spilling the medication

A patient has had a DNR order for several years, but is now re-thinking this. The patient asks the nurse if he can change his DNR order, so all appropriate measures will be done to save his life. Which of the following responses is correct? A) "Are you sure about this?" B) "It is too late. Once you are DNR, you cannot change it" C) "Not a problem, I will contact your physician immediately" D) "You will have to ask the physician tomorrow during morning rounds"

ANSWER: C Explanation: - A patient can change their code status at anytime - Waiting until the next day to talk to the physician could have negative consequences. The physician needs to be notified as soon as possible - Questioning the patient's decision can damage the nurse-patient relationship making the patient defensive towards the nurse

A 91-year-old patent with end stage renal failure is refusing to take his medications because of the side effects and lack of effectiveness. How should the nurse respond? A) "Don't be difficult, these medications will help you" B) "Legally, you have to take these medications. Would you like to discuss your feelings?" C) "You have the right to refuse any of your medications. Would you like to talk about why you don't want to take the mediations?" D) "You have to take the medications, the physician ordered them"

ANSWER: C Explanation: - A patient has the legal right to refuse any treatment or medication. The nurse should respect the patient's decision and encourage the patient to explore his feelings and emotions - "Don't be difficult" is incorrect because the nurse is not respecting the patient's decision, and this statement may cause the patient to become defensive towards the nurse

A nurse is caring for a group of patients requiring I.V. medication administration. Which of the following patients is most suitable for a central venous catheter? A) Patient receiving blood products B) Patient receiving potassium chloride C) Patient receiving total parenteral nutrition D) Patient receiving vasopressors

ANSWER: C Explanation: - A patient receiving total parenteral nutrition requires a central venous catheter. Peripheral venous catheters can only infuse fluids with less than 10% dextrose - Patients receiving blood products do not require central venous access - Although central venous access is preferred for the administration of vasopressors and potassium chloride, a peripheral catheter is acceptable

Four patients all require the attention of the nurse. Who should the nurse see first? A) A 12-year-old with asthma asking to ablate B) A 15-year-old post-op patient complaining of continuous, achy pain C) A 16-year-old with a pneumothorax complaining of shortness of breath D) An 8-year-old waiting to be discharged

ANSWER: C Explanation: - A patient with a pneumothorax that is experiencing shortness of breath needs immediate attention to prevent respiratory failure or other negative outcomes - A patient waiting to be discharged is stable and a low priority - Post surgical pain is expected and not an emergency - Ambulation should be encouraged, but it is not an urgent need

A patient suffering from respiratory failure requires mechanical ventilation. The physician has ordered the patient to be restrained. Which type of restraint is most appropriate in this situation? A) Four-point B) Shackles C) Soft limb D) Vest

ANSWER: C Explanation: - A soft limb restraint can be applied to the patient's wrists to prevent pulling at the endotracheal tube while maintaining patient safety and preventing skin breakdown - Four-point restraints should be reserved for patients with a psychiatric illness or altered mental status that pose a risk to themselves or staff members. The use of four-point restraints should be reserved for only extreme situations - A vest restraint is used to keep a patient in bed - Shackles are metal and used for prisoners

"Acetaminophen 650 mg, PO, q4h, for temperature greater than 101.5" is which type of medication order? A) PRN order B) Standard order C) Standing order D) Stat order

ANSWER: C Explanation: - A standing order, or protocol, establishes guidelines for administering medications in specific situations with specific criteria - Standard orders are for routine and scheduled mediations - Stat orders should be initiated immediately for urgent problems - PRN, or as-needed, ordered are prescribed for a specific patient need and are administered based on the nurse's judgement

The nurse is preparing to administer a subcutaneous heparin injection. At what angle should the nurse insert the needle? A) 15 degrees B) 30 degrees C) 45 degrees D) 60 degrees

ANSWER: C Explanation: - A subcutaneous injection should be given at a 45 or 90 degree angle - IM injections should be administered at a 90 degree angle using a quick motion - An intradermal injection should be given at a 15 degree angle

A nurse is performing wound care on a 3-day post-operative patient who has undergone exploratory laparotomy with vertical abdominal incision. Which of the following would indicate that the nurse is cleansing the operative site correctly? A) The nurse cleanses from the center of the incision going laterally B) The nurse cleanses from the outer portion of the incision going inward C) The nurse cleanses the incision from top to bottom and then laterally from the center out D) The nurse cleanses the incision in circular motion

ANSWER: C Explanation: - Always wipe from the cleanest area to the least cleanest area. In vertical wounds, this is usually from top to bottom and then laterally from the center out. An exploratory laparotomy involves vertical midline incision into the abdomen - Horizontal woulds must be cleansed from the center of the incision going outward - Stab or drain wounds must be cleansed in circular motion

A nurse is preparing to administer bedtime medication to a patient. She finds a filled, unlabeled syringe in the patient's room. What action is most appropriate? A) Administer the medication B) Call the previous nurse to verify the medication C) Discard the syringe in a sharps container D) Label the medication

ANSWER: C Explanation: - Any unlabeled medication should be discarded to avoid medication errors - The other three options are unsafe and should be avoided

Susan is determining whether her patient has achieved the goals laid out in the care plan. What step of the nursing process is this? A) Analysis B) Assessment C) Evaluation D) Planning

ANSWER: C Explanation: - During the Evaluation step, the nurse assesses the effectiveness of the care plan - The nurse develops strategies to decrease or resolve the patient's problems during the Planning step - During the Assessment step, the nurse collects data about the patient and the family - During the Analysis step, the nurse identifies a patient's responses to actual or potential health problems

An elderly woman is admitted to the hospital after several adverse reactions to her medications. This patient may benefit from: A) Additional medications to reduce adverse effects B) Longer administration intervals with increased dosages C) Smaller dosages D) Weekly visits to the physician

ANSWER: C Explanation: - Elderly patients often have reduced hepatic and renal function. This can result in elevated blood levels and increased side effects. The patient would benefit from a decrease in her dosage - Increased dosage with longer intervals could increase amount of side effects - Weekly visits to the physician would not change the patient's drug reactions - Adding additional medications would further complicate the situation and not fix the underlying problem

When administering an IM injection to an adult, the nurse ensures proper insertion depth by choosing a needle length of: A) 0.5-1 inch B) 0.75-1.25 inches C) 1-1.5 inches D) 1.5-2 inches

ANSWER: C Explanation: - For IM injections: Adult, 1-1.5 inches Children, 0.5-1 inches

While caring for a stable infant, the physician writes an order to start an I.V. infusion at 400 ml/hr. The nurse should question this order because infants are at risk for: A) Arrhythmias B) Deep vein thrombosis C) Fluid overload D) Sinusitis

ANSWER: C Explanation: - Infants are at particular risk for fluid overload because of their size. Initiating an I.V. infusion at 400 ml/hr on a stable infant should be questioned - Arrhythmias, deep vein thrombosis, and sinusitis are not risks associated with I.V. fluid administration

A nurse is preparing to administer a lipid emulsion to a patient requiring total parenteral nutrition. Which of the following fatty acids is present in lipid emulsions? A) Arachidonic acid B) Elaidic acid C) Linoleic acid D) Oleic acid

ANSWER: C Explanation: - Linoleic acid is an omega-6 essential fatty acid. A patient deficient in linoleic acid will be immunosuppressed and at risk for infection - Arachidonic acid, oleic acid, and elaidic acid are nonessential fatty acids and are not found in lipid emulsions

Of the following during diagnoses, which is most appropriate for the care plan of a patent having trouble remembering to take all of his medications? A) Anxiety B) Loss of hope C) Noncompliance D) Risk of self harm

ANSWER: C Explanation: - Noncompliance is a common nursing diagnosis used to manage a patient's drug regimen. Noncompliance can be related to many things, including the complexity, cost, duration, values, access, and knowledge - The nurse may list other diagnoses, depending on the risks or side effects of the medications and the patient's comorbidities - Anxiety, risk of self harm, and loss of hope are not appropriate nursing diagnosis

The nurse administers a PPD test to a co-worker. The nurse will read the test at: A) 12-24 hours B) 24-48 hours C) 48-72 hours D) 72-96 hours

ANSWER: C Explanation: - PPD (Purified protein derivative) or tuberculosis skin tests should be read 48 to 72 hours after administration

A patient refuses chemotherapy based on religious beliefs. The hospital staff must follow his decision based on which patient right? A) The right to counsel B) The right to informed consent C) The right to refuse treatment D) The right to suffer

ANSWER: C Explanation: - Patients have the right to refuse any treatment as long as he/she is competent and aware of the risks - The right to informed consent does not apply since the patient is not consenting to anything - The right to counsel is a legal term with no association with health care

Before administering medications, the nurse should assess the kidney and liver function of which of the following populations? A) Adolescents B) Newborns C) Premature neonates D) School-aged children

ANSWER: C Explanation: - Premature neonates may have suboptimal growth and maturation of the kidneys and liver, therefore, their ability to metabolize drugs may be altered

Which of the following is appropriate documentation by the nurse? A) Client does not like the previous nurse and does not want to stay in the hospital B) Client had a terrible night, client is feeling worse today and requests the IV be removed C) Left lower lobe has course crackles, right lobe clear to auscultation, client reports cough is removed D) Pressure ulcer noted posteriorly, draining serosanguinous fluid

ANSWER: C Explanation: - Proper documentation criteria includes descriptions, such as objective findings that are smelled, seen, felt, or heard. Subjective information including symptoms and response to therapies may include statements made by the client which should be recorded using exact words with the use of quotations when appropriate. Changes should be noted and documentation should be sequential and organized - Pressure ulcer documentation should include type, depth, size (length and width), location, stage, exudates, and other objective descriptors-including client report of pain if present - Documentation should relate to the care of the client, be factual and specific, and avoid judgments and interpretations. Drawing conclusions about the client's feelings or thoughts is not appropriate documentation. Documenting the client's feelings about staff or roommates is not appropriate and does not contribute to documenting this client's care - Documenting that the client had a terrible night is not precise. The client's report should prompt the nurse to perform a focused interview for further information. It would be more appropriate to document the number of hours a patient appeared to be awake or a patient's complaint of insomnia

A hospital nurse discovers a fire in a patient room. After rescuing the patient and pulling the fire alarm, the nurse attempts to control the spread of the fire using an extinguisher. Which type of prevention is this? A) Primary prevention B) Quaternary prevention C) Secondary prevention D) Tertiary prevention

ANSWER: C Explanation: - Secondary prevention consists of reducing the intensity and duration of the crisis, in this case, a fire - Primary prevention consists of preventing the disaster from happening - Tertiary prevention consists of reducing injury and damage after a crisis - Quaternary is not a type of prvention

The Client Self-Determination Act of 1990 requires all hospitals to do which of the following? A) Collect data on contagious diseases B) Collect data on patient falls C) Inform patients about advance directives D) Inform patients about medication side effects

ANSWER: C Explanation: - The Client Self-Determination Act of 1990 requires all hospitals to inform patients about advance directives

A nurse administers a medication to a patient with pneumonia. Which of the following is the nurse responsible for documenting? A) Onset of action B) Patient's opinion of medications C) Reaction to medication D) Therapeutic range of the medication

ANSWER: C Explanation: - The nurse is legally responsible for documenting the administration time, dose, and the patient's reaction (including effectiveness and any adverse reactions) - The nurse is not responsible for documenting the onset of action, the therapeutic range, or the patient's opinion on medications

A 79-year-old male patient has cancer with end-stage renal disease. Which of the following excludes the patient from qualifying for hospice? A) The patient has not completed a will B) The patient is prescribed narcotic pain medication C) The patient is trying a new cancer treatment still in clinical trials D) The patient prefers not to tell his family why he is going to hospice

ANSWER: C Explanation: - The patient's choice to continue treatment options excludes him from hospice - Pain medication is considered normal for hospice and palliative care - The other two options do not exclude the patient from hospice care

Who is responsible for obtaining informed consent from a patient? A) The charge nurse B) The pharmacist C) The physician D) The primary nurse

ANSWER: C Explanation: - The physician is responsible for obtaining the informed consent for a procedure or surgery after explaining the procedure, as well as the risks involved to the patient. It must be the physician involved in the procedure

When preparing a patent for surgery, the nurse learns that the patient stopped taking her blood pressure medication because it was too expensive. The nurse should collaborate with which health care team member to provide the patient with information and resources for lowering medication costs? A) Chaplain B) Respiratory therapist C) Social worker D) Vascular surgeon

ANSWER: C Explanation: - The social worker can find community resources to aid the patient in praying for her medication. Also, the social worker can contact pharmacies to find cheaper alternatives - The chaplain, vascular surgeon, and respiratory therapist are not trained to assist patients with medication costs

When assessing a patient for posture and appearance, the nurse recognizes that the patient is lying still and complaining of abdominal pain. Slight jarring of the bed causes agonizing pain. The nurse assesses that the origin of the pain my be: A) Biliary B) Meningeal C) Peritoneal D) Renal

ANSWER: C Explanation: - This pain may be of peritoneal origin. This is a well-localized pain that causes rigidity of the abdominal muscles where the pain increases with any pressure or motion - Pain of renal origin begin in the flank area and may radiate to the lower abdomen, back and groin - Pain of biliary origin is in the right upper quadrant and may radiate to the right shoulder - Pain of meningeal origin is associated with headache, nuchal rigidity, and photophobia. Pain is increased when the neck is flexed toward the chest

Which of the following nurse behaviors is inappropriate and should be reported to the nurse manager? A) The nurse helps the family find ways to be less dependent on the nursing staff B) The nurse informs the patient of ongoing changes in the care plan C) The nurse presents her own opinions to the patient in an attempt to influence the patient's decisions D) The nurse uses therapeutic communications when discussing the patient's needs

ANSWER: C Explanation: - This type of behavior constitutes over involvement and a non-therapeutic, inappropriate relationship with the patient and family - The there choices help empower the patient and family, and help to build a therapeutic relationship

A physician orders a blood transfusion for an anemic patient. Before transfusing the patient, the nurse should first: A) Ask the patient for their hospital number B) Initiate an infusion of normal saline C) Obtain a blood sample for typing and crossmatching D) Obtain the patient's vital signs

ANSWER: C Explanation: - To ensure compatibility between the patient and the donor blood, the patient's blood needs to be screened for typing and crossmatching - The other options should be done before transfusing, but typing and crossmatching should be done first

A nurse is caring for an 8-year-old with H.I.V. is having trouble reading the dosage on a medication order. What should the nurse do? A) Ask another nurse if they can read it B) Ask the patient what dose they normally take C) Call the physician to clarify the order D) Look up the dosage in a drug index

ANSWER: C Explanation: - To prevent medication errors, the physician should be contacted in order to clarify the correct dose - A drug index will give common doses or a range of doses, not the specific dose the physician wants - Asking the patient or another nurse could lead to potential errors

While preparing to administer a subcutaneous injection, the nurse disinfects the injection site and waits for how long before administering the injection? A) 1 minute B) 15 seconds C) 30 seconds D) 45 seconds

ANSWER: C Explanation: - Waiting 30 sends to allow the disinfectant to dry reduces tissue irritation, and is the current recommendation by the World Health Organization

A nurse is reviewing a physician order for a medication that she does not recognize. After the nurse looks up the medication in a drug reference with no success, what should she do next? A) Ask the patient if she knows the drug B) Call the physician, the order is probably written incorrectly C) Contact the pharmacist D) Give the medication

ANSWER: C Explanation: - A pharmacist is the most reliable source of information about medications - Do not call the physician until you can confirm the drug name is incorrect - Never ask the patient about the drug. The nurse will appear incompetent and unqualified - Never administer a medication you don't know

A nurse is assessing her patient and notices the wrong I.V. are infusing. What should the nurse do first? A) Change the fluids when the current bag is complete B) Stop the infusion and initiate the correct fluids C) Stop the infusion and notify the physician D) Write an incident report

ANSWER: C Explanation: - The nurse should notify the physician after stopping the wrong I.V. fluids. - The nurse should only change the I.V. fluids after contacting the physician - An incident report may be completed after the correct solution is initiated.

A nurse is preparing to administer intravenous morphine when she notices the patient's I.V. site is swollen and red. What should the nurse do next? A) Apply a cold compress B) Check for potency C) Discontinue the I.V. D) Notify the physician

ANSWER: C Explanation: - The patient's I.V. site is showing signs of infection and should be discontinued immediately. The nurse should then start a new I.V. in a different location - Notifying the physician is not needed. The nurse can discontinue an I.V. and start a new one without the approval of the physician - Checking for potency and applying a cold compress is not appropriate

A tracheostomy was inserted into a patient with COPD to relieve airway obstruction. The nurse knows that the patient is a risk for ineffective airway clearance if: A) The patient attempt to cough while covering the tracheostomy tube opening with clean gauze B) The patient has bronchovesicular lung sounds C) The patient has thick secretions D) The physician placed the patient's sedative drug on hold

ANSWER: C Explanation: - Thick secretions can impair the patient's ability to clear the airway, putting them at risk for hypoxia - Bronchovesicular lung sounds are normal when heard between the 1st and 2nd intercostal spaces - Removing sedation will increase the patient's alertness and his ability to clear secretions - Attempting to cough through the tracheostomy tube is beneficial and will help clear the lungs of secretions

A patient has an elevated serum osmolality and a serum sodium level of 159 mEq/L. The most beneficial I.V. fluid would be: A) Dextrose 10% in water (D10W) B) Dextrose 5% in Lactated Ringer's (D5LR) C) Dextrose 5% in normal saline (D5NS) D) Dextrose 5% in water (D5W)

ANSWER: D Explanation - The patient is in a hypertonic state and should not receive hypertonic fluid. D5W is the only isotonic fluid and is the correct choice - D5NS, D10W, and D5LR are all hypertonic fluids

A nursing student is preparing an I.V. injection from an ampule. The nurse preceptor reminds her to use a(n): A) 18 gauge needle B) 22 gauge needle C) Face mask D) Filter needle

ANSWER: D Explanation: - A filter needle is used when preparing medications from ampules to prevent glass from being drawn into the syringe - The needle gage is not important for this preparation, as you need a filter needle instead - A face mask is not needed

A nurse is monitoring a patient receiving one unit of packed red blood cells. The patient reports feeling chilly and new back and flank pain at a level of 6/10. How should the nurse respond? A) Administer diphenhydramine immediately B) Assess vital signs C) Decrease the transfusion flow rate D) Stop the blood and report the symptoms immediately

ANSWER: D Explanation: - Acute hemolytic transfusion reactions are commonly caused by an ABO incompatibility and can occur during the transfusion or within 24 hours after the infusion. The patient may report during at the IV site, chills, and pain in the back or flank. Fever, tachycardia, and/or tachypnea may also be noted - When symptoms of a reaction to a blood product transfusion are noted or reported, the nurse must first stop the transfusion and keep the vein open with a slow infusion or normal saline - The nurse should next report these symptoms tot he RN and/or provider immediately. The provider may have orders for medications to treat the symptoms. The Blood Bank will also be called to collect the blood bag and tubing so they can investigate the cause of the reaction - In an acute hemolytic reaction, incompatible RBCs with antigens from the wrong blood group are attacked and destroyed by antibodies in the patient's pasta, leading to widespread hemolysis. These antibodies activate complement and tissue factor is released by RBC debris, triggering the clotting cascade. Disseminated intravascular coagulation (DIC) results, causing shock, acute renal failure, and even death - In the case of an allergic reaction, Benadryl may be administered after stopping the transfusion and starting NS. Anaphylaxis is a life-threatening allergic reaction that ma occur after only a few milliliters of blood have been transfused. With this the of reaction, the patient reports difficulty breathing, wheezing, and coughing. There may be nausea and vomiting, but no fever. Other signs include low blood pressure, loss of consciousness, respiratory arrest, and circulatory shock. Urgent treatment is essential and may also include giving epinephrine - Assessing the vital signs is important, but in the event of reported or observed signs of a transfusion reaction, no further assessment is required before stopping the transfusion. After this is done, the symptoms can be reported and vital signs taken

A nurse is preparing an I.V. medication from a vial. After the nurse removes the cap from the unused vial, she should: A) Draw air into the syringe B) Insert the needle C) Put on gloves D) Wipe the vial top with an alcohol swab

ANSWER: D Explanation: - An unused vial with a cap is not guaranteed to be sterile. The nurse should wipe the top of the vial with an alcohol swab before inserting the needle

The nurse is discontinuing a central venous catheter. Which of the following steps should be taken? A) Elevate the head of bed B) Flush the catheter with heparin C) Instruct the patient to breath continuously D) Position patient in Trendelenburg's position

ANSWER: D Explanation: - Arterial air emboli are more dangerous than air in the venous system. Steps are taken to increase central venous pressure (CVP), which is normally lower in blood vessels that are above the level of the heart and also during inspiration. - The patient should be placed in the Trendelenburg position with a downward tilt of 10 to 30 degrees. This is to promote venous filling and raise CVP and ensure that the catheter exit site (e.g., neck, arm) is lower than the height of the patient's heart. If not possible, supine position is sufficient - Instruct the patient to hold his or her breath and perform a Valsalva maneuver (bear down) - Flushing the catheter with heparin prior to removal is unnecessary

A child with a recent kidney transplant has requested to have the same nurse everyday. Which of the following is the best response? A) "It is against hospital policy to assign the same nurse to you everyday" B) "It is important to have a variety of nurses to ensure the best possible care" C) "This will not work, we want to avoid over-involvement" D) "We will try to assign the same nurse to you, but the may be difficult on some days due to staffing issues"

ANSWER: D Explanation: - Assigning the same nurses to a patient should be encouraged. This will promote continuity of care and decrease patient anxiety - Having a variety of nurses does not ensure quality of care - Over-involvement should be considered when making patient assignments, but in this situation there is no evidence of over-involvement

After the insertion of a central venous catheter, the nurse should: A) Initiate fluid infusion B) Notify the physician C) Remove the guide wire D) Wait for x-ray confirmation of catheter placement

ANSWER: D Explanation: - Because central venous lines increase the risk of pneumothorax, a chest x-ray is needed to confirm catheter location and the absence of a pneumothorax - The nurse should not infuse I.V. fluids or medications or remove the guide wire until catheter location has been confirmed by x-ray - Notifying the physician is unnecessary

A nurse is preparing to administer a blood transfusion to an anemic patient. Which of the following interventions takes priority? A) Assess the vital signs once during the transfusion B) Document blood product administration in the patient's medical record C) Inform the patient of vital sign changes D) Instruct the patient to report swelling, lower back and flank pain, itching, or difficulty breathing

ANSWER: D Explanation: - Because of a potential life threatening reaction, the patient should first be instructed to report signs and symptoms of a blood transfusion reaction - Documenting the blood administration in the patients medical record is important, but this intervention is not critical to the patient's health - The nurse should assess the patient's vital signs at least every hour during blood transfusions

A nurse preceptor is teaching a student how to properly administer an extended relate tablet. Which of the following is true about extended-release tablets? A) They can be crushed and administered through a nasogastric tube B) They can be crushed and combined with applesauce C) They should never be administered whole D) They should never be crushed or chewed

ANSWER: D Explanation: - Crushing or chewing an extended release or sustained release tablet will alter its absorption, and increase the risk of adverse reactions

Based on Maslow's hierarchy of needs, which of the following should be the nurse's first priority? A) Administering a scheduled beta-blocker to a patient B) Allowing a patient's wife to visit him C) Providing emotional support to a family member D) Starting tube feeding on an unconscious patient

ANSWER: D Explanation: - Food is on the first level in Maslow's hierarchy of needs - Emotional support for a family member is level 4 (esteem) - Allowing the patient's wife to visit is level 3 (love/belonging) - Administering a scheduled beta blocker is lever 2 (safety, health)

While preparing to administer an IM injection, the nurse should choose which muscle? A) Latissimus dorsi B) Tibialis anterior C) Trapezius D) Vastus lateralis

ANSWER: D Explanation: - IM injection sites, in order of preference, are vests lateralis, deltoid, and ventrogluteal muscles - The dorsogluteal muscle is no longer recommended due to the location of the sciatic nerve

A child is admitted to the hospital with pneumonia. The nurse observes bruises on the child's back and arms. The mother is present in the patient's room. What should the nurse do next? A) Ask the mother if she is abusing her child B) Call the police C) Notify the physician of suspected child abuse D) When the mother leaves, ask the child if she feels scared or unsafe at home

ANSWER: D Explanation: - If the nurse suspects abuse, he or she should ask the patient if they feel safe at home - Asking the mother would be accusatory, and calling the police or physician before exploring the situation further would be inappropriate.

The nurse is providing a newly diagnosed diabetic with information about her new medication. The nurse is performing which nursing role? A) Delegation B) Mandatory reporter C) Patient advocate D) Patient educator

ANSWER: D Explanation: - In this scenario, the nurse is acting as a patient educator by instructing the patient on her new medications

A nurse gave the wrong patient a dose of Fentanyl. After assessing the patient, the nurse fills out an incident report. What is the purpose of an incident report? A) To be stored in the nurses file B) To discipline the nurse C) To notify the board of nursing D) To promote quality improvement

ANSWER: D Explanation: - Incident reports are used to evaluate quality of care, problems with policies or procedures, and to prevent further occurrences - Incident reports are for the facility's use only and are not sent to the board of nursing - Some hospitals track the number of incident reports in order to provide proper staff education

The physician orders guaifenesin, 3 teaspoons P.O. as needed. What is the conversion of 1 teaspoon to the metric system? A) 1 cc B) 15 ml C) 5 mg D) 5 ml

ANSWER: D Explanation: - One teaspoon is equal to 5 ml - Milligrams (mg) is a unit of mass, not volume - 1 ml is equal to 1 cc

The nurse is caring for an unconscious patent and must decide what is best for the patient. Which of the following principles is the nurse applying? A) Autonomy B) Good samaritan C) Justice D) Paternalism

ANSWER: D Explanation: - Paternalism is when health care professionals must decide what is best for the patient and act without consent. Paternalism takes place one in specific circumstances, such as the patient's loss of consciousness

A nursing student administers an I.V. medication but forgets to prime the syringe. The patient then becomes confused and pale. Suspecting an air embolus, what is the appropriate response? A) Place patient in high-Fowler's position B) Place patient in semi-Fowler's position C) Place patient in the supine position D) Place the patient on her left side, or in Trendelenburg's position

ANSWER: D Explanation: - Placing the patient on her left side of in Trendelenburg's position, will allow the air embolus to collect in the right atrium. This will prevent the air embolus from entering the pulmonary circulation. The two positions can be applied together, with the patient lying on her left side and her feet raised

Which of the following must the nurse document when administering medications? A) Drug metabolism B) Drug onset C) Patient's reaction to the drug D) Time of administration

ANSWER: D Explanation: - The nurse should document the medication time of administration and dose

When documenting in the patient's chart, the nurse should: A) Leave a line blank in between each line of writing B) Sign each entry with the nurse's initials C) Use a pencil, so the nurse can erase all errors D) Use an ink pen

ANSWER: D Explanation: - The patient's chart is legal document, so the nurse should use a pen with all documentation - Each entry should be signed with the nurse's full name and title - The nurse should not leave blank lines in the patient's medical record, as this could allow other healthcare workers to make additions - It is illegal to erase errors in a legal document, such as a medical record

A nurse discovers that she accidentally administered the wrong dose of medication. After assessment and confirmation that the patient is stable, what should she do next? A) Fill out an incident report B) Inform the patient C) Notify the charge nurse D) Notify the physician

ANSWER: D Explanation: - The physician is the only person that can fix the situation with additional orders. The nurse cannot give a reversal medication or provide other interventions that require a physician order - The nurse should also fill out an incident report after the situation is rectified, and inform the charge nurse - The nurse may inform the patient of the error, but this is not necessary

An elderly patient with respiratory failure informs the nurse that she does not want to be placed on a ventilator. What should the nurse do next? A) Consult with thee patient's family B) Have the patient sign a DNR form C) Notify the hospice team D) Notify the physician

ANSWER: D Explanation: - The physician must determine patient competency before a DNR or DNI form can be signed - A DNR order must be signed by the physician in order to make it valid - The patient's family may only be consulted with consent from the patient - The hospice team must be consulted by a physician order

A patient was recently admitted to hospice care for lung cancer. After filling out his advance directive, the patient feels the physician is uninterested in his care. Which of the following statements made by the nurse best addresses the patient's concerns about the advanced directive? A) "After you fill out an advanced directive, the physician plays a limited role to allow you space and time to be with your family." B) "Once you are admitted to hospice, the physician plays a passive role" C) "Your physician is required by law to help you, so don't worry" D) "Your physician will continue to take care o you. The advanced directive just states what type of care you want, so we can provide that care even when you cannot tell us to."

ANSWER: D Explanation: - This option provides correct information regarding the advance directive - All other option do not address the purpose of an advance directive or alleviate the patient's concerns.

A patient is receiving intravenous vancomycin. The physician wants to know the medication's effectiveness, so a trough drug level is ordered. The nurse should obtain the patient's blood sample: A) 1 hour before drug administration B) 2 hours before drug administration C) Immediately after drug administration D) Immediately before drug administration

ANSWER: D Explanation: - Vancomycin levels are monitored to maintain a therapeutic dose. A trough is measured during the drug's lowest level, immediately before the next administered dose - Obtaining a blood sample too early will not represent a trough - Obtaining a blood sample after administering the medication would measure the peak, not trough

When administering a subcutaneous injection of heparin, the nurse should use a: A) 18 gauge needle B) 20 gauge needle C) 22 gauge needle D) 25 gauge needle

ANSWER: D Explanation: - When administering a subcutaneous injection, the nurse should use a 25 or 27 gauge needle

While preparing to administer an intradermal injection, the nurse attaches the syringe to: A) 18 gauge needle B) 20 gauge needle C) 22 gauge needle D) 25 gauge needle

ANSWER: D Explanation: - When administering an intradermal injection, the nurse should use a short, 25 or 27 gauge needle

The nurse is caring for a patient with an infiltrated I.V. from normal saline. After the nurse removes the I.V., she expects the physician to order the application of: A) Alternate warm and cold compresses every 20 minutes B) Cold compress for 20 minutes C) Lidocaine D) Warm compress for 20 minutes

ANSWER: D Explanation: - When applied to the infiltrated area, warm compresses increase circulation, and absorption of fluid. To prevent injury to the skin, the warm compares should be removed after 20 minutes for a period of 15 minutes - Warm compresses have traditionally been used, as it increases circulation and vasodilation which will hep reabsorb the excess fluid. New research has shown mixed results. Some sources say that warm compresses should be used if the solution is isotonic with a normal pH or if the fluid infiltrated over a long period. Whereas cold compresses should be used if the infiltration is recent or if the solution is hypertonic - Lidocaine is not indicated for I.V. infiltration

A patient goes into cardiac arrest and the nurse initiates CPR. A second nurse responds to the call for help. What should the role of the second nurse be? A) Administer cardiac medications B) Apply the defibrillator pads C) Check the patient's advance directive D) Compressions or respiration

ANSWER: D Explanation: - When performing CPR with the two person technique, the American Heart Association recommends the two nurses switch off on compressions and breathing - The advance directive should be known prior to the initiation of CPR - Cardiac medication and the use of a defibrillator should be done soon after the onset of cardiac arrest, but quality chest compressions and airway management is the first step with the two person technique

A chest x-ray is ordered to confirm the placement of a central venous catheter. The tip of the catheter should be in the: A) Jugular vein B) Right ventricle C) Subclavian vein D) Superior vena cava

ANSWER: D Explanation: - When positioned properly, the tip of a central venous catheter should be in the superior vena cava. In a large lumen vein, blood can flow around the catheter without being impeded, allowing for infusion of large amounts of medication

The patient is scheduled for surgery later in the day. The surgeon is very busy with another surgery and asks the nurse to obtain informed consent. How should the nurse proceed? A) Ask the physician's assistant to obtain the consent B) Delegate the task to the charge nurse C) Explain the risks and alternatives of the surgery, and obtain written consent D) Inform the physician that he must legally obtain informed consent from the patient

ANSWER: D Explanation: - The physician involved in the surgery must explain the surgery to the patient and obtain written informed consent - A physician's assistant cannot obtain an informed consent, it must be the surgeon - RNs can only obtain informed consent if they have been specially trained to perform the procedure. Inserting a peripherally inserted central catheter (PICC) is an example of a situation where trained nurses obtain informed consent from the patient

Which of the following best describes the goal of discharge planning and education? A) Ensuring the patient's long-term dependence on the hospital B) Increasing the hospital stay to improve patient outcomes C) Preventing the need for primary care D) Teaching the patient how to care for themselves

ANSWER: D Explanation: - Teaching self-care aids in preparation for the patient's transition from the hospital setting to home or long-term care facility is beneficial because this can reduce the chance of re-admission - The patient needs primary care to reduce hospitalization and medical costs - Discharge planning and patient teaching should help the patient become less dependent on the hospital - Increasing hospital stays will increase costs and may negatively affect patient outcomes

A blind patient is scheduled for a prostatectomy and an informed consent is needed. The nurse should do which of the following when obtaining an informed consent from a patient who is legally blind? A) Ask the patient to thoroughly read the consent B) Get a verbal consent since a blind patient cannot sign a consent form C) Have a family member or friend sign the consent D) Read the consent aloud with an impartial witness present

ANSWER: D Explanation: - The consent from should be read aloud to a blind patient. The physician and the nurse should make sure the patient understands the procedure, its risks, and alternative treatments - With a blind patient, it is recommended that an impartial witness is present to observe the consent process or that a recording be made of the consent, but this is not required by law - The validity of consent does not depend on the form in which it was given, verbal or written. It depends on it being voluntary and being given by an informed person with the mental capacity to consent - A family member or friend should not sign the consent form unless the patient is unable - A blind patient cannot read a consent, but he can sign a consent

A 54-year-old male patient underwent a thoracotomy. A chest tube was placed to help drain the blood and fluid in the pleural space. The nurse expects the hourly drainage to be less than: A) 100 ml/hr B) 200 ml/hr C) 400 ml/hr D) 50 ml/hr

ANSWER: A Explanation: - Chest tube drainage greater than 100 ml/hr is considered excessive. As much as 500 to 1000 ml may be drained in the first 24 hours post chest surgery - If drainage is excessive, the physician should be notified as this may require additional interventions to determiine the cause

The nurse is administering hyrdomorphone, 1 mg PO, to a patient with moderate abdominal pain. The nurse can expect the patient's pain to improve after: A) 15-30 minutes B) 15-60 minutes C) 30-60 minutes D) 5-10 minutes

ANSWER: A Explanation: - Hydromorphone, when administered orally, has an onset of 15-30 minutes, a peak of 30-60 minutes, and duration of 2-3 hours

A 45-year-old has been put on the organ transplant waiting list. Which of the following is the most important factor for selecting donor-recipient match? A) Age and blood type B) Compatible tissue and blood type C) Compatible tissue, blood type, and gender D) Immediate need

ANSWER: B Explanation: - Compatible tissue and blood type is most important when matching a donor to a recipient - Age and size should be similar, but doesn't need to be exact - Gender is not relevant - Need is important, but is not the deciding factor

The nurse is administering an insulin injection. The nurse decides the best site for this type of injection is: A) Abdomen B) Anterior aspect of thighs C) Outer aspect of upper arms D) Superior buttocks

ANSWER: A Explanation: - Although all options are acceptable subcutaneous injection sites, injection into the abdomen has as much as 50 percent more absorption than the arm - The arm has better absorption than the thighs or buttocks

A nurse is administering PPD test to other healthcare workers. The nurse inserts the needle at what angle? A) 15 degrees B) 30 degrees C) 45 degrees D) 60 degrees

ANSWER: A Explanation: - An intradermal injection should be given at a 15 degree angle - A PPD test is a diagnostic test for tuberculosis - A subcutaneous injection should be given at 45 to 90 degree angle - IM injections should be administered at a 90 degree angle using a quick motion

A patient wishes to be DNR and not have heroic measures taken to save his life. Which of the following principles is the nurse upholding by supporting this decision? A) Autonomy B) Beneficence C) Justice D) Nonmaleficence

ANSWER: A Explanation: - Autonomy is the right to make your own decisions. The nurse is respecting the patients wishes by supporting the decision

A patient with lung cancer is admitted for respiratory acidosis. The patient informs the nurse that he does not want to be mechanically ventilated. What should the nurse do next? A) Call the physician immediately B) Consult the patient's family C) Determine the patient's competency, then have him sign a do-not-intubate form D) Have the patient sign a do-not-intubate form

ANSWER: A Explanation: - Only the physician can determine patient competency and provide adequate information before the patient can sign a do-not-intubate or do-not-resuscitate form - The nurse cannot determine patient competency or have the patient sign an advanced directive form - Consulting the family is a violation of patient confidentiality

A nurse approaches her nurse manager to advocate for the hiring of more nurses to reduce the nurse-to-patient ratio. What rationale should the nurse emphasize? A) Quality of care and patient outcomes B) Staff morale C) Staff recruitment D) Stress reduction

ANSWER: A Explanation: - Quality of care and improved patient outcomes should be the center of any institutional change or policy change - Although reducing the nurse-to-patient ratio would increase recruitment, reduce stress, and boost morale, quality of patient care should come first.

A patient with multiple fractures, including a skull fracture, is unconscious but has an advance directive and power of attorney. Some friends visit and ask the nurse what the patient's prognosis is. How should the nurse respond? A) "Due to confidentiality, I cannot discuss the patient's condition. You will have to talk with his power of attorney." B) "I can't tell you, so don't ask" C) "The prognosis is not good." D) "You will have to ask the patient"

ANSWER: A Explanation: - The nurse cannot discuss confidential information without the patient's consent. The nurse should politely inform the visitors that she cannot discuss patient information, and that they should talk with the patient's power of attorney. - The patient is unconscious and unable to answer the visitor's questions

A patient's sister is in nursing school and requests to see the patient's medical record. She states that it would be a great learning opportunity. What should the nurse do? A) Inform her that showing her the patient's medical record would be a breach of confidentiality B) Let her review the chart with the supervision of a staff member C) Teach her proper documentation and use the patient's chart as an example D) Tell the patient's sister to get out of nursing while she still can, then deny her the chart

ANSWER: A Explanation: - The nurse cannot show anyone the patient's chart, as this would be a breach of patient confidentiality (unless the person is directly involved in the patient's care).

A nurse is administering vesicant chemotherapy and is trying to protect against extraversion. Which of the following actions is most appropriate? A) Check for blood return in the I.V. B) Check the right patient, right medication, and right dose C) Use sterile technique when initiating chemotherapy D) Wear a gown and mask

ANSWER: A Explanation: - The nurse should confirm that the I.V. is in the vein by checking for blood return - Vesicant chemotherapy can cause severe soft tissue damage when it infiltrates

A nurse is administering vesicant chemotherapy and is trying to protect against extravasation. Which of the following actions is most appropriate? A) Check for blood return in the I.V. B) Check for right patient, right medication, and right dose C) Use sterile technique when initiating chemotherapy D) Wear a gown and mask

ANSWER: A Explanation: - The nurse should confirm that the I.V. is in the vein by checking for blood return. - Vesicant chemotherapy can cause severe soft tissue damage when it infiltrates.

A patient, who is a potential organ donor, has been admitted to the hospital with a poor prognosis. The patient's family would like to contact the recipient after the surgery. Which of the following responses by the nurse is best? A) "I will contact the transplant coordinator so she can discuss this with you" B) "The physician will have to approve it" C) The recipient is required to contact you within 180 days" D) "You cannot contact the recipient or his family"

ANSWER: A Explanation: - The transplant coordinator typically speaks with the family about the donor process and answers questions - Contact is allowed after the surgery as long as consent is obtained from both the donor's family and the recipient - The recipient is not required or obligated to contact the donor's family - The physician does not have to approve this process

A 58-year-old Pakistani patient with colon cancer complains of severe pain. He refuses all pain medication. What should the nurse do next? A) Ask the patient about his refusal B) Document the patient's refusal C) Inform the patient's family D) Notify the physician

ANSWER: A Explanation: - Pain beliefs can differ significantly between cultures. The nurse should discuss the situation with the patient and figure out his meaning of pain. - Documentation and notifying the physician are appropriate after further assessment. - Notifying the patient's family may be breaching the patient's confidentiality.

A nurse is counseling a 16-year-old boy about health promotion. Which of the following statements, if made by the boy, indicates a need for further intervention? A) I don't use condoms when having sex because my girlfriend is on the pill B) I drink at least a liter of sports drink whenever I play basketball for more than an hour. C) Since my dad keeps a rifle at home, he has enrolled me in a hunter education course D) When I go out with my buddies who drink alcohol, I'm always the designated driver.

ANSWER: A Explanation: - All sexually active adolescents should be encouraged to use condoms, even if they are using another form of birth control. - Drinking sports fluids during physical activity is common and safe, although the need for sports drinks is in question - Teaching gun safety to teenagers is a way of preventing future injuries. - Designating a driver who abstains from substance abuse is safe and should be encouraged.

A 16-month-old girl with Down syndrome has several cardiac defects that are inoperable. The parents are struggling to decide the next step. Subsequently, a care conference is held consisting of the family, the physician, the social worker, and the chaplain. Why should the nurse be involved in this discussion? A) The nurse can act as the patient advocate and the liaison between the parents and the health care team B) The nurse can lead the group in prayer C) The nurse has witnessed many deaths and can help comfort the parents D) The nurse is an expert in terminal illnesses

ANSWER: A Explanation: - Since the nurse has direct contact with the patient and family, she can help speak with the family as well as help the physician communicate the prognosis and medical options - Nurse are generally not experts in terminal illnesses and don't necessarily witness deaths - Leading the group in prayer is for the chaplain

A community health nurse is conducting health teaching on preventing food-borne illness among high-risk individuals. The nurse emphasizes the importance of proper food handling, food buying, and eating. Which of the following should be included? (Select all that apply) A) Clean the wheel of the can nopener B) Do not eat raw ground beef C) Never buy unpasteurized milk D) Refrigerator should be set at 44 degrees F or colder and the freezer is at 10 degrees F or colder E) Store eggs at 45 degrees F

ANSWER: A, B, C Explanation: - Eggs should be stored in the refrigerator between 34 and 40 degrees F - Refrigerators should be set at 34-40 degrees F (37 is ideal) while the freezer should be at 0 F to avoid spoilage of stored food - Unpasteurized milk can carry harmful microorganisms that could cause food poisoning - Cleaning the wheel of a can opener and refraining from eating raw foods, especially raw meat products, are way to prevent foodborne illness

Which of the following practices is necessary to maintain sterility during a surgical procedure? (Select all that apply) A) Avoid talking or coughing in front of the sterile field B) Avoid turning your back to the sterile field C) Keep the sterile field free from moisture D) Keep your arms below the waist level to prevent contamination E) The circulating nurse should not reach over the sterile field F) Wear an appropriate size exam glove

ANSWER: A, B, C, E Explanation: - Avoiding talking or coughing, and preventing moisture are some of the guidelines used by the health care team to maintain sterility during a surgical procedure - Talking or coughing in front of the sterile field may transmit microorganisms from saliva - Moisture allows microorganisms to move across a cloth or paper barrier - Arms must always be above the waist level to prevent contamination - Exam gloves are used in handling unsterile materials and are not appropriate to be used during a sterile procedure - The circulating nurse is not sterile so should avoid reaching over or touching the sterile field - Sterile personnel who need to change position should move face to face, but never turn their back to the sterile field

A nurse is providing discharge instructions to a patient receiving transcutaneous electrical nerve stimulation (TENS). The nurse should include which of the following information? (Select all that apply) A) Positive and negative electrodes are placed over the painful site B) TENS can cause burns C) TENS is a form of neuromodulation analgesia D) The patient can adjust the pulsation E) The patient can adjust voltage F) This therapy is rarely effective

ANSWER: A, C, D, E Explanation: - Both a positive and negative electrode are placed over the painful site within several inches of each other. - The patient can control both voltage and pulsation - TENS has been shown to effectively relieve pain for many people - Transcutanneous electrical nerve stimulation (TENS) is a form of neuromodulation analgesia that safely administers low voltage electrical current to both deep and superficial nerves. It is used for chronic pain.

A nonprofit health care organization has had a large increase in revenue the past year without a significant increase in expenses. What action can be anticipated? A) The organizational profits are distributed to stockholders B) The revenue is distributed across every department for patient service improvement C) Use the extra profit to pay taxes D) Use the profit to pay bonuses to the organization's top performers

ANSWER: B Explanation: - A nonprofit uses its revenue to re-invest in the organization and is tax-exempt - A nonprofit does not have stockholders, does not make a profit, and does not distribute revenue as bonuses

The nurse is teaching a mother on safety measures when caring for a 19-month-old child. Which of the following statements by the mother indicates that the teaching provided by the nurse regarding safety has been effective? A) "I should give ipecac syrup to my child if she ingests a poisonous substance" B) "I should keep all medicines in a securely locked cabinet" C) "I should never let my child out of my sight" D) "I should not feed my child cooked vegetables because it may burn her"

ANSWER: B Explanation: - Accidental ingestion of medication and other poisonous substances such as cleaning solutions is one of the major safety issues when caring for toddlers. Thus it's important to keep these materials away from the child's reach and lock the cabinet where these substances are stored. - Call the local poison control center first before giving ipecac or any substance that induces vomiting is not recommended. - Cooked vegetables are appropriate for a 19-month-old - Children should be monitored, but parents should not feel anxiety or need to constantly surveil their children.

The nurse caring for a patient with a hydromorphone PCA set at a basal rate of 0.1 mg per hour, with a 0.1 mg bolus every 10 minutes. The nurse finds the patient stuporous and difficult to arouse. After treating and stabilizing the patient, the nurse should: A) Ask the patient to rate his pain B) Check the PCA pump to verify that the settings are correct C) Notify the physician and request a lower basal rate D) Request that the PCA be discontinued

ANSWER: B Explanation: - After stabilizing the patient from opioid toxicity, the nurse should verify that the patient was receiving the correct dosage. The ordered dosage was safe for an adult patient, so the error may have been programming the PCA pump. - Requesting that the PCA be discontinued or that the dosage be lowered is not appropriate until the nurse investigates the reason for opioid toxicity.

A nurse is preparing to administer an intramuscular injection and observes a few small air bubbles in the syringe. Small air bubbles will alter which aspect of medication administration? A) Absorption B) Dose C) Duration D) Onset of action

ANSWER: B Explanation: - Air bubbles can alter the amount of medication the patient receives, therefore, the nurse should attempt to remove all air bubbles - A few small air bubbles are not harmful to the patient when injected (fun fact: In animal studies, the ability of the lungs to filter air bubbles fails when the air enters the circulation at a rate greater than 0.30 ml/kg per minute. With an average worldwide weight of 62 kg, this would be greater than 18 ml of air per minute!) - Air bubbles will not alter the absorption, duration, or onset of action

Is a nurse required to obtain consent from an 8-year-old patient who is undergoing a heart transplant? A) Since the child is a minor, he does not need to be informed about the surgery because his mother gives consent B) The child must be informed about the surgery, while his mother gives consent C) The child must sign the informed consent form D) The child only needs to know the risks of the surgery while his mother gives consent

ANSWER: B Explanation: - Any child who is in the concrete operations stage of development must give assent, not consent. This is usually any child over 7 years of age - Assent means knowledge of the surgery and agreement with the parent or other person giving consent

A child has informed the nurse that her mother is abusing her. Which of the following is a breach of the patient's confidentiality? A) Assessing the child for signs of abuse B) Informing another nurse who was a victim of abuse, so they may talk to each other C) Notifying child protective services D) Notifying the child's physician

ANSWER: B Explanation: - Discussing a patient with a nurse not involved in the care of the patient is a breach of confidentiality - The nurse should notify the physician and child protective services after she assesses the patient for signs of abuse

The nurse is preparing to administer a rectal medication. The nurse knows that what is a common side effect of per rectum drug administration? A) Constipation B) Decreased rate of absorption C) Hypersensitivity reaction D) Rectal bleeding

ANSWER: B Explanation: - Drug administration via the rectal route is preferred for certain drugs that may be destroyed in the GI tract or when oral administration is not possible because of vomiting or difficulty swallowing PO medications - The rate (speed) of rectal drug absorption is often lower than the oral route, due to the relatively small surface area available for drug uptake - Some drugs have an increased extent of absorption even when the rate of absorption not increased. This is because per rectum drugs avoid the hepatic first pass effect. For this reason, rectal doses are frequently lower than PO doses - Bleeding is not a common disadvantage of rectal route - Hypersensitivity is no more likely by this route than others

A nurse is preparing to administer I.V. fluids that lower serum osmolarity and pull fluid out of the intravascular space. Which fluid should the nurse administer? A) Hypertonic B) Hypotonic C) Isotonic D) Supratonic

ANSWER: B Explanation: - Hypotonic solution contains less solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity and pull fluid out of the vascular space by diffusion (due to the concentration gradient) - Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity and pull fluid into the vascular space by diffusion (due to the concentration gradient) - Isotonic solution has equal osmolarity compared to serum. This would not create a concentration gradient and not pull fluids into or out of the vascular space

After the physician explains the risks and benefits of a surgery, the patient signs the consent. A few hours later, the patient asks the nurse about the risks. Which of the following is the best response? A) Encourage the patient to refuse the surgery B) Notify the physician, informed consent was not obtained C) Provide the information requested D) Tell the patient there are no risks

ANSWER: B Explanation: - In order to obtain informed consent, the patient must understand all the risks and benefits of the procedure. In this scenario, the patient dos not fully understand the risks, therefore, the physician needs to re-explain the risks in order to obtain informed consent

One year ago, a patient's husband gave consent for mechanical ventilation. The patient is currently in a long-term care facility and still requires mechanical ventilation through a tracheostomy. The patient's husband is having regrets and asks the nurse if the ventilator can be removed. Which of the following responses by the nurse best explains the legal rights of the power of attorney? A) "That decision is difficult to make" B) "This is something we ned to discuss with the physician, but legally, previous decisions can be changed" C) "We cannot do that, the decision has been made to keep her alive" D) "You don't want to keep her alive anymore?"

ANSWER: B Explanation: - Previous decisions can be changed, as this is the husband's right as the power of attorney - The other answer choices are inappropriate responses by the nurse

A patient receiving total parenteral nutrition is to be discharged for home care. As a nurse, you recognize that preventing complications, such as infection, metabolic imbalances, and problems with the catheter, are major concerns that must be included in your discharge plan. So, when conducting the discharge teaching, which of the following will you emphasize? A) Catheter and tubings should be changed once a week B) Check blood sugar and temperature C) Pallor, swelling, and immobility at the insertion site are signs of infection and should be reported D) Take antibiotics as prophylaxis

ANSWER: B Explanation: - Prophylactic antibiotics are not generally prescribed for patients with central venous catheters - To prevent bacterial contamination, tubings should be changed every 3 days - Rise in temperature and unexplained hyperglycemia are symptoms of sepsis - The signs of infection are tenderness, redness, and possible drainage on the insertion site

A nurse is preparing to administer an enema to a 9-year-old with severe constipation. Which of the following patient positions should be used? A) Prone B) Sim's C) Supine D) Trendelenburg

ANSWER: B Explanation: - Sim's position, or left lateral recumbent, is the preferred position for administering enemas because it uses gravity to help the fluid move through the curve of the colon - Supine, prone, and trendelenburg positions are not appropriate for administering enemas

A 7-year-old Chinese child presents to the emergency room with her parents. The child is febrile and hypotensive. The nurse observes red, welt-like lesions covering the child's back. What is the most likely cause of these lesions? A) Abuse B) Cultural practices C) Rocky Mountain spotted fever D) Type III hypersensitivity

ANSWER: B Explanation: - Some traditional Chinese people perform Gua Sha, also known as coining or spooning - Gua Sha involves repeated pressured strokes with a coin or spoon in order to rid the body of illness - This is often confused with abuse when done to children, but understanding the family's cultural background can help make this distinction - Rock Mountain spotted fever is caused by the Rickettsial bacterium and presents with a maculopapular rash and petechial rash - A type III hypersensitivity reaction, or immune complex reaction, occurs when antigen- antibody complexes form and give rise to an inflammatory response. A rash can develop

Which of the following is true regarding organ and tissue donation? A) A nurse cannot contact the organ donation organization without a written order from a physician B) The family has the opportunity to speak with an organ donation coordinator C) The nurse is required to be an expert on the organ donation process D) The nurse is required to believe in organ donation

ANSWER: B Explanation: - The family should have the opportunity to speak with an organ donation coordinator. A coordinator has the knowledge and interpersonal skills to approach the family and discuss the donation process - Physician support is desired, but the nurse can contact the organ donation organization without a physician order - The primary nurse is not required to believe in organ donation or be an expert on the subject. The nurse should stay objective and supportive of the family's needs.

A patient who will undergo plastic surgery tells the nurse she is embarrassed about the surgery and asks the nurse not to tell anyone. How should the nurse respond? A) "I am required to tell your family" B) "I cannot discuss any information about you to anyone who is not directly involved in your care" C) "I won't tell anyone, I promise" D) "If your friends ask, I cannot lie"

ANSWER: B Explanation: - The nurse has a legal obligation to maintain patient confidentiality - "Required to tell your family" and "if your friends ask" would breach patient confidentiality - "I won't tell, I promise" would not alleviate the patient's concerns and it is not a professional response

A patient is prescribed a medication in capsule form, but he is having difficulty swallowing. How should the nurse solve this problem? A) Administer the capsule as ordered B) Check for availability of a different route C) Open the capsule and dissolve the contents in water D) Withhold the medication

ANSWER: B Explanation: - The nurse should check for other forms of routes available, most medications come in multiple forms - Dissolving the medication may alter its onset of action, absorption, and duration - The nurse should never withhold a medication without the approval of the physician

A nurse from an adult medical-surgical unit floats to a pediatric intensive care unit to help. The nurse has no experience with pediatrics or critical care. What should the nurse do next? A) Ask the charge nurse for a reduced workload B) Ask the nursing supervisor to help identify which tasks the nurse is qualified for C) Ask the pediatric nurses about the differences in care for peds vs. adults D) Refuse to float because of inexperience

ANSWER: B Explanation: - The supervisor can help the nurse identify which tasks she is qualified for and which tasks she can do without jeopardizing her PN license - Asking the charge nurse for a reduced workload may be appropriate, but you first need to identify which tasks are beyond your knowledge and which tasks you feel comfortable with.

A patient is admitted to the hospital with an INR of 3.9, history of GI bleeding, and osteomyelitis. The patient is complaining of bone pain so the nurse prepares to administer morphine. Which route should be avoided? A) I.V. B) IM C) Oral D) SQ

ANSWER: B Explanation: - With an elevated INR of 3.9, the patient is at risk for bleeding. - Muscles are highly vascular, and due to the patient's high INR, this intramuscular (IM) route should be avoided due to the risk of bleeding and hematoma formation. - Another method of administration (PO, IV, subcutaneous injection) would be used for this patient. Morphine is available in a wide variety of forms for administration to include liquid, tablets, extended release capsules, injections, and suppositories.

Which of the following actions is the nurse's role as collaborator of care when meeting with a family of an ill 1-year-old? A) Consulting another physician B) Coordinate with all healthcare workers involved in the patient's care, while providing the family with information about them. C) Inform the family of the child's prognosis D) Notify the family of newly discovered findings

ANSWER: B Explanation: - The nurse's role is to coordinate with all health care workers involved in the patient's care. The nurse should explain the roles of the different services and disciplines to the family. - The other three options are responsibility of the physician.

The nurse is preparing to administer 500 ml of 5% dextrose in normal saline over 1 hour. The I.V. tubing has a drop factor of 15 get/ml. What is the drip rate? A) 100 gtt/minute B) 125 gtt/minute C) 150 gtt/minute D) 75 gtt/minute

ANSWER: B Explanation: - 500 ml/60 minutes x 15 get/ml = 125 get/minute

A patient is interested in a new health insurance plan with fixed payment rates. Which of the following options would be best suited for her? A) Catastrophic health insurance B) Health-maintenance organization C) Preferred provider organization D) Private health insurance

ANSWER: B Explanation: - A health-maintenance organization provides health care for a fixed rate - Preferred provider organizations provide services through select providers under contract with the organization - Private health insurers will not offer health care for a fixed price - Catastrophic insurance is a high deductible, low premium plan intended for catastrophic illness

Which of the following interventions take priority when a nurse is ending a shift? A) Empty the trash cans B) Finish documenting the interventions and care provided during the shift C) Report off to the charge nurse D) Stock the patient's room with supplies

ANSWER: B Explanation: - Documentation is very important, it provides a legal record of the interventions performed by the nurse. If it's not charted, it wasn't done - The other three options can be done but they do not take priority over documentation

Three nurses are discussing a patient's manic symptoms in the cafeteria. The patient's daughter overhears details that she was unaware of and begins to tell the rest of the family. The nurses are guilty of which of the following? A) Battery B) Breach of confidentiality C) Neglect D) Uninformed consent

ANSWER: B Explanation: -The nurse shared confidential patient information to a third party, which is considered a breach in confidentiality. -Uninformed consent is illegal and may result in criminal charges, however, this term does not describe the scenario. -Neglect and battery are forms of torts, or a civil wrong (not a legal wrong). These terms does not describe the scenario.

A nurse is feeding a patient with pancreatitis through an enteral feeding tube. It is important that the nurse perform which of the following before administration of feeding solution? (Select all that apply) A) Assist the patient to a right side-lying position B) Check if borborygmi sound is present C) Flush the tube with 50 ml of water D) Measure residual volume of previous feeding

ANSWER: B, D Explanation: - Checking for borborygmi sounds (rumbling & gurgling) helps the nurse assess GI function and movement - Aspirating gastric contents confirms that the feeding tube is in the stomach and not the lungs. This also confirms that the previous feedings were absorbed - Feedings are often withheld when residual volume is greater than 150 ml, but this number varies among institutions and physicians. Check with the physician - Positioning the patient in a semi-fowler's position or higher prevents aspiration - 30 ml of water is instilled before feeding the patient

Before administering I.V. medication into an unused I.V. catheter, the nurse should flush the I.V. line with: A) Dextrose 5% in water B) Half-normal saline C) Lactated Ringer's D) Normal saline

ANSWER: D Explanation: - Before using an I.V. catheter for medication administration, the nurse should flush the line with normal saline to confirm potency - The use of other solutions is not advised

A terminally ill patient has identified her husband as her durable power of attorney. The husband then demands that a new physician take over his wife's care. How should the nurse react? A) Ask the patient's children which physician they prefer B) Continue calling the original physician for orders C) Respect the wishes of the husband D) Tell the husband that he doesn't have the right to change physicians for his wife

ANSWER: C Explanation: - As the durable power of attorney, the husband has the power to change the physician caring for his wife - Ignoring the husband's decision or telling him that he doesn't have the right to make this decision would be inappropriate - The patient's children have no power to make medical decisions, therefore, asking them would be inappropriate

A patient is developing hives after the administration of blood products. The physician has ordered a one time dose of diphenhydramine. Which of the following side effects can the nurse expect? A) Bradycardia B) Excessive salivation C) Sedation D) Urinary incontinence

ANSWER: C Explanation: - Diphenhydramine is a first generation antihistamine - Expected side effect include sedation and anticholinergic effects - Urinary incontinence, excessive salvation, and bradycardia are opposite of the expected anticholinergic effects caused by diphenhydramine Mnemonic: Antimuscarinic/Anticholinergic Side Effects The ABCD'S of anticholinergic side effects - Anorexia - Blurry vision - Constipation/Confusion - Dry Mouth - Stasis of urine

The nurse is providing care to a patient with Clostridium difficile. Which of the following actions demonstrates proper use of isolation precautions? A) The nurse uses hand sanitizer when leaving the room B) The nurse wears gown and gloves only when touching the patient C) The nurse wears gown and gloves, and washes her hands with soap and water before leaving the room D) The nurse wears a gown, gloves, N95 respirator, and eye protection

ANSWER: C Explanation: - Gown and gloves should be worn when caring for a patient with Costridium difficile AT ALL TIMES. Hand sanitizer is not sufficient enough, so soap and water should be used - Eye protection and a N95 respirator are only needed for airborne precations

A nurse is preparing to administer I.V. fluids that will not alter serum osmolarity or pull fluid into or out of the intravascular space. Which fluid should the nurse administer? A) Hypertonic B) Hypotonic C) Isotonic D) Supertonic

ANSWER: C Explanation: - Isotonic solution has equal osmolarity compared to serum. This would not create a concentration gradient and not pull fluids into or out of the vascular space - Hypotonic solution contains less solutes than the serum, making its osmolarity lower. This will lower the serum osmolarity and pull fluid out of the vascular space by diffusion (due to the concentration gradient) - Hypertonic solution contains more solutes than the serum, making its osmolarity higher. This will raise the serum osmolarity and pull fluid into the vascular space by diffusion (due to the concentration gradient) - Supertonic solution does not exist

A nurse is providing discharge instructions to a Chinese patient. The patient is turned away from the nurse and does not make eye contact. Which of the following is most appropriate? A) Ask the patient to pay attention B) Come back at a later time when the patient is more interested C) Continue with the discharge instructions D) Position herself to be infront of the patient at all times

ANSWER: C Explanation: - Many Chinese, due to a difference in culture, show respect by not making eye contact or avoiding direct, face-to-face communication. - The nurse should view this patient's actions as normal and continue with discharge instructions.

A patient at the clinic is prescribed a Schedule III narcotic analgesic for chronic pain. The nurse should instruct the patient that the prescription will become void if not filled within: A) 3 months B) 30 days C) 6 months D) 72 hours

ANSWER: C Explanation: - Prescriptions for Schedule III substances expire 6 months after the date written - Examples of Schedule III narcotics include products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine), and buprenorphine (Suboxone).

A nurse is helping a patient and realizes she is receiving the wrong I.V. medication. The first action taken by the nurse should be: A) Call the physician B) Find the nurse who initiated the I.V. medication C) Stop the infusion D) Write an incident report

ANSWER: C Explanation: - The nurse should immediately stop the infusion to avoid any further harm to the patient. The nurse should then notify the physician to determine the next course of action - The three remaining choices should be done, but not until after stopping the infusion and re-establishing a safe environment.

The nurse needs to know a patient's blood glucose and asks the unlicensed assistive personnel (UAP) if she has been trained on fingersticks per facility protocol. The assistant reports she has not been officially trained at this facility, but has performed fingersticks at a pervious job. What should the nurse do? A) Ask another nurse to perform the fingerstick B) Let the nursing assistant perform the fingerstick unsupervised C) Perform the fingerstick while the UAP observes and then document this in the UAP's training log D) The LPN should perform the fingerstick

ANSWER: C Explanation: - The nursing assistant must be trained per the facility policy. The nurse should allow the UAP to observe the procedure and document that as part of training. LPNs may participate in the training of assistive staff - Unlicensed Assistive Personnel (UAP) may assist in a variety of direct client care activities like taking vital signs, performing range-of-motion exercises, bathing, providing catheter care, bed making, and feeding patients who cannot feed themselves - Tasks that may be delegated to UAP are those that are regularly recurring in the care of clients according to established steps, and have a predictable outcome. Tasks delegated to UAP may not involve ongoing assessment, interpretation, or decision-making that cannot be separated from the actual tasks - Though facility policy may vary, UAP may be trained or obtain urine specimens, give enemas, even and perform blood glucose tests if it's allowed at the facility - The nurse should not allow the UAP to perform this task until official training has been completed - The nurse should not assume the nursing assistant knows how to do a fingerstick correctly, nor should the nurse ask another nurse to do it.

A patient with advanced lung cancer has been placed on the transplant list. While discussing the patient's situation with the nurse, the physician states that the patient most likely will continue to smoke despite being on the transplant list. How should the nurse respond? A) "Don't you want to save his life?" B) "He doesn't smoke a lot" C) "It is difficult to quit smoking" D) "With the right education and support system, he can quit smoking"

ANSWER: D Explanation: - The nurse is advocating for her patient - Stating that the patient does not smoke a lot or that it is difficult to quit is not patient advocacy

A 16-year-old needs a kidney biopsy but written consent is needed. Which of the following situations can a written consent be obtained without her parents' acknowledgement? A) The patient is intelligent and understands the surgery B) The patient is over 16 years of age C) The patient lives independently of her parents D) The patient wants to be a physician

ANSWER: C Explanation: - The patient is n emancipated minor. To be an emancipated minor, the patient must be under 18 years old and be considered an adult. - To be considered an adult, the patient needs to meet one of the following criteria; graduated high school, married, or living independently. - The other answer choice have no effect on the patients legal ability to sign an informed consent document.

A postoperative patient is in the post-anesthesia care unit (PACU) after undergoing an appendectomy. The nurse assessed the patients vital signs with a temperature of 94.5 degrees Fahrenheit. What should the nurse do next? A) Monitor vital signs for any changes B) Notify the physician C) Provide a warm blanket D) Turn up the room's thermostat

ANSWER: C Explanation: - The patient's temperature should be at least 96.8 degrees F before discharging from the PACU - Heat loss commonly occurs during surgery - The patient should not be warmed too quickly, as this can cause vasodilation and fluid shifts - If a warm blanket is insufficient, then the nurse should notify the physician

A patient in DKA with a UTI needs an insulin infusion and I.V. antibiotics. The nurse is unsure if I.V. insulin is compatible with I.V. Azithromycin. Who should she ask about I.V. compatibility? A) The charge nurse B) The nursing supervisor C) The pharmacist D) The physician

ANSWER: C Explanation: - The pharmacist is trained to answer questions about medications, and should be used as a resource for all medication questions - The physician, the charge nurse, and the nursing supervisor do not specialize in pharmacology

A nurse is assessing a patient's vital signs. Which of the following about upper extremity blood pressure measurement is correct? A) The bladder should be 16 cm long B) The bladder should cover the entire limb circumference C) The bottom of the cuff should be about 2 cm above the antecubical space D) The bottom of the cuff should be as close to the antecubical space as possible

ANSWER: C Explanation: - This will place the bladder directly over the brachial artery to ensure proper compression and blood pressure measurement - Placing the cuff too close to the ante cubical space will result in a false reading - The length of the uninflected bladder should cover about 75% of the limb circumference

The nurse withholds an ordered medication because the patient has been called for a psych consult on another floor and will eat lunch afterward. What should the nurse do next? A) Administer the dose with his meal after the procedure B) Document the omission C) Notify the physician about the held dose D) Prepare the patient or his appointment; transportation will arrive soon

ANSWER: C Explanation: - When withholding a medication for any reason, the nurse should notify the physician for approval. Then, the nurse should document the omission and the reason - The nurse should not administer the dose after the appointment without the physician's approval and an order

A nurse caring for a 8-year-old with H.I. V. is having trouble reading the dosage on a medication order. What should the nurse do? A) Ask another nurse if they can read it B) Ask the patient what dose they normally take C) Call the physician to clarify the order D) Look up the dosage in a drug index

ANSWER: C Explanation: - To prevent medication errors, the physician should be contacted in order to clarify the correct dose. - A drug index will give common dose or a range of doses, not the specific dose the physician wants. - Asking the patient or another nurse could lead to potential errors.

Which of the following blood transfusion matches would cause a hemolytic reaction? A) A-negative blood to an A-positive patient B) A-positive blood to an AB-positive patient C) B-positive blood to a B-negative patient D) O-negative blood to a B-negative patient

ANSWER: C Explanation: - A hemolytic reaction occurs with a Rh or ABO incompatibility - The Rhesus factor is the presence of proteins on the cell, which is what the body reacts to. Rh negative blood can donate to Rh positive blood if its the same type, because there are no proteins - O-negative is the universal donor, because it does not have A or B properties, and A and B blood types do not have O antibodies - AB patients can receive both A & B blood types, as long as there is a Rh compatibility

The nurse is preparing to administer vancomycin 500 mg I.V., over 60 minutes. The solution is 250 ml and the I.V. tubing has a drop factor of 15 gtt/ml. What is the drip rate? A) 25 gtt/minute B) 50.5 gtt/minute C) 60 gtt/minute D) 63 gtt/minute

ANSWER: D Explanation: - 250 ml/60 minutes x 15 gtt/ml = 62.5 gtt/minute. This is rouded up to 63 gtt/minute

Which of the following should be included in the performance evaluations of nursing staff? A) Areas needing improvement, documented in writing B) Date of next evaluation C) Other nurses' evaluations to give a comparison D) Strengths and areas needing improvement

ANSWER: D Explanation: - A nurse evaluation should include the nurse's strengths and areas needing improvement - All aspects of the evaluation should be in writing - Next evaluation date does not need to be scheduled, but expectations for improvement and a time frame should be discussed - Other nurses' evaluations should be kept confidential

A 10-year-old patient is admitted after sustaining a broken arm in a snowmobile accident. Which of the following should be consulted? A) Dietician B) Home health nurse C) Respiratory therapist D) Social Worker

ANSWER: D Explanation: - After a traumatic event, the social worker can help provide the patient with resources to help with emotional support and coping. Also, inpatient social workers usually evaluate injured children for signs of neglect or abuse - There is no indication that a dietitian, respiratory therapist, or a home health nurse is needed. Social worker is the best answer choice.

A home health nurse is caring for an elderly man with advanced dementia. The patient has a bruised eye and abdomen, and seems withdrawn. The nurse suspects abuse, but the patient is unable to communicate due to his dementia. What should the nurse do next? A) Ask the patient to report the problem B) Keep an eye on the situation until there is proof C) Notify the patient's family D) Report the suspected abuse to the local authorities

ANSWER: D Explanation: - As a mandatory reporter, the nurse must report the alleged elder abuse within 24 hours. - The patient is unable to report to abuse himself due to his advanced dementia - Notifying the family could make the situation worse, because a family member could be the abuser - Waiting for proof goes against the nurse's legal obligation

To help a mother anticipate the safety needs of her 9-year-old son who is learning to ride a bicycle, the nurse should teach that: A) A formal course of instruction is recommended B) The child must never ride without a parent nearby C) The child must ride on the sidewalk D) Wearing a helmet is recommended

ANSWER: D Explanation: - Correct use of a helmet is important in preventing head injuries - Riding with a parent does not ensure the child's safety - A formal course of instruction does not indicate what content is included - Riding on the sidewalk can cause problems for pedestrians, does not prevent injuries, and it is not permissible in some areas

When giving an I.M. influenza vaccine, the nurse should insert the needle at what angle? A) 15 degrees B) 45 degrees C) 60 degrees D) 90 degrees

ANSWER: D Explanation: - IM injections should be administered at a 90 degree angle using a quick motion - An intradermal injection should be given at a 15 degree angle - A subcutaneous injection should be given at a 45 to 90 degree angle

A nurse receives a patient from the operating room after placement of chest tubes. The tubes were placed because of a right lower lobectomy due to a chest injury. The nurse notices a dark, red fluid following into the collection chamber amounting to 75 ml when the patient tried to change positions. The nurse should: A) Auscultate the chest for adventitious sounds B) Call the surgeon C) Clamp the chest tube D) Continue to monitor drainage

ANSWER: D Explanation: - It is normal that fluid may drain into chest tubes when the patient is trying to change positions. Dark blood is normal and indicates that there is no active bleeding inside the pleural space - Since this event is normal when the patient is trying to change position, the nurse just need to document the characteristics and amount of drainage - Other choices are unnecessary because draining of dark fluid is normal when the patient is moving or changing positions

A nurse is caring or a 7-year-old with appendicitis and multiple bruises. The nurse suspects the child is being abused. What should the nurse do? A) Discuss it with another nurse B) Notify the physician C) Question the mother D) Report the case to authorities

ANSWER: D Explanation: - Nurses are considered mandatory reporters and must report suspected abuse to the local authorities - Questioning the mother can increase the risk of harm to the child - Discussing the situation with another nurse is a breach of patient confidentiality - The nurse should notify the physician, but this is less important than reportin to the authorities

A nurse administers 20 mg of morphine sulfate, PO, to a patient. The nurse should reassess the patient's pain rating: A) 15 minutes after administration B) 2 hours after administration C) 20 minutes after administration D) 60 minutes aftr administration

ANSWER: D Explanation: - Oral pain medications, like morphine, take up to one hour for onset. The nurse should reassess for pain one hour after administration. - For I.V. pain medications, the nurse should reassess 30 minutes after administration

A patient post-tonsillectomy is transferred back to his room from the post-anesthetic care unit (PACU). What is the safest progression of diet for the patient? A) NPO and then clear liquids for 2 weeks B) NPO, clear liquid diet and then a regular diet C) NPO, clear liquid diet for 2 months D) NPO, clear liquid, full liquid, soft diet, and then diet as tolerated.

ANSWER: D Explanation: - Post-tonsillectomy patients follow the normal progression of diet after surgery. Historically, on the first post-operative day, the patient will be NPO until normal bowel function has returned. Then the patient will be advanced to clear liquids, full liquids, soft diet, and finally a regular diet as tolerated. - Current research shows that most patients can be safely started on a diet prior to signs of the return of bowel function. - The other diet progressions listed are incorrect.

A nurse smells a potent odor coming from the patient's bathroom shortly after the patient's orthopedic surgery. The nurse suspects the patient is smoking marijuana. What should the nurse do first? A) Ask the patient to dispose of the marijuana B) Inform the patient about the dangers of smoking C) Inform the patient that smoking is not allowed in the hospital D) Notify security and the patient's physician

ANSWER: D Explanation: - Security guards are specially trained for situations like this - The physician should be notified because drugs can affect the healing process and other drugs may have been use by the patient - All other options are incorrect. Illegal substances need to be reported to the authorities and simply telling the patient to stop is not enough

"Metroprolol, 5 mg I.V., Now" is which type of medication order? A) PRN order B) Standard order C) Standing order D) Stat order

ANSWER: D Explanation: - Stat orders should be initiated immediately for urgent problems - A standing order, or protocol, establishes guidelines for administering medications in specific situations with specific criteria. - Standard orders are for routine and scheduled medications - PRN, or as-needed, orders are prescribed for a specific patient need and are administered based on the nurse's judgement.

A nurse is preparing to give a suppository medication to a patient with diarrhea. What approach is best? A) Administer the medication 10 minutes after the last stool B) Administer via oral route C) Ask the patient to insert the suppository while in the bathroom D) Withhold the medication and contact the physician

ANSWER: D Explanation: - Suppositories should not be given to patients with diarrhea because the medication would discharged with the stool, unabsorbed. The physician should be contacted to obtain a new order - The nurse cannot change the route without the approval of the physician - Never have a patient administer their own suppository

The nurse fills out an incident report after a patient received the wrong blood transfusion. What should the nurse do next? A) Document in the patient's record that an incident report was completed B) Make a copy of the incident report for the patient's chart C) Stabilize the patient D) Withhold the incident report from the patient's medical record

ANSWER: D Explanation: - The incident report is an internal document for the hospital and should not be mentioned in the medical record, nor should a copy be made for the patient's record - The incident report is for the institution's own records to help improve policies and procedures - The patient should already be stable before the nurse fills out an incident report

A nurse manager notices that an increased number of incident reports are completed because of late medication administration around lunch time. What action should the nurse manager take? A) Ask the kitchen staff to alter their tray delivery schedule B) Ask the physician to schedule medications at a different time C) Ask the staff to eat lunch later in the day D) Investigate staff and patient lunch times, the availability of staff during lunch hours, and the number and types of medications that need to be administered

ANSWER: D Explanation: - The nurse manager should evaluate the process and circumstances as a whole before determining solutions - The nurse manager should not change patient and staff lunch times before evaluating the entire situation - The physician should not be asked to change medication schedules because certain medications need to be administered with food or before meal

You take a verbal order over the phone. What step should be taken to ensure the accuracy of the order? A) Ask another nurse to review the order B) Ask another nurse to write down the order C) Do not administer the medication until the physician signs the order D) Read back the order to the physician

ANSWER: D Explanation: - The nurse should ALWAYS read back the order to the physician over the phone to ensure accuracy and patient safety - The drug may be administered before the physician has a chance to sign the order and asking another nurse to write down the order is not necessary - Asking another nurse to review the order may be helpful, but it is not as important as repeating the order back to the physician

A nurse receives an order for an intramuscular injection for a 3-year-old patient. Which of the following sites should the nurse use for the I.M. injection? A) Rectus femoris B) Sartorius C) Tibialis anterior D) Vastus lateralis

ANSWER: D Explanation: - The vastus laterals is located at the anterior-lateral aspect of the thigh. This is the recommended site for I.M. injections on a toddler - To find the precise location, find the upper quadrant between the greater trochanter and the knee joint

A newly diagnosed diabetic is being cared for on a medical unit. Which of the following tasks can be delegated to a nursing assistant? A) Administer insulin as ordered B) Assess for foot ulcers C) Explain the symptoms of hypoglycemia to the patient D) Test urine for ketones

ANSWER: D Explanation: - Unlicensed personnel should be delegated tasks that are routine and unchanging, with expected outcomes. - A registered nurse should perform the assessment, patient education, and medication administration.

While obtaining a patient's blood pressure, the nurse takes which of the following steps to ensure accuracy? A) Check a blood pressure in both arms B) Have the patient lie down to promote venous return C) Have the patient stand up D) Inflate the cuff at least 30 mm Hg higher than the radial pulse disappears

ANSWER: D Explanation: - When obtaining a blood pressure, the nurse should palpate the rail or brachial artery while inflating the cuff. When the pulse disappears, inflate the cuff with an additional 30 mm Hg or more. This prevents the failure to recognize an ausculatory gap - The other three options are not needed for accuracy

A nurse administers Zofran to a nauseated patient but forgets to document the administration. The charge nurse is aware of this mistake and makes the appropriate changes to the medication administration record. Which type of documentation error is this? A) Addition B) Late entry C) Omission D) Unauthorized entry

ANSWER: D Explanation: - If a nurse documents for another nurse, this is an unauthorized entry. - Omission is when information is missing from the patient's record - Late entry is when a nurse documents at a time later than when it should have been documented. - Addition is not a term for a documentation error.

A physician writes a medication order. Which of the following should be included in the order? A) Adverse drug reactions B) Indication C) Medication allergies D) Route

ANSWER: D Explanation: - Physician signature, patient's full name, drug name, dosage, route, time schedule, order date and time should be included in all medication orders. - Possible adverse reactions, indication, and allergies are not included in medication orders.

A patient has been admitted with a radial fracture. Which of the following patient statements legally requires further investigation by the nurse? A) "Am I going to miss work because of this? I don't want to lose my job" B) "I feel so stupid" C) "My boyfriend drove me here." D) "My boyfriend is very angry with me."

ANSWER: D Explanation: - This statement, along with the patient's injury, suggests domestic abuse. The nurse should investigate further. - The other statements are common and do not legally require follow-up.

The nurse develops strategies to resolve the patient's problems during which step of the nursing process? A) Analysis B) Assessment C) Evaluation D) Planning

ANSWER: D Explanation: - The nurse develops strategies to decrease or resolve the patient's problems during the Planning stem - During the Assessment step, the nurse collects data about the patient and family - During the Analysis step, the nurse identifies the patient's responses to actual or potential health problems - During the Evaluation step, the nurse assesses the effectiveness of the care plan

A nurse noticed a nursing assistant entering the room of a patient with tuberculosis. Which action by the nursing assistant demonstrates a need for education on airborne precautions? A) The nursing assistant does not remove the blood pressure cuff that is in the room. B) The nursing assistant removes all protective equipment, except for the N95 respirator, and performs hand hygiene before exiting the room. C) The nursing assistant wears a gown, gloves, N95 respirator, and eye protection. D) The nursing assistant wears a mask and gloves.

ANSWER: D Explanation: -Patients with TB need to be in isolation using airborne precautions. Anyone entering the room needs to wear personal protective equipment (PPE) such as a gown, gloves, N95 respirator, and eye protection. -Equipment taken into the room needs to stay in the room. -Removal of protective equipment and hand hygiene should always be done before exiting the room, except for removal of the N95 respirator.