review questions NUR 231 exam 2

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further

2

What does the Braden Scale evaluate? 1. Skin integrity at bony prominences, including any wounds 2. Risk factors that place the patient at risk for skin breakdown 3. The amount of repositioning that the patient can tolerate 4. The factors that place the patient at risk for poor healing

2

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? 1. Category/stage II 2. Category/stage IV 3. Unstageable 4. Suspected deep-tissue damage

3

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? 1. Reminiscence 2. Validation therapy 3. Reality orientation 4. Body image interventions

3

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: 1. Presbyopia. 2. Presbycusis 3. Cataract(s). 4. Depression.

3

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert image inch more.

3

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine

3

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

1

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

1

A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away because she is not going to take it. What is the nurse's next action? 1. Ask the patient's reason for refusal 2. Consult with the patient's parents for advice 3. Take the medication away and chart the patient's refusal 4. Tell the patient that her health care provider knows what is best for her

1

A postoperative patient currently is asleep. Therefore the nurse knows that: 1. The sedative administered may have helped him sleep, but it is still necessary to assess pain. 2. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. 3. Pain assessment is not necessary. 4. The patient can be switched to the same amount of medication by the oral route.

1

An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need. 2. Blood glucose stores are depleted and the cells do not have energy to use oxygen. 3. Carbon dioxide production increases due to hyperventilation. 4. Carbon dioxide production decreases due to hypoventilation.

1

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? 1. Raise the head of the bed to 45 degrees or higher. 2. Get the oxygen saturation with a pulse oximeter. 3. Take the blood pressure and respiratory rate. 4. Notify the health care provider of the shortness of breath.

1

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Delirium. 2. Depression. 3. New-onset dementia. 4. Worsening dementia.

1

What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

1

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure reduction 3. Negative pressure wound therapy 4. Sanitization

1

You are a new graduate nurse completing your orientation on a very busy intensive care unit. You cannot read a health care provider's order for one of your patient's medications. You have heard from more experienced nurses that this health care provider does not like to be called, and you know that another of the health care provider's patients is very unstable. What is the most appropriate next step for you to take? 1. Call the health care provider to clarify the order 2. Talk with your preceptor to help you interpret the order 3. Refer to a medication manual before giving the medication 4. Use your best judgment and critical thinking and administer the dose you think the health care provider ordered

1

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the surgeon. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1, 4

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.) 1. SpO2 levels 2. Amount, color, and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg

1,2,4

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

1,2,4

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

1,2,5

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

1,3

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure ulcers 5. To immobilize area

1,3

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) 1. Transcutaneous electrical nerve stimulation (TENS) 2. Administer naloxone (Narcan) 2 mg intravenously 3. Provide back massage 4. Reposition the patient 5. Withhold any pain medication and tell the patient that she is at risk for addiction

1,3,4

After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection. What should the nurse do next? (Select all that apply.) 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding so nothing needs to be done 6. Apply ice to the site for relief of burning pain

1,3,4

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1,3,4

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board) 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when repositioning patient 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1,3,5

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

1,3,5

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination if the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1,4

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1.Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1,4

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1,4,5

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1,4,6

Match the pressure ulcer categories/stages with the correct definition. 1. Category/stage I 2. Category/stage II 3. Category/stage III 4. Category/stage IV a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c. Full thickness tissue loss; muscle and bone visible. May include undermining. d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

1a, 2d, 3b, 4c

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Hypoglycemic reaction.

2

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so she can complete her assessment. 193 3. Call adult protective services because you suspect elder mistreatment. 4. Assess patient's cognitive status.

2

A nursing student is administering ampicillin PO. The expiration date on the medication wrapper was yesterday. What is the appropriate action for the nursing student to take next? 1. Ask the nursing professor for advice 2. Return the medication to pharmacy and get another tablet 3. Call the health care provider after discussing this situation with the charge nurse 4. Administer the medication since medications are good for 30 days after their expiration date

2

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: 1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis

2

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs

2

After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to: 1. Follow ISMP guidelines for safe medication abbreviations. 2. Explain to the health care provider that the order needs to be given to a registered nurse. 3. Write down the order on the patient's order sheet and read it back to the health care provider. 4. Ensure that the six rights of medication administration are followed when giving the medication.

2

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program

2

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part? 1239 1. Binder 2. Ice bag 3. Elastic bandage 4. Absorptive dressing

2

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy

2

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record

2

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

3

What statement made by a 2-year-old patient's mother indicates that she understands how to administer her son's eardrops? 1. "To straighten his ear canal, I need to pull the outside part of his ear down and back." 2. "I need to straighten his ear canal before administering the medication by pulling his ear upward and outward." 3. "I need to put my son in a chair and make sure that he's sitting up with his head tilted back before I give him the eardrops." 4. "After I'm done giving him his eardrops, I need to make sure that my son remains sitting straight up for at least 10 minutes."

2

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2

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

2

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

2,3

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

2,3

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.) 1. Yell so the patient can hear you. 2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 4. Send a written copy of the instructions home with him and tell him to have the family review them. 5. Include the family caregiver in the teaching session.

2,3,5

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2,3,5

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2,3,5

You are working in a health clinic on a college campus. You need to administer medroxyprogesterone acetate intramuscularly (IM) to a female patient for birth control. You look up this medication in a reference manual and determine that it is viscous and injections can be painful. On the basis of this information, you plan which of the following when administering this medication? (Select all that apply.) 1. Inject the medication over 3 minutes to reduce pain associated with the injection 2. Administer the medication in the ventral gluteal site 3. Use the Z-track method when administering the medication 4. Use the deltoid site for medication administration 5. Ask the patient questions about her major and which classes she is taking during the injection to provide distraction

2,3,5

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2,4

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2,4

A nurse admits a 72-year-old patient with a medical history of hypertension, heart failure, renal failure, and depression to a general medical patient care unit. The nurse reviews the patient's medication orders and notes that the patient has three health care providers who have ordered a total of 13 medications. What is the most appropriate action for the nurse to take next? 1. Give the medications after identifying the patient using two patient identifiers 2. Provide medication education to the patient to help with adherence to the medical plan 3. Review the list of medications with the health care providers to ensure that the patient needs all 13 medications 4. Set up a medication schedule for the patient that is least disruptive to the expected treatment schedule in the hospital

3

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? 1. Coughing up sputum occasionally 2. Coughing up thin, watery sputum after nebulization 3. Decreased ability to clear airway through coughing 4. Lung sounds clear only after coughing

3

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3

Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?

3

Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place

3

. When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1. Necrotic tissue 2. Wound drainage 3. Wound circumference 4. Cleansed wound

4

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

4

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority? 1. Complete an occurrence report. 2. Notify the health care provider. 3. Inform the charge nurse of the error. 4. Assess the patient for adverse effects.

4

A nursing student is administering medications to a patient through a gastric tube (G-tube). Which of the following actions taken by the nursing student requires the nursing instructor to intervene? 1. The nursing student places all the patient's medications in different medicine cups. 2. The nursing student evaluates each medication and holds the tube feeding before administering a medication that needs to be administered on an empty stomach. 3. The nursing student flushes the tube with 30 mL of water between each medication. 4. The nursing student crushes a nifedipine extended-release tablet and mixes it with water before administering it.

4

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? 1. Tell the student that temporary confusion is normal and simply requires reorientation 2. Tell the student to increase the patient's fluid intake since the urine is concentrated 3. Tell the student that her assessment findings are normal for an older adult 4. Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

4

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness

4

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

4

A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child? 1. A medication cup 2. A teaspoon 3. A 5-mL syringe 4. An oral-dosing syringe

4

For which of the following health problems is a patient who has a 40-year history of smoking at risk? 1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress-related illnesses 4. Cardiopulmonary disease and lung cancer

4

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Physical changes usually do not affect sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

4

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? 1. When the sexual partner passes away, the survivor no longer feels sexual. 2. A decrease in an older adult's libido occurs. 3. Any outward expression of sexuality suggests that the older adult is having a developmental problem. 4. All older adults, whether healthy or frail, need to express sexual feelings.

4

The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? 1. Dementia. 2. Elder abuse. 3. Delirium. 4. Alcohol abuse.

4

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

4

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

4

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

4,2,1,3

Name the three important dimensions to consistently measure to determine wound healing.

width, length, and depth