Summer 2019 Test One

What is the most important skill of the nurse leader? Priority setting Time Management Clinical decision making Clinical care coordination

Clinical care coordination

Near Miss

Codeine was ordered for a patient who is allergic to it. The nurse recognized the error and contacted the physician for an alternative order.

A licensed practical nurse cares for a client with attention deficit hyperactivity disorder. The client's mother informs the nurse, "I've been encouraging her to try meditation to improve her focus." Which statements about the health belief of the client's mother are true? The mind and body constitute a single unit. The sick may be anointed in the hope of a miracle cure. Health is the absence of disease or signs and symptoms of disease. A healthy balance can be maintained by following social and moral practices dictated by religion. A symptom of ill health is the body's means of communicating to the mind that something needs to be changed in the client's life.

The mind and boy constitute a single unit.

Health promotion efforts for the chronically ill client should include interventions related to primary prevention. What should this include? Encouraging daily physical exercise Performing yearly physical examinations Providing hypertension screening programs Teaching a person with diabetes how to prevent complications

Encouraging daily physical exercise

Criminal Law Relates to crime and the prosecution by the government of a person who commits an act that is classified as a crime

Example Assisted Suicide

Tort Law Offers relief to individuals who sustain harm from the wrongful acts of others

Example Malpractice suit against a physician administering an incorrect dose of IV medication that resulted in the death of the patient

Property Law Governs ownership

Example Ownership of frozen embryos

Contract Law Governs contracts that are voluntary and deliberate and legally binding agreements between two or more people

Example Performance of surgery other than what is specified in the consent form

Constitutional Law Deals with the interpretation and implementation of the United States constitution

Example Right to have an abortion

Errors of commission are errors of doing the wrong thing.

Examples of errors of commission include raising the head of the bed of a 2-hour postoperative neurosurgery patient with orders to remain flat for 12 hours; hanging a bottle of intravenous fluid without the ordered KCl; and catheterizing the wrong patient.

Errors of execution are errors related to doing the right thing incorrectly.

Examples of errors of execution are contaminating a wound when changing the dressing; moving a patient up in bed in a manner that drags the patient's tissues and creates a shearing injury; and giving incorrect information when teaching the patient about his or her medications.

Errors of omission are errors of not doing the right thing.

Examples of errors of omission are not doing discharge teaching; not ambulating a patient; and not checking placement of a nasogastric tube before a feeding.

Which statement regarding health disparities is true? Health disparities cannot be entirely eliminated. Genetics are the main cause of health disparities. Body mass index and genetic makeup contribute to health disparities. Health disparities encompass differences in incidence, prevalence, mortality rate, and burden of diseases.

Health disparities encompass differences in incidence, prevalence, mortality rate, and burden of diseases.

Which member of a primary hospice team is responsible for rendering personal care and assisting with the bathing of clients? Hospice aide Primary nurse Volunteer coordinator Bereavement coordinator

Hospice aide

What economic factors increase the cost of health care? Select all that apply. Malpractice insurance Advances in technology Increasing number of aging individuals Changes in the health-care delivery system Multisystem health-care chains or networks

Malpractice insurance Advances in technology Increasing number of aging individuals

Near-miss event An error that could have caused harm to a patient, but did not, as a result of chance, prevention, or some intervention that mitigated the impact. The majority of adverse events are near-miss events

Mild variation in standard of care Caused by human or system error Does not reach the patient Does not cause harm Use FMEA to analyze causes

Which nursing intervention involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with patients, families, and other health care providers? Milieu therapy Coordination of care Health teaching and health maintenance Pharmacologic, biologic, and integrative therapies

Milieu therapy

Adverse Event An error that results in moderate to severe harm to a patient. One of the most common adverse events involves medication administration

Moderate variation in standard of care Caused by human or system error Reaches the patient Minimal or no harm Use FMEA to analyze causes

Isotonic Solutions Osmolarity of 250 to 375 mOsm/L

Normal Saline (NS) 0.9% NaCl in Water Lactated Ringer's (LR) D5W (IN THE BAG) Dextrose 5% in water Normosol-R (Normosol)

What criteria should the nurse consider when determining if an infection should be categorized as a health care-associated infection? Originated primarily from an exogenous source. Is associated with a drug resistant microorganism. Occurred in conjunction with treatment for an illness. Still has the infection despite completing the prescribed therapy.

Occurred in conjunction with treatment for an illness.

While delegating care for a client, a lead nurse orders the staff nurse to give reports on time and to complete documentation after attending a client-care conference. Which other nursing responsibility may be included while coordinating care during a nursing shift? Conduct teaching sessions Plan time to assist colleagues Prepare medications for administration Discuss difficulties with experienced colleague

Prepare medications for administration

A client with a head injury has been receiving dexamethasone. The health care provider plans to reduce the dosage gradually and to continue a lower maintenance dosage. Which effect associated with the gradual dosage reduction of the drug should the nurse explain to the client? Builds glycogen stores in the muscles Produces antibodies by the immune system Allows the increased intracranial pressure to return to normal Promotes return of cortisone production by the adrenal glands

Promotes return of cortisone production by the adrenal glands

How is public health nursing different from community health nursing? Public health nursing focuses on population. Public health nursing focuses on health promotion. Public health nursing is part of a primary healthcare delivery system. Public health nursing requires nurses to hold a graduate degree.

Public health nursing focuses on population.

A client with chronic asthma is being cared for in the inpatient care unit. To assess the client on a regular basis would be delegated to which healthcare team member? Charge nurse Registered nurse Patient care associate Licensed practical nurse

Registered nurse

The nurse instructs the assistive personnel to help a high-fall-risk client with toileting every two hours. Which right of delegation is expressed in this situation? Right task Right direction Right supervision Right circumstance

Right direction

Sentinel event A serious error that results in patient death or a serious, undesirable outcome as a result of the error

Severe variation in standard of care Caused by human or system error Reaches the patient Death or major harm Use RCA to analyze causes

Which hospice team member can assist in solving any conflicts between a caregiver and client? Social worker Hospice nurse Medical director Nurse coordinator

Social Worker

Which team member of the hospice interdisciplinary team helps the clients and their families handle grief issues? Hospice aide Social worker Medical director Nurse coordinator

Social worker

Which is the definition of health equity? Factors that help explain why some people experience poorer health than others The health of a person or community along with the many measures that contribute to this health Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations Something that is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged

Something that is achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged

Fluid Volume Excess Signs and Symptoms

Sudden weight gain, dependent edema, vascular overload: bounding pulse, distended neck veins when upright, dyspnea, pulmonary edema if severe

Fluid Volume Deficit Signs and Symptoms

Sudden weight loss, skin tenting, dry muscous membranes, vascular underload: rapid thready pulse, postural BP drop lightheadedness, flat neck veins when supine, oliguria, syncope, shock if severe

Sentinel Event

Tap water in hospital was contaminated with Legionella. A patient's family member used tap water to humidify the patient's oxygen. The patient contracted Legionnaire's disease and died.

The ______________ is a closed-loop communication technique used to evaluate patient understanding and retention of material

Teach Back method

A 70-year-old client with minor burns on his hands and legs receives care from a voluntary home health agency. Which of these statements about this agency are true? Select all that apply. The agency receives fees from the client. This agency offers public health services. This agency includes county health departments. A community-based board of directors governs this agency. This agency will provide care to the client for 24 hours a day

The agency receives fees from the client. This agency offers public health services. A community-based board of directors governs this agency.

7. After a patient has been given preoperative sedatives, which safety precaution do you take? 1. Reinforce to patient to remain in bed or on the stretcher 2. Raise the side rails and keep the bed or stretcher in the high position 3. Determine if patient has any allergies to latex 4. Obtain informed consent immediately after sedative administration

1. Reinforce to patient to remain in bed or on the stretcher

The surgeon is responsible for having the consent form signed before sedation is given and before surgery is performed

You, as a nurse, are not responsible for providing detailed information about the surgical procedure. Rather, your role is to clarify facts that have been presented by the surgeon and dispel myths and that the patient or family may have about the surgical experience. You verify that the consent form is signed, and you serve as a witness to the signature, not to the fact that the patient is informed

A client complains to a nurse that his or her IV site is "sore." The nurse notes that the site is red and edematous, but there is no palpable cord or streak. Using the criteria for infusion phlebitis, what should the nurse document as the severity of this phlebitis? a. 1+ b. 2+ c. 3+ d. 4+

c. 3+

While a solution is infusing, which of the following is a treatment for venous spasm? a. Apply a cold pack to the site. b. Increase the flow rate of the solution. c. Apply a warm compress to the site. d. Administer pain medication.

c. Apply a warm compress to the site

Signs and symptoms of circulatory overload include: a. Low blood pressure b. Weight loss of 2 pounds over 1 day c. Bounding pulse d. Fever

c. Bounding pulse

11.A nurse is caring for a client with a central line. The client is febrile, shivering, and hypotensive. The nurse suspects that the client may have an infection and orders a blood culture. Which organism is responsible for most cases of catheter-related bloodstream infections? a. Enterococcus b. Escherichia coli c. Coagulase-negative staphylococci d. Pseudomonas

c. Coagulase=negative stephylococci

You are performing a venipuncture and an ecchymosis forms over and around the insertion area, which has become raised and hardened. You are unable to advance the cannula into the vein. These are signs of: a. Phlebitis b. Infiltration c. Hematoma d. Occlusion

c. Hematoma

A patient is recovering from general anesthesia. What is the nurse's main concern during the immediate postoperative period? a. Airway b. Pupillary reflexes c. Return of sensations d. Level of consciousness

c. Return of sensations

When preparing an IV solution that contains potassium, the nurse knows that a contraindication to the potassium infusion would be a. diarrhea. b. serum sodium level of 145 mEq/L. c. serum potassium level of 5.6 mEq/L. d. dehydration.

c. serum potassium level of 5.6 mEq/L

The nurse is discussing the use of technology in relation to patient education. Which of the following sites is considered the least credible for patient education material? a) Governmental sites (.gov) b) Educational sites (.edu) c) Nonprofit sites (.org) d) Commercial sites (.com)

d) Commercial sites (.com)

A nurse suspects that a client with IV access may be experiencing a venous spasm. What is the first sign/symptom of venous spasm? a. Redness along the vein b. Increased temperature c. A sense of cold in the extremity d. A sharp pain extending from the site of infusion

d. A sharp pain extending from the site of infusion

An intensive care nurse is caring for a client who is experiencing an occlusion of his or her central venous catheter by a blood clot. Which agent is most frequently used to clear an occlusion caused by a blood clot? a. 1% hydrochloric acid b. 70% ethanol c. Sodium bicarbonate d. Alteplase (Activase)

d. Alteplase (Activase)

8.A nurse is caring for a client who has a newly implanted port. For which complication, specifically associated with implanted ports, should the nurse observe? a. Air embolus b. Occlusion c. External catheter breakage d. Displacement of the septum

d. Displacement of the septum

While monitoring a patient who is receiving an infusion of a crystalloid solution, the nurse will monitor for which potential problem? a. Bradycardia b. Hypotension c. Decreased skin turgor d. Fluid overload

d. Fluid overload

The nurse is preparing an infusion for a patient who has a deficiency in clotting factors. Which type of infusion is most appropriate? a. Albumin 5% b. Packed RBCs c. Whole blood d. Fresh frozen plasma

d. Fresh frozen plasma

Which member of a hospice team coordinates assignments among volunteers? Hospice aide Hospice volunteer Volunteer coordinator Bereavement coordinator

Volunteer coordinator

How is electrolyte concentration measured? a) Sputum sample b) Urine sample c) Blood sample d) Stool sample

c) Blood sample

A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages on the basis of his blood sugar results. This type of activity addresses learning in the cognitive domain at the level of ___________

Application

Which nursing theorist most closely relates to the concept of patient education? a) Jean Watson b) Florence Nightingale c) Dorothea Orem d) Martha Rogers

c) Dorothea Orem

A registered nurse is discussing with a licensed practical nurse (LPN) the state health department's recently issued safety precautions regarding flu in the community. Which statement made by the LPN about this agency indicates effective learning? "It's supported by tax-deductible contributions." "It's governed by the hospital board of directors." "It's been given the tax status of a nonprofit health agency."

"It's been given the tax status of a nonprofit health agency."

The nurse is counseling a client with diabetes. Which statements made by the nurse are based on the second level of health promotion as per the U.S. Department of Public Health? Select all that apply. "You should undergo a colonoscopy twice in a year." "You should perform self glucose screening every day." "You should have your hemoglobin test done every two months." "You should follow your diet as prescribed by the dietician." "You should perform regular exercise to maintain a normal health status."

"You should follow your diet as prescribed by the dietician." "You should perform regular exercise to maintain a normal health status."

Folk health belief system

"third world" beliefs and practices.

Phillips 16-Step Peripheral-Venipuncture Method

(Precannulation) 1. Check the LIP orders 2. Hand hygiene 3. Equipment collection and preparation 4. Patient assessment, psychological preparation, patient identification 5. Site selection and vein distention (Cannulation) 6. Attention to pain management 7. Catheter selection 8. Gloving 9. Site preparation 10. Vein entry, direct versus indirect 11. Catheter stabilization and dressing management (Postcannulation) 12. Labeling 13. Equipment disposal 14. Patient education 15. Rate calculations 16. Documentation

IV Dose Calculation

(mL/hr X DF)/minutes = gtt/min

Tort Law

-Civil tort refers to an action or omission that results in harm to a person -tort must cause an injury that the law believes entitles the injured party to compensation -includes unintentional and intentional conduct -unintentional tort, such as negligence, is based on the concept of fault, meaning that liability (fault) attaches to an incorrect act or mistaken omission that caused harm even if the act or omission is unintentional -intentional tort is based on the perspective that the wrongdoer acted intentionally to harm the patient and violate the patient's rights and should be held responsible -examples of intentional torts include assault and battery, false imprisonment, invasion of privacy, defamation, intentional infliction of emotional distress, abuse of process, and malicious prosecution

Preoperative Teaching Checklist Consider these items when planning individualized preoperative teaching for patients and families

-fears and anxieties -surgical procedure -preoperative routines (e.g., NPO, blood samples, showering) -Invasive procedures (e.g., lines, catheters) -coughing, turning, deep breathing -incentive spirometer (how to use, how to tell when used correctly) -lower extremity exercises -stockings and pneumatic compression devices -early ambulation -splinting -pain management

A patient will be receiving diazepam (Valium), 2 mg, IV push as part of preprocedure sedation. The medication is available in an injectable solution of 5 mg/mL. How many milliliters will the nurse give for this dose?

0.4 mL

Which of the following are examples of a nurse participating in primary care activities? (Select all that apply.) 1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2. Assessing the nutritional status of older adults who come to the community center for lunch 3. Working with patients in a cardiac rehabilitation program 4. Providing home wound care to a patient 5. Teaching a class to parents at the local grade school about the importance of immunizations

1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2. Assessing the nutritional status of older adults who come to the community center for lunch 5. Teaching a class to parents at the local grade school about the importance of immunizations

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? 1. How to use an inhaler during an asthma attack 2. The need to avoid people who smoke to prevent asthma attacks 3. Where to purchase a medical alert bracelet that says she has asthma 4. The importance of maintaining a healthy diet and exercising regularly

1. How to use an inhaler during an asthma attack

Which of the following are characteristics of managed care systems? (Select all that apply.) 1. Provider receives a predetermined payment for each patient in the program. 2. Payment is based on a set fee for each service provided. 3. System includes a voluntary prescription drug program for an additional cost. 4. System tries to reduce costs while keeping patients healthy. 5. Focus of care is on prevention and early intervention.

1. Provider receives a predetermined payment for each patient in the program. 4. System tries to reduce costs while keeping patients healthy 5. Focus of care is on prevention and early intervention

A nurse is preparing to provide a patient with instructions for how to perform incentive spirometry. The patient will likely have incisional pain after returning from an elective colon resection. Which of the following steps for incentive spirometry is the patient likely to have the most difficulty performing? (Select all that apply.) 1. Assuming semi-Fowler's or high-Fowler's position 2. Setting the incentive spirometer device scale at the volume level to be attained 3. Placing the mouthpiece of the incentive spirometer so lips completely cover the mouthpiece 4. Inhaling slowly while maintaining constant flow through unit until it reaches goal volume 5. Breathing normally for a short period between each of the 10 breaths on incentive spirometry 6. Ending with two coughs after the end of 10 incentive spirometry breaths hourly

1. Assuming semi-Fowler's or high-Fowler's position 4. Inhaling slowly while maintaining constant flow through until until it reaches goal volume 6. Ending with two coughs after the end of 10 incentive spirometry breaths hourly

The primary reason that you need to include family members when you teach a patient preoperative exercises is so they can: 1. Coach and encourage the patient after surgery. 2. Demonstrate to the patient at home. 3. Relieve the nurse by getting the patient to do the exercises every 2 hours. 4. Practice with the patient while he or she is waiting to be taken to the operating room.

1. Coach and encourage the patient after surgery

Vein Selection Criteria (Short Peripheral Catheter)

1. In adults, veins that should be considered include those on the dorsal and ventral surfaces of the upper extremities. For pediatric infusion, additional site selection can include the veins of the scalp and lower extremities.. 2. Routinely initiate venipuncture in the distal areas of the upper extremities; subsequent cannulation should be made proximal to the previously cannulated site. 3. Consideration should be given to use of visualization technologies that aid in vein identification, such as transillumination or near infrared technology. 4. Areas to avoid include: a. Veins of the lower extremities; these should not be used in the adult population because of risk of embolism and thrombophlebitis b. Compromised veins, such as those that are hard and sclerosed c. Areas of venipunctures with subsequent injury to the vein d. Areas of flexion, such as the wrist or elbow, because of increased risk of infiltration and phlebitis; in the case of the antecubital fossa, PIV placement interferes with blood sampling and may prevent the use of those veins if a peripherally inserted central catheter (PICC) or midline catheter is required. e. Veins in the lateral surface of the wrist above the thumb for approximately 4-5 inches because of the potential for nerve damage f. The ventral surface (inner aspect) of wrist because of pain on insertion and possible nerve damage g. The affected extremity when there is evidence of cellulitis, presence of an arteriovenous fistula, history of lymph node dissection (e.g., breast surgery), affected extremity from a stroke, or history of radiation therapy to that side

A patient is admitted through the emergency department following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open-reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this patient include: (Select all that apply.) 1. Intermittent pneumatic compression stockings. 2. Vitamin K therapy. 3. Passive range-of-motion exercises every 4 hours. 4. Subcutaneous heparin or enoxaparin (Lovenox). 5. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.

1. Intermittent pneumatic compression stockings 4. Subcutaneous heparin or enoxaparin (Lovenox)

You are caring for a patient after surgery who had a liver resection. His prothrombin time (PT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions do you perform? (Select all that apply.) 1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes. 4. Wean oxygen therapy. 5. Provide comfort through bathing.

1. Notify the surgeon 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement 3. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes

Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system? 1. Patient safety 2. Evidence-based practice 3. Patient satisfaction 4. Maintenance of competency

1. Patient safety

A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? 1. Patient will be able to walk 200 feet without shortness of breath. 2. Wound will heal without signs of infection. 3. Patient will express concerns related to return to home. 4. Patient will identify strategies to improve sleep habits.

1. Patient will be able to walk 200 feet without shortness of breath

A nurse is using data collected from the unit to monitor the incidence of falls after the unit implemented a new fall protocol. The nurse is working in which area? 1. Quality improvement (QI) 2. Health care patient system 3. Nursing informatics 4. Computerized nursing network

1. Quality improvement (QI)

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures do nurses in these areas implement to prevent a latex reaction? (Select all that apply.) 1. Screen patients about food allergies known to have cross-reactivity to latex. 2. Have a latex allergy cart available at all times. 3. Communicate with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a patient with latex sensitivity is identified. 4. Schedule the patient with a latex allergy for the last operative case of the day. 5. Plan for the patient to be admitted to a private room after surgery.

1. Screen patients about food allergies known to have cross-reactivity to latex 2. Have a latex allergy cart available at all times 3. Communicate with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a patient with latex sensitivity is identified

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? 1. Telling approach 2. Selling approach 3. Entrusting approach 4. Participating approach

1. Telling approach

The nursing staff is developing a quality program. Which of the following are nursing-sensitive indicators from the National Database of Nursing Quality Indicators (NDNQI) that the nurses can use to measure patient safety and quality for the unit? (Select all that apply.) 1. Use of physical restraints 2. Pain assessment, intervention, and reassessment 3. Patient satisfaction with food preparation 4. Registered nurse (RN) education and certification 5. Number of outpatient surgical cases per year

1. Use of physical restraints 2. Pain assessment, intervention, and reassessment 4. Registered nurse (RN) education and certification

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply.) 1. Vital signs, type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 3. Verification of the patient using one identifier and the type of surgery performed 4. Review of pertinent events occurring in the operating room (OR) while at the nurses' station 5. Location of patient's family members

1. Vital signs, type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 5. Location of patient's family members

Magnesium

1.5-2.5 mEq/L

Hypotonic Solutions Osmolarity below 250mOsm/L

1/2 Normal Saline (1/2 NS) 0.45% NaCl in Water D5W (PHYSIOGICALLY) Dextrose 5% in water

The order reads: "Infuse 1000 mL of normal saline over the next 8 hours." The IV tubing has a drop factor of 15 gtt/mL. Calculate the mL/hour rate, and calculate the drops/minute setting for the IV tubing with this gravity infusion.

125 mL/hour; 31 gtts/min

Sodium

135-145 mEq/L

What is an example of a voluntary home health agency? City health department Visiting nurse association County health department Nursing home-based health agency

Visiting nurse association

Which activity performed by a nurse is related to maintaining competency in nursing practice? 1. Asking another nurse about how to change the settings on a medication pump 2. Regularly attending unit staff meetings 3. Participating as a member of the professional nursing council 4. Attending a review course in preparation for a certification examination

4. Attending a review course in preparation for a certification examination

A community center is presenting a nurse-led program on the Patient Protection and Affordable Care Act. Which statement made by a participant indicates a need for further teaching? 1. "My small company will now have to offer the 75 employees health insurance or pay a penalty." 2. "As long as my son is a full-time student in college, I will be able to keep him on my health insurance until he is 26 years old." 3. "I signed up for the state health insurance exchange before the designated deadline to make sure I had health insurance." 4. "Since I have now been diagnosed with diabetes, my health insurance plan cannot charge me higher premiums."

2. "As long as my son is a full-time student in college, I will be able to keep him on my health insurance until he is 26 years old."

You are assigned to care for the following patients on your surgical unit. On the basis of the information provided, which patient do you need to see first? 1. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.) 3. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic 4. A 48-year-old following total knee replacement who needs help repositioning in bed

2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) wiht a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.)

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: 1. A teaching plan. 2. A learning objective. 3. Reinforcement of content. 4. Enhancing the children's self-efficacy.

2. A learning objective

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? 1. Telling 2. Analogy 3. Demonstration 4. Simulation

2. Analogy

You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, his heart rate is 110. What is your next action? 1. Stop exercise immediately and have him sit in a nearby chair. 2. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. 3. Tell him that he needs to walk further to reach a heart rate of 120. 4. Have him walk slower; he has reached his maximum.

2. Ask him how he feels, determine if there is any discomfort or shortness of breath; and, if not, continue exercise

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? 1. Simulation 2. Demonstration 3. Group instruction 4. One-on-one discussion

2. Demonstration

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? 1. Describing difficulties a family member has had in taking insulin 2. Expressing the importance of learning the skill correctly 3. Being able to see and understand the markings on the syringe 4. Having the dexterity needed to prepare and inject the medication

2. Expressing the importance of learning the skill correctly

The nurse is organizing a disease prevention program for a specific cultural group. To effectively meet the needs of this group the nurse will: (Select all that apply.) 1. Assess the needs of the community in general. 2. Involve those affected by the problem in the planning process. 3. Develop generalized goals and objectives for the program. 4. Use educational materials that are simplistic and have many pictures. 5. Assess commonly held health beliefs among the cultural group. 6. Educate the specific cultural group about Western concepts of health and illness. 7. Include cultural practices that are relevant to the specific community.

2. Involve those affected by the problem in the planning process 5. Assess commonly held health beliefs among the cultural group 7. Include cultural practices that are relevant to the specific community

A nurse is presenting information to a management class of nursing students on the topic of financial reimbursement for achievement of established, measurable patient outcomes. The nurse is presenting information to the class on which topic? 1. Prospective payment system 2. Pay for performance 3. Capitation payment system 4. Managed care systems

2. Pay for performance

A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? (Select all that apply.) 1. Loss of sensation at the surgical site 2. Reduction of fear and anxiety 3. Amnesia about procedure 4. Monitoring in phase I recovery 5. Close monitoring for airway patency

2. Reduction of fear and anxiety 3. Amnesia about procedure

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because: 1. He or she needs to get the patient into the operating room (OR) quickly to start the surgery because of the low BP. 2. The surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery. 3. The nurse anticipates the need for a fluid bolus to increase the patient's BP. 4. The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.

2. The surgery may need to be delayed to recheck the patient's WBC count and investigate the source of fever before surgery

Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.) 1. Risk for bleeding is increased. 2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 4. Metabolic demands are increased. 5. Physical mobility is often impaired.

2. Ventilatory capacity is reduced 3. Fatty tissue has a poor blood supply 5. Physical mobility is often impaired

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.) 1. When there are visitors in the room 2. When the patient states that he or she is pain free 3. Just before lunch, when the patient is most awake and alert 4. When the patient is talking about current stressors in his or her life 5. When the patient is being transported for a procedure

2. When the patient states that he or she is pain free 3. Just before lunch, when the patients is most awake and alert

Phosphorus

2.8-4.5 mg/dL

Which of the following nursing activities is provided in a secondary health care environment? 1. Conducting blood pressure screenings for older adults at the Senior Center 2. Teaching a clinic patient with chronic obstructive pulmonary disease purse-lipped breathing techniques 3. Changing the postoperative dressing for a patient on a medical-surgical unit 4. Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit

3. Changing the postoperative dressing for a patient on a medical-surgical unit 4. Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit

When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner? 1. Printed pamphlets on cardiovascular disease and dietary recommendations from the American Heart Association 2. A role-play activity requiring the patient to select proper foods from a wide selection 3. Colored visual diagrams that categorize foods according to fat and sodium content 4. A lecture-style discussion on heart healthy diet options

3. Colored visual diagrams that categorize foods according to fat and sodium content

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? 1. Teach the patient's spouse 2. Focus on knowledge the patient will need in a few weeks 3. Provide only the information that the patient needs to go home 4. Convince the patient that learning about her health is necessary

3. Provide only the information that the patient needs to go home

A group of staff nurses notice an increased incidence of medication errors on their unit. After further investigation it is determined that the nurses are not consistently identifying the patient correctly. A change is needed quickly. What type of quality improvement method would be most appropriate? 1. PDSA 2. Six Sigma 3. Rapid-improvement event (RIE) 4. A randomized controlled trial

3. Rapid-improvement event (RIE)

A nurse is using the Plan-Do-Study-Act (PDSA) strategy to do a quality improvement project to decrease patient falls on a nursing unit. Place the steps in the correct sequence for PDSA. 1. Bedside change of shift report is piloted on two medical-surgical units. 2. Patient satisfaction levels after implementation of the bedside report are compared to patient satisfaction levels before the change. 3. The nursing council develops a strategy for bedside change of shift report. 4. After modifications are made in the shift report elements, bedside shift report is implemented on all nursing units.

3. The nursing council develops a strategy for bedside change of shift report 1. Bedside change of shift report is piloted on two medical-surgical units 2. Patient satisfaction levels after implementation of the bedside report are compared to patient satisfaction levels before the change 4. After modifications are made in the shift report elements, bedside shift report is implemented on all nursing units

A patient tells a nurse that she is enrolled in a preferred provider organization (PPO) but does not understand what this is. What is the nurse's best explanation of a PPO? 1. This health plan is for people who cannot afford their own health insurance. 2. This health plan is operated by the government to provide health care to older adults. 3. This health plan gives you a list of physicians and hospitals from which you can choose. 4. This is a fee-for-service plan in which you can choose any physician or hospital

3. This health plan gives you a list of physicians and hospitals from which you can choose.

Potassium

3.5-5.0 mEq/L

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: 1. Speaks loudly. 2. Presents the information once. 3. Expects the patient to understand the information quickly. 4. Allows the patient time to express himself or herself and ask questions.

4. Allows the patient time to express himself or herself and ask questions

The nurses on a medical unit have seen an increase in the number of pressure ulcers that develop in their patients. They decide to initiate a quality improvement project using the Plan-Do-Study-Act (PDSA) model. Which of the following is an example of "Do" from that model? 1. Implementing the new skin care protocol on all medicine units 2. Reviewing the data collected on patients cared for using the protocol 3. Reviewing the quality improvement reports on the six patients who developed ulcers over the last 3 months 4. Based on findings from patients who developed ulcers, implementing an evidence-based skin care protocol

4. Based on findings from patients who developed ulcers, implementing an evidence-based skin care protocol

Because an older adult is at increased risk for respiratory complications after surgery, the nurse needs to: 1. Withhold pain medications and ambulate the patient every 2 hours. 2. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. 3. Orient the patient to the surrounding environment frequently and ambulate him or her every 2 hours. 4. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.

4. Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. Which type of content is the nurse providing? 1. Simulation 2. Restoring health 3. Coping with impaired function 4. Health promotion and illness prevention

4. Health promotion and illness prevention

Which of the following statements is true regarding Magnet status recognition for a hospital? 1. Nursing is run by a Magnet manager who makes decisions for the nursing units. 2. Nurses in Magnet hospitals make all of the decisions on the clinical units. 3. Magnet is a term that is used to describe hospitals that are able to hire the nurses they need. 4. Magnet is a special designation for hospitals that achieve excellence in nursing practice

4. Magnet is a special designation for hospitals that achieve excellence in nursing practice

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? 1. Infection: Notify surgeon and anticipate administration of antibiotics. 2. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. 3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. 4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently

In the postanesthesia care unit (PACU) a nurse notes that a patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse's priority intervention at this time is: 1. Suction the pharynx and bronchial tree. 2. Give oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.

4. Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward

A patient needs to learn to use a walker. Which domain is required for learning this skill? 1. Affective domain 2. Cognitive domain 3. Attentional domain 4. Psychomotor domain

4. Psychomotor domain

Calcium

8.5-10.5 mg/dL

Chloride

95-105 mEq/L

Adverse Event

A nursing assistant bringing hot tea to a patient trips, and the tea spills burning the patient's arm and hand.

Priority postoperative assessements

Airway • Is it patent? • Is the neck in proper alignment? Breathing • What is the quality and pattern of the breathing? • What is the respiratory rate and depth? • Is the patient using accessory muscles to breathe? • Is the patient receiving oxygen? At what setting? What is the pulse oximetry reading? Mental Status • Is the patient awake, able to be aroused, oriented, and aware? • Does the patient respond to verbal stimuli? Surgical Incision Site • How is it dressed? • Review the amount of drainage on the dressing immediately. • Is there any bleeding or drainage under the patient? • Are any drains present? • Are the drains set properly (e.g., compressed if they should be compressed, not kinked, patient not lying on them)? • How much drainage is present in the drainage container? Temperature, Pulse, and Blood Pressure • Are these values within the patient's baseline range? • Are these values significantly different from when the patient was in the postanesthesia care unit (PACU)? Intravenous Fluids • What type of solution is infusing and with what additives? • How much solution was remaining on arrival? • How much solution infused in the transport time from PACU? • At what rate is the infusion supposed to be set? Is it? Other Tubes • Is there a nasogastric or intestinal tube? • What is the color, consistency, and amount of drainage? • Is suction applied to the tube if ordered? Is the suction setting correct? • Is there a Foley catheter? • Is the Foley draining properly? • What is the color, clarity, and volume of urine output

The goal of all patient education is _________________________.

Change

Hypertonic Solutions Osmolarity of 375 mOsm/L or higher

D5NS (Dextrose 5% in 0.9% saline) D5 1/2NS (Dextrose 5% in 0.45% saline) D5LR (Dextrose 5% in Lactated Ringer's)

The osmolarity imbalance ____________________ occurs when fluids in the body are too concentrated.

Hypernatremia

What is the role of a case manager in a healthcare organization? To delegate work on the unit suitably To follow up with the client after discharge To provide direct care for the client at the bedside To unite the strategic direction of the organization

To follow up with the client after discharge

What is the goal of the American Hospital Association (AHA) with respect to clients' rights? To provide federal funding to institutions To protect the confidentiality of clients' health information To maintain written policies and procedures regarding advance directives To promote clients' knowledge regarding their rights as consumers of health care

To promote clients' knowledge regarding their rights as consumers of health care

A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply. Using informatics Applying quality improvement Using evidence-based practice Providing patient-centered care Working in an interdisciplinary team

Using informatics Using evidence-based practice Providing patient-centered care

Which of the following are considered adult learning principles? (Select all that apply.) a) Learning is voluntary and self-initiated. b) Learning is directed and controlled by the teacher. c) Learning is reinforced by prompt feedback from the teacher. d) Learning is related to an immediate need, problem, or deficit. e) Learning cannot be effective within a group atmosphere.

a) Learning is voluntary and self-initiated c) Learning is reinforced by prompt feedback from the teacher d) Learning is related to an immediate need, problem, or deficit

Which of the following signs and symptoms are associated with hypomagnesemia? (Select all that apply.) a) Seizures b) Decreased neuromuscular excitability c) Muscle cramps and twitching d) Cardiac dysrhythmias e) Polyuria

a) Seizures c) Muscle cramps and twitching d) Cardiac dysrhythmias

Which of the following are considered common sources of fluid loss in the human body? (Select all that apply.) a) Urine b) Feces c) Tears d) Skin e) Respiration

a) Urine b) Feces d) Skin e) Respiration

Which statement best describes health literacy? Health literacy refers to: a) a patient's ability to understand and interpret health-related information and instructions. b) the process nurses use to impart health care information. c) the patient's ability to read and understand all written materials. d) the patient's ability to read and follow prescription labels.

a) a patient's ability to understand and interpret health-related information and instructions

For a patient to have a nursing diagnosis of Noncompliance, the patient must have the desire to comply with the prescribed treatment plan. a) True b) False

a) true

The surgical nurse is reviewing operative cases scheduled for the day. Which of these patients is more prone to complications from general anesthesia? a. A 79-year-old woman who is about to have hip replacement surgery b. A 49-year-old male athlete who quit heavy smoking 12 years ago c. A 30-year-old woman who is in perfect health but has never had anesthesia d. A 50-year-old woman scheduled for outpatient laser surgery for vision correction

a. A 79-year-old woman who is about to have hip replacement surgery

A patient is recovering from general anesthesia. What is the nurse's main concern during the immediate postoperative period? a. Airway b. Pupillary reflexes c. Return of sensations d. Level of consciousness

a. Airway

Which action by the nurse is most appropriate for the patient receiving an infusion of packed red blood cells? a. Flush the IV line with normal saline before the blood is added to the infusion. b. Flush the IV line with dextrose before the blood is added to the infusion. c. Check the patient's vital signs once the infusion is completed. d. Anticipate that flushed skin and fever are expected reactions to a blood transfusion.

a. Flush the IV line with normal saline before the blood is added to the infusion

A nurse suspects that a client, who is receiving IV therapy, may be experiencing local complications. Which signs are considered local complications of IV therapy? a. Phlebitis, venous spasm, and hematoma b. Septicemia, air embolus, and hematoma c. Speed shock, septicemia, and venous spasm d. Phlebitis, pulmonary edema, and speed shock

a. Phlebitis, venous spasm, and hematoma

A nurse has difficulty withdrawing blood from a central tunneled catheter but is able to infuse fluids through the line. The nurse should anticipate that this difficulty is most likely due to: a. the formation of a fibrin sheath. b. the presence of venous thrombosis. c. the precipitation of medication. d. the catheter tip being pressed up against the vein wall.

a. the formation of a fibrin sheath

Which of the following patients would least likely experience a fluid and electrolyte imbalance? a) A 6-month-old with a common cold b) A 23-year-old with an upper extremity bone fracture c) A 48-year-old with a history of renal disease d) An 86-year-old living in a long-term care facility

b) A 23-year-old with an upper extremity bond fracture

Which of the following signs and symptoms are associated with too little volume (a fluid deficit)? (Select all that apply.) a) Bounding pulse b) Oliguria c) Skin tenting d) Dyspnea e) Postural hypotension

b) Oliguria c) Skin tenting e) Postural hypotensiond

Which two hormones influence the distribution of calcium within the fluids in the body? a) Insulin and glucose b) Parathyroid hormone and calcitonin c) Aldosterone and antidiuretic hormone d) Cortisol and parathyroid hormone

b) Parathyroid hormone and calcitonin

Which of the following statements regarding patient education is true? a) Learning will occur whether or not the patient is ready to learn. b) Patient motivation will determine when, how, and if patient education will occur. c) If learning materials are well-structured, the teaching techniques will not need to change based on the age of the patient. d) Patient education focuses on giving health care providers more control regarding their patients' health and learning needs

b) Patient motivation will determine when, how, and if patient education will occur

In which stage of the educational process does the nurse determine which teaching methods will be used to meet the patient's educational needs? a) Learner assessment b) Planning c) Implementation d) Evaluation

b) Planning

The nurse is teaching a patient's family how to change a wound dressing. The nurse assembles the supplies necessary for the dressing change and demonstrates the procedure. The nurse then asks the family to demonstrate the dressing change. Which of the following best describes what the nurse has implemented? a) Cognitive teaching b) Psychomotor teaching c) Affective teaching d) Formal teaching

b) Psychomotor teaching

Which of the following best describes absorption? a) The addition of fluid and electrolytes to the body b) The movement of fluid and electrolytes into the bloodstream c) The process of moving fluid and electrolytes between the various body fluid compartments d) The removal of fluid and electrolytes from the body

b) The movement of fluid and electrolytes into the bloodstream

A nurse is assessing a client's IV infusion site that has been in place for 1 hour. The infusion has slowed and the client complains of severe pain at the insertion site. The client states, "It feels like an electric shock moving up my arm." There is blanching over the site and redness around it. Which condition should the nurse suspect? a. Occlusion b. Hematoma c. Venous spasm d. Thrombophlebitis

c

Which of the following best defines the concept of fluid and electrolyte balance? a) The movement of fluids and electrolytes in the body to maintain homeostasis b) The process of regulating the extracellular fluid volume, body fluid osmolarity, and plasma concentrations of electrolytes c) The process by which the human body excretes excess fluids and electrolytes d) The process by which electrolytes are circulated within the human body to maintain homeostasis

b) The process of regulating the extracellular fluid volume, body fluid osmolarity, and plasma concentrations of electrolytes

Developing a patient education plan based on an identified need is the responsibility of the LPN/LVN. a) True b) False

b) false

A patient states that his I.V. site is sore. You assess the site and note redness and swelling but no signs of palpable cord or streak. Using the criteria for infusion phlebitis, what is the severity of this phlebitis? a. 3+ b. 2+ c. 1+ d. 0

b. 2+

During initial venipuncture, a nurse has difficulty advancing the cannula into a client's vein and observes ecchymosis over and around the insertion area. The area is also raised and hard. Based on this information, what should the nurse conclude? a. Phlebitis has started. b. A hematoma has formed. c. The vessel has collapsed. d. A venous spasm has occurred.

b. A hemotoma has formed

The nurse is administering an IV solution that contains potassium chloride to a patient in the critical care unit who has a severely decreased serum potassium level. Which action(s) by the nurse are appropriate? (Select all that apply.) a. Administer the potassium by slow IV bolus. b. Administer the potassium at a rate no faster than 20 mEq/hr. c. Monitor the patient's cardiac rhythm with a heart monitor. d. Use an infusion pump for the administration of IV potassium chloride. e. Administer the potassium IV push.

b. Administer the potassium at a rate no faster than 20 mEq/hr c. Monitor the patient's cardiac rhythm with a heart monitor d. Use an infusion pump for the administration of IV potassium chloride

A nurse is caring for multiple clients with peripheral IV devices. Which client is at the greatest risk for the development of IV-related phlebitis? a. A 3-year-old child b. An immunosuppressed client c. An 80-year-old man who is dehydrated d. A client with peripheral infusion of 0.45% sodium chloride

b. An immunosuprressed client

After removing an over-the-needle catheter, a nurse notices that the tip has broken off and can be palpated at the site. Which action should be taken by the nurse first? a. Notify the physician immediately. b. Apply a tourniquet above the insertion site. c. Remove the tip with a scalpel. d. Assess the client for respiratory complications.

b. Apply a tourniquet above the insertion site

Which of following will reduce the risk for infiltration? a. Use of pumps or controllers to manage the I.V. rate b. Avoiding placing the cannula in areas of flexion c. Use of needleless systems d. Use of larger-bore catheters

b. Avoid placing the cannula in areas of flexion

Strategies for VAD-related infection prevention include: a. Changing the needleless connector daily b. Hand hygiene c. Wearing a mask during I.V. administration d. Daily bathing with Betadine solution

b. Hand hygeine

To prevent air embolism during CVAD removal, the nurse should: a. Instruct patient to deep breathe during the procedure b. Have patient in the supine position during removal c. Apply an occlusive dressing after removal d. Have patient lie in bed for 1 hour after removal

b. Have patient in the supine position during removal c. Apply an occlusive dressing after removal

The nurse is administering an NMBD to a patient during a surgical procedure. Number the following phases of muscle paralysis in the order in which the patient will experience them. (Number 1 is the first step.) a. Paralysis of intercostals and diaphragm muscles b. Muscle weakness c. Paralysis of muscles of the limbs, neck, and trunk d. Paralysis of small rapidly moving muscles (fingers, eye)

b. Muscle weakness d. Paralysis of small rapidly moving muscles (fingers, eye) c. Paralysis of muscles of the limbs, neck, and trunk a. Paralysis of intercostals and diaphragm muscles

Signs and symptoms of catheter tip migration during the dwell time include: a. Loss of hearing b. Palpitations c. Increased respiratory rate d. Fever

b. Palpitations

Which of the following are local complications associated with infusion therapy? a. Speed shock, septicemia, and venous spasm b. Phlebitis, venous spasm, and hematoma c. Septicemia, thrombophlebitis, and hematoma d. Phlebitis, pulmonary edema, and speed shock

b. Phlebitis, venous spasm, and hematoma

During a patient's recovery from a lengthy surgery, the nurse monitors for signs of malignant hyperthermia. In addition to a rapid rise in body temperature, which assessment findings would indicate the possible presence of this condition? (Select all that apply.) a. Respiratory depression b. Tachypnea c. Tachycardia d. Seizure activity e. Muscle rigidity

b. Respiratory depression c. Tachypnea e. Muscle rigidity

A patient is about to receive a dose of the nonprotein plasma expander dextran. The nurse knows that this product is indicated for which type of blood loss? a. Slow loss of 20% or less b. Slow loss of 20% to 50% c. Slow loss of over 50% or acute loss of 20% d. Loss of 80% or more

b. Slow loss of 20% to 50%

A nurse is evaluating a client who began receiving IV therapy 3 hours earlier. The nurse observes that the client's face is flushed and that the client has an irregular pulse rate. The client reports having a headache and has a tight feeling in the chest. The nurse suspects speed shock, which is: a. a systemic disease caused by the presence of pathogenic microorganisms in the body. b. a systemic reaction that occurs when a foreign substance is rapidly introduced into the circulation. c. an undesirable effect occurring within a client, as a result of two or more drugs being given concurrently. d. a sudden obstruction of a blood vessel by a clot or foreign material that is formed or introduced into the circulatory system.

b. a systemic reaction that occurs when a foreign substance is rapidly introduced into the circulation

When assessing a patient who is about to receive an albumin infusion, the nurse knows that a contraindication for albumin would be a. acute liver failure. b. heart failure. c. severe burns. d. fluid-volume deficit.

b. heart failure

Which nursing diagnosis is possible for a patient who is now recovering after having been under general anesthesia for 3 to 4 hours during surgery? a. Impaired urinary elimination related to the use of vasopressors as anesthetics b. Increased cardiac output related to the effects of general anesthesia c. Risk for falls related to decreased sensorium for 2 to 4 days postoperatively d. Impaired gas exchange due to the CNS depressant effect of general anesthesia

d. Impaired gas exchange due to the CNS depressant effect of general anesthesia

You check an infusion site on a patient and find swelling and cool skin temperature. Also, the patient's skin appears blanched and feels rigid, and the infusion rate has slowed. These are signs of: a. Phlebitis b. Catheter embolus c. Hematoma d. Infiltration

d. Infiltration

A nurse assesses a client's central line and notes that it is not functioning properly. The nurse notes intermittent catheter malfunction, difficulty drawing blood, and positional IV. Compression of the catheter is confirmed by radiographic x-ray. What is the most likely explanation for these findings? a. Catheter malposition b. Catheter fracture c. Thrombophlebitis d. Pinch-off syndrome

d. Pinch-off syndrome

The physician has requested "lidocaine with epinephrine." The nurse recognizes that the most important reason for adding epinephrine is that it a. helps to calm the patient before the procedure. b. minimizes the risk for an allergic reaction. c. enhances the effect of the local lidocaine. d. reduces bleeding in the surgical area.

d. reduces bleeding in the surgical area

Nurses need to be particularly cautious when administering an intravenous (IV) fluid with _________________ in it. If this electrolyte is given too rapidly, it can cause cardiac dysrhythmias.

potassium