Unit 1 Semester 2
The nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs). Which statement by the client indicates effective learning? 1 "I will use condoms when having sex with an infected partner." 2 "I will perform a genital self-examination every month before bathing." 3 "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." 4 "I will consult with my primary health care provider when there is a rash or ulcer on my genitalia."
"I will consult with my primary health care provider when there is a rash or ulcer on my genitalia."
The nurse teaches a group of nursing students about the physiological changes that occur during pregnancy. Which statement by a student indicates effective teaching? 1 "Hepatic metabolism decreases for antiseizure medications." 2 "Enterohepatic recirculation causes a decrease in medication reabsorption." 3 "Bowel motility decreases, causing a decrease in intestinal transit time." 4 "Renal blood flow is doubled during the third trimester, which increases the glomerular filtration rate."
"Renal blood flow is doubled during the third trimester, which increases the glomerular filtration rate."
Which physiological changes are expected during the first trimester of pregnancy? Select all that apply. One, some, or all responses may be correct. 1 Fatigue 2 Increased libido 3 Morning sickness 4 Breast enlargement 5 Braxton Hicks contractions
1 Fatigue 3 Morning sickness 4 Breast enlargement
For a client with bipolar disorder in the manic phase, which signs and symptoms are expected? Select all that apply. One, some, or all responses may be correct. 1 Irritability 2 Grandiosity 3 Pressured speech 4 Thought blocking 5 Psychomotor retardation
1 Irritability 2 Grandiosity 3 Pressured speech
A pregnant woman continues to consume alcohol during pregnancy. Which teratogenic effects might the nurse expect to see in the fetus or neonate? Select all that apply. One, some, or all responses may be correct. 1 Stillbirth 2 Ebstein anomaly 3 Neural tube defects 4 Spontaneous abortion 5 Intellectual disabilities
1 Stillbirth 4 Spontaneous abortion 5 Intellectual disabilities
Which signs and symptoms are characteristic of Alzheimer dementia? Select all that apply. One, some, or all responses may be correct. 1 Ambivalence 2 Forgetfulness 3 Flight of ideas 4 Loose associations 5 Expressive aphasia
2 Forgetfulness 5 Expressive aphasia
Which signs and symptoms are the "four A's" of Alzheimer disease? 1 Amnesia, apraxia, agnosia, aphasia 2 Avoidance, aloofness, asocial, asexual 3 Autism, loose association, apathy, affect 4 Aggressive, amoral, ambivalent, attractive
Amnesia, apraxia, agnosia, aphasia
To implement primary prevention of sexually transmitted infections (STIs) the nurse is counseling an adolescent. Which would be the priority nursing action? 1 Help the adolescent recognize the risk. 2 Provide complete information about STIs. 3 Assess the adolescent's sexual risk behaviors. 4 Educate the adolescent about proper preventive measures.
Assess the adolescent's sexual risk behaviors.
Which sexually transmitted infection causes condylomata acuminate? 1 Chlamydia 2 Gonorrhea 3 Herpes simplex 4 Human papillomavirus (HPV)
Human papillomavirus (HPV)
Which nursing action has the highest priority for a client with delirium? 1 Maintaining skin integrity 2 Planning for behavioral interventions 3 Creating a calm and safe environment 4 Maintaining personal contact through touch
Creating a calm and safe environment
For a client with a bipolar mood disorder, manic episode, which factor would the nurse consider when planning care? 1 Client is likely to feel embarrassed by the manic behavior 2 Client is acutely aware of the environment and reality 3 Client should be able to control the acting-out behavior 4 Client is likely to engage in bingeing and purging behavior
Client is acutely aware of the environment and reality
The nurse understands that a teratogen would cause neural tube defects in which stage of pregnancy? 1 Fetal period 2 Presomite period 3 Embryonic period 4 Preimplantation period
Embryonic period
During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Which additional assessment would the nurse report immediately to the health care provider? 1 Increased appetite 2 Recent weight loss 3 Feelings of warmth 4 Fluttering in the chest
Fluttering in the chest
Which sexually transmitted infection receives antiviral medications as the treatment of choice? 1 Syphilis 2 Gonorrhea 3 Genital herpes 4 Chlamydial infection
Genital herpes
Which sexually transmitted infection is caused by a virus? 1 Syphilis 2 Gonorrhea 3 Genital warts 4 Chlamydial infection
Genital warts
Which symptom of mild anxiety would the nurse expect from the client at 6 weeks' gestation who appears mildly anxious as she waits for her first obstetric appointment? 1 Dizziness 2 Breathlessness 3 Abdominal cramps 4 Increased alertness
Increased alertness
For a client with bipolar I disorder, manic episode, which factor would be considered to meet rest and sleep needs? 1 Experiences few sleep pattern disturbances 2 Requires less sleep than the average person 3 Is easily stimulated, and this interferes with sleep 4 Needs to expend energy to be tired enough to sleep
Is easily stimulated, and this interferes with sleep
A client was prescribed a medication for pregnancy-induced hypertension and later developed muscle weakness, edema, and nausea. Which medication was administered to the client to treat pregnancy-induced hypertension? 1 Nifedipine 2 Terbutaline 3 Indomethacin 4 Magnesium sulfate
Magnesium sulfate
Which parameter would the nurse assess first when evaluating memory impairment in a client with Alzheimer disease? 1 Disorientation of self 2 Recollection of past events 3 Remembrance of recent events 4 Impaired ability to name objects
Remembrance of recent events
Which medication would the nurse expect to be prescribed first to reduce the symptoms of a female client who has severe cramping, pain, backache, and a migraine headache and presents with anxiety and mood swings? 1 Sertraline 2 Buspirone 3 Ibuprofen 4 Spironolactone
Sertraline
The nurse is assessing a pregnant client during the third trimester. Which clinical finding is expected in the later stages of pregnancy? 1 Tachycardia 2 Dyspnea at rest 3 Progressive dependent edema 4 Shortness of breath on exertion
Shortness of breath on exertion
A client with a bipolar disorder, depressed episode, displays an increase in depression over the past month. Which behavior is expected? 1 Elated affect 2 Loose associations 3 Physical exhaustion 4 Slowed thought processes
Slowed thought processes
A client abuses alcohol during pregnancy. Which condition would the nurse anticipate to see in the newborn? 1 Stillbirth 2 Heart defects 3 Growth delay 4 Multiple defects
Stillbirth
Which sexually transmitted infections are caused by bacteria? Select all that apply. One, some, or all responses may be correct. 1 Syphilis 2 Hepatitis 3 Gonorrhea 4 Herpes simplex 5 Trichomoniasis
Syphilis Gonorrhea
A medication is administered to a client in her third trimester of pregnancy. Which statement regarding the medication administration is correct? 1 The dose of medication should be increased for pregnant clients. 2 No medications should be administered to the pregnant client. 3 Medication dosages should not be altered for a pregnant client. 4 Medication dosage may need to be decreased for pregnant clients.
The dose of a medication should be increased for pregnant clients.
When assessing high-risk behaviors, which question specifically identifies a blood-related risk for a sexually transmitted infection? a. "Have you ever received donor semen, eggs, or transplanted tissue?" b. "Have you ever exchanged sex for drugs, money, or shelter?" c. "How do you protect yourself from HIV and sexually transmitted infections?" d. "Have you ever injected drugs using shared equipment?"
a. "Have you ever received donor semen, eggs, or transplanted tissue?"
A 29-yr-old female patient is diagnosed with Chlamydia during a routine pelvic examination. The nurse knows that teaching regarding the management of the condition has been effective when the patient says which of the following? a. "My partner will need to take antibiotics at the same time I do." b. "Go ahead and give me the antibiotic injection, so I will be cured." c. "I will use condoms during sex until I finish taking all the antibiotics." d. "I do not plan on having children, so treating the infection is not important."
a. "My partner will need to take antibiotics at the same time I do."
A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting? a. "What kinds of things do you do to reduce or cope with your stress?" b. "Tell me about your family history—do any relatives have problems with stress?" c. "Tell me about exercise—how far do you typically run when you go jogging?" d. "Stress can interfere with sleep. How much did you sleep last night?"
a. "What kinds of things do you do to reduce or cope with your stress?"
Which patient will the nurse plan on teaching about the Gardasil vaccine? a. A 24-yr-old female patient who has not been sexually active b. A 34-yr-old female patient who has multiple sexual partners c. A 24-yr-old female patient who is pregnant for the first time d. A 34-yr-old female patient who is in a monogamous relationship
a. A 24-yr-old female patient who has not been sexually active
The nurse in the outpatient clinic notes that the following patients have not received the human papillomavirus (HPV) vaccine. Which patients should the nurse plan to teach about benefits of the vaccine (select all that apply)? a. A 24-yr-old male patient who has a history of genital warts b. An 18-yr-old male patient who has had one male sexual partner c. A 38-yr-old female patient who has never been sexually active d. A 20-yr-old female patient who has a newly diagnosed Chlamydia infection e. A 30-yr-old female patient whose sexual partner has a history of genital warts
a. A 24-yr-old male patient who has a history of genital warts b. An 18-yr-old male patient who has had one male sexual partner d. A 20-yr-old female patient who has a newly diagnosed Chlamydia infection
The nurse is preparing assignments in a pediatric unit for the night shift. Which of the following would be appropriate to assign the LPN? a. A 5-year-old child who had an appendectomy about 6 hours ago b. A 4-year-old child admitted for severe epiglottitis who is running a fever of 102° F c. A 6-year-old child admitted with dehydration and receiving IV therapy d. A 7-year-old child who received inhalation burns 2 days ago and has a tracheostomy
a. A 5-year-old child who had an appendectomy about 6 hours ago
A patient complains of insomnia during his stay in the hospital. Which nursing diagnosis would be a top priority for this patient? a. Anxiety related to hospitalization b. Ineffective Coping related to hospitalization c. Denial related to hospitalization d. High Risk for Insomnia related to hospitalization
a. Anxiety related to hospitalization
What should the nurse do to assess competence before delegating a task to an LPN? a. Ask if the LPN has previous experience performing the task. b. Ask if the LPN is willing to perform the task. c. Ask another nurse if the LPN is competent. d. Assume the LPN is competent due to her years of service.
a. Ask if the LPN has previous experience performing the task.
A 46-yr-old patient who has had blood drawn for an insurance screening has a positive Venereal Disease Research Laboratory (VDRL) test. Which action should the nurse take next? a. Ask the patient about past treatment for syphilis. b. Explain the need for blood and spinal fluid cultures. c. Schedule fluorescent treponemal antibody absorption (FAT-Abs) testing. d. Assess for the presence of chancres, flulike symptoms, or a rash on the trunk.
a. Ask the patient about past treatment for syphilis.
Based on the goal of making optimal use of the level of preparation of the licensed practical nurse (LPN), which task should the nurse (RN) delegate to the LPN? a. Assisting with a lumbar puncture b. Transporting a patient to the radiology department c. Restocking the sterile supplies d. Distributing afternoon nutrition supplements
a. Assisting with a lumbar puncture
On vaginal examination of a 30-year-old woman, the nurse documents the following findings: profuse, thin, grayish white vaginal discharge with a "fishy" odor; complaint of pruritus. On the basis of these findings, the nurse suspects that this woman has: a. Bacterial vaginosis (BV). b. Candidiasis. c. Trichomoniasis. d. Gonorrhea.
a. Bacterial vaginosis (BV).
The nurse knows that which of the following medical conditions are most commonly associated with anxiety? (Select all that apply.) a. Cancer b. Pancreatitis c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism
a. Cancer c. Hypothyroidism d. Dysrhythmias e. Encephalitis f. Hyperthyroidism
A 19-yr-old patient has genital warts around her external genitalia and perianal area. She tells the nurse that she has not sought treatment until now because "the warts are so disgusting." Which nursing diagnosis is consistent with these data? a. Disturbed body image related to feelings about the genital warts b. Ineffective coping related to denial of increased risk for infection c. Risk for infection related to lack of knowledge about transmission d. Anxiety related to impact of condition on interpersonal relationships
a. Disturbed body image related to feelings about the genital warts
The nurse is teaching primary prevention of cognitive impairment at a community health fair. Which topics would be included in the presentation? (Select all that apply.) a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. c. Complete a Mini Mental Status Exam (MMSE) yearly. d. Correct acid-base imbalances related to underlying disease processes. e. Wear a seat belt whenever riding in a motorized vehicle. f. Complete a Confusion Assessment Method (CAM) scale yearly.
a. Do not use substances such as cannabis and alcohol. b. Wear helmets when riding bicycles and motorcycles. e. Wear a seat belt whenever riding in a motorized vehicle.
A 55-year-old male patient post-myocardial infarction (MI) asks the nurse whether he will be healthy enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and betablockers. During health teaching, the nurse understands that the three phases of the four-stage model of the human sexual response cycle that are of concern for this patient include which phases? a. Excitement, plateau, and orgasmic b. Plateau, orgasmic, and resolution c. Excitement, orgasmic, and resolution d. Arousal, excitement, and plateau
a. Excitement, plateau, and orgasmic
A woman has a thick, white, lumpy, cottage cheese-like discharge, with patches on her labia and in her vagina. She complains of intense pruritus. The nurse practitioner would order which preparation for treatment? a. Fluconazole b. Tetracycline c. Clindamycin d. Acyclovir
a. Fluconazole
A 39-yr-old patient with a history of IV drug use is seen at a community clinic. The patient reports difficulty walking, stating, "I don't know where my feet are." Diagnostic screening reveals positive Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FTA-Abs) test results. Based on the patient history, what will the nurse assess (select all that apply)? a. Heart sounds b. Genitalia for lesions c. Joints for swelling and inflammation d. Mental state for judgment and orientation e. Skin and mucous membranes for gummas
a. Heart sounds d. Mental state for judgment and orientation e. Skin and mucous membranes for gummas
Which viral sexually transmitted infection is characterized by a primary infection followed by recurrent episodes? a. Herpes simplex virus (HSV)-2 b. Human papillomavirus (HPV) c. Human immunodeficiency virus (HIV) d. Cytomegalovirus (CMV)
a. Herpes simplex virus (HSV)-2
Before beginning work on a culturally diverse hospital unit, the nurse should perform which action first? a. Improve self-awareness of one's own biases b. Attend an anti-discrimination rally or march c. Build rapport and trust with the patients d. Take a foreign language class
a. Improve self-awareness of one's own biases
A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement? a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.
a. Leave a night light on in the room at all times.
Which infection, reported in the health history of a female patient who is having difficulty conceiving, will the nurse identify as a risk factor for infertility? a. N. gonorrhoeae b. Treponema pallidum c. Condyloma acuminatum d. Herpes simplex virus type 2
a. N. gonorrhoeae
A patient in the medical-surgical unit is diagnosed with anemia and complains of weakness. Which of the following assignments could be given to the nursing assistant? a. Organize the patient's meal tray for dinner. b. Talk with the patient about managing rest and activities. c. Get a diet history and list of the patient's favorite foods. d. Take an apical pulse and listen to the lungs for crackles.
a. Organize the patient's meal tray for dinner.
An 82-year-old patient who is in the hospital awakens from sleep and is disoriented to where she is at the present time. The nurse reorients the patient to her surroundings and helps the patient return to sleep. What data does the nurse consider as a probable cause of the patient's confusion? a. Pain medication received earlier in the night b. The death of the patient's spouse 2 years ago c. The patient's history of diabetes d. The age of the patient
a. Pain medication received earlier in the night
A healthcare provider whose native country is India is explaining the treatment plan to a patient. The patient tells the nurse she is having trouble understanding the provider but is embarrassed about asking to repeat the information over and over. The nurse should assess for which results due to this disparity in provider-patient communication? (Select all that apply.) a. Patient dissatisfaction b. Optimal health outcome c. Poor adherence d. Increased patient confidence e. Improved communication
a. Patient dissatisfaction c. Poor adherence
An experienced nurse tells the student nurse, "I have found that most Hispanic immigrants live in unsanitary conditions but are hard workers." How should the student nurse best classify this statement? a. Stereotyping b. Prejudice c. Discrimination d. Misinformed
a. Stereotyping
An essential component of counseling women regarding safe sex practices includes discussion regarding avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections and human immunodeficiency virus is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to a number of aspects of condom use. The most important of these is: a. Strategies to enhance condom use. b. Choice of colors and special features. c. Leaving the decision up to the male partner. d. Places to carry condoms safely.
a. Strategies to enhance condom use.
A patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.
a. The patient was oriented and alert when admitted.
After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient? a. Tobacco use b. Family history c. Cholesterol level d. Head injury history
a. Tobacco use
What would be the best example of delegation? a. Transferring to another nurse the responsibility of caring for a patient requiring a blood transfusion b. Providing guidance to an LPN to hang blood on a patient c. Assigning a series of nursing unit tasks to the certified nursing assistant d. Assisting a new nurse to understand the rules and regulations of the Nurse Practice Act
a. Transferring to another nurse the responsibility of caring for a patient requiring a blood transfusion
A 20-yr-old female patient who is being seen in the family medicine clinic for an annual physical examination reports being sexually active. The nurse will plan to teach the patient about a. testing for Chlamydia infection. b. immunization for herpes simplex. c. infertility associated with the human papillomavirus (HPV). d. the relationship between the herpes virus and cervical cancer.
a. testing for Chlamydia infection.
A 25-year-old single woman comes to the gynecologist's office for a follow-up visit related to her abnormal Papanicolaou (Pap) smear. The test revealed that the patient has human papillomavirus (HPV). The client asks, "What is that? Can you get rid of it?" Your best response is: a. "It's just a little lump on your cervix. We can freeze it off." b. "HPV stands for 'human papillomavirus.' It is a sexually transmitted infection (STI) that may lead to cervical cancer." c. "HPV is a type of early human immunodeficiency virus (HIV). You will die from this." d. "You probably caught this from your current boyfriend. He should get tested for this."
b. "HPV stands for 'human papillomavirus.' It is a sexually transmitted infection (STI) that may lead to cervical cancer."
The nurse needs to discuss a problem with the nursing assistant. The nursing assistant has left several rooms cluttered with trash and not cleaned appropriately. Which comment by the nurse would be the best way to approach the problem? a. "I checked on the four rooms you were assigned, and they are really a mess." b. "Have you had a problem completing your work assignment today?" c. "All four of the patient rooms assigned to you today are messy with a lot of trash in them." d. "Family members have been really upset today. Why have you not cleaned up the rooms assigned to you?"
b. "Have you had a problem completing your work assignment today?"
The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate? a. "How do you feel about what happened to you as a child?" b. "How do you feel about what is going on right now?" c. "Remember a time when you were calm." d. "Tap your hands until the feeling goes away."
b. "How do you feel about what is going on right now?"
Which of the following statements indicates the nurse's understanding of accountability in the delegation process? a. "I am solely accountable for the actions of the delegate." b. "I am accountable for assessing the delegate's competency before delegation." c. "The delegate is responsible for telling the nurse if he/she is competent." d. "The manager is responsible for providing feedback to the delegate."
b. "I am accountable for assessing the delegate's competency before delegation."
The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"
b. "I don't know."
A 32-yr-old patient who is diagnosed with Chlamydia tells the nurse that she is very angry because her husband is her only sexual partner. Which response should the nurse make first? a. "You may need professional counseling to help resolve your anger." b. "It is understandable that you feel angry about contracting an infection." c. "Your feelings are justified and you should share them with your husband." d. "It is important that both you and your husband be treated for the infection."
b. "It is understandable that you feel angry about contracting an infection."
A nurse is reviewing delegation with a graduate nurse. The nurse knows that the teaching has been successful when the graduate nurse states which of the following? a. "The nurse can delegate assessments to the nurse assistants." b. "The nurse must create the care plan based on assessment findings." c. "The nursing assistants cannot perform bed baths on postsurgical patients." d. "The LPN can perform discharge teaching."
b. "The nurse must create the care plan based on assessment findings."
The nurse wishes to use guided imagery to help an anxious patient relax. Which comment would be appropriate to include in the guided imagery script? (Select all that apply.) a. "Imagine others treating you the way they should, the way you want to be treated..." b. "With each breath, you are feeling calmer, more relaxed, almost as if you are floating..." c. "You are alone on a beach; the sun is warm; and you hear only the sound of the surf..." d. "You have taken control; nothing can hurt you now; everything is going your way..." e. "You have grown calm; your mind is still; there is nothing to disturb your well-being..." f. "You will feel better as work calms down, as your boss becomes more understanding..."
b. "With each breath, you are feeling calmer, more relaxed, almost as if you are floating..." c. "You are alone on a beach; the sun is warm, and you hear only the sound of the surf..." e. "You have grown calm; your mind is still; there is nothing to disturb your well-being..."
The nurse is caring for diverse population groups at a health clinic. Which of the following patients demonstrates a potential health disparity group? a. A 26-year-old woman who is receiving follow-up after a car accident. b. A 30-year-old immigrant who does not speak English. c. A 28-year-old man who needs a tetanus booster. d. A 12-month-old with an appointment for immunizations.
b. A 30-year-old immigrant who does not speak English.
A nurse working in a pediatric clinic recognizes that which child is most at risk for cognitive impairment? a. An infant who is being fed reconstituted powdered formula b. A toddler living in an older home that is being remodeled c. A preschooler who attends a play group 3 days a week d. A school-age child who rides a school bus 5 days a week
b. A toddler living in an older home that is being remodeled
Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? a. Develop a plan to minimize difficult behavior. b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment. d. Refer the patient and caregivers to appropriate community resources. e. Help the patient and caregivers choose memory enhancement methods. f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.
b. Administer the prescribed memantine (Namenda). c. Remove potential safety hazards from the patient's environment.
The nurse in the immunization clinic should place emphasis on educating and reaching which groups about the disease preventing effects of immunizations? (Select all that apply.) a. Caucasian b. African American c. Low income d. Middle income e. High income
b. African American c. Low income d. Middle income
The charge nurse is assigning patients for care. There are two registered nurses (RNs), an LPN, and a certified nursing assistant (CNA). The charge nurse would assign which of the following patients to the LPN? a. An older adult who is receiving IV chemotherapy through a central line and will need a dressing change b. An adult patient diagnosed with insulin-dependent diabetes who will need dressing changes on several stasis ulcers on the lower extremities c. An adult patient with a right fractured femur and right arm in a cast who needs to urinate d. An older patient with terminal cancer who will be transferred to hospice
b. An adult patient diagnosed with insulin-dependent diabetes who will need dressing changes on several stasis ulcers on the lower extremities
There is a temporary agency registered nurse assigned to the nursing unit. You have no knowledge of this nurse's skills, and you want to assign the nurse to a patient who has a fresh tracheostomy. How should you handle this situation? a. Assign the nurse to the patient with the tracheostomy and hope for the best. b. Ask the nurse about his or her competency to care for the patient with the tracheostomy. c. Assign the patient to another nurse, and use the temporary agency nurse to do simple care tasks. d. Call the agency and ask for a nurse skilled in the care of a patient with a tracheostomy.
b. Ask the nurse about his or her competency to care for the patient with the tracheostomy.
To optimally use the level of preparation of the LPN who previously worked in an emergency department, which task should the registered nurse delegate to the LPN? a. Transporting a patient to the laboratory b. Assisting with a thoracentesis c. Restocking and counting the sterile supplies d. Passing afternoon nutrition supplements and waters
b. Assisting with a thoracentesis
The nurse is caring for a Chinese patient diagnosed with cancer who is suffering from pain, yet refuses analgesia administration. What type of health disparities is this patient exhibiting? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable
b. Avoidable and unacceptable
Which type of health disparities are most frequently encountered by nurses in clinical and community settings? a. Avoidable and acceptable b. Avoidable and unacceptable c. Unavoidable and acceptable d. Unavoidable and unacceptable
b. Avoidable and unacceptable
Care management of a woman diagnosed with acute pelvic inflammatory disease (PID) most likely would include: a. Oral antiviral therapy. b. Bed rest in a semi-Fowler position. c. Antibiotic regimen continued until symptoms subside. d. Frequent pelvic examination to monitor the progress of healing.
b. Bed rest in a semi-Fowler position.
The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic? a. Encourage the patient to begin dating again, perhaps with members of her church. b. Discuss how divorce support groups could increase coping and social support. c. Note that being so particular about potential friends reduces social contact. d. Discuss using the Internet as a way to find supportive others with similar values.
b. Discuss how divorce support groups could increase coping and social support.
What would be the best example of supervision? a. Assigning nursing care for a group of five patients to a nurse b. Following up with a CNA on the assigned task of ambulation and feeding two patients c. Assigning a urinary catheterization and collection of sterile culture to an LPN d. Scheduling the LPN to administer medications on the unit for the afternoon
b. Following up with a CNA on the assigned task of ambulation and feeding two patients
To detect human immunodeficiency virus (HIV), most laboratory tests focus on the: a. virus. b. HIV antibodies. c. CD4 counts. d. CD8 counts.
b. HIV antibodies.
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication
b. Having the patient's family member administer the medication
Which of the following statements about the various forms of hepatitis is accurate? a. A vaccine exists for hepatitis C but not for hepatitis B. b. Hepatitis A is acquired by eating contaminated food or drinking polluted water. c. Hepatitis B is less contagious than human immunodeficiency virus (HIV). d. The incidence of hepatitis C is decreasing.
b. Hepatitis A is acquired by eating contaminated food or drinking polluted water.
The viral sexually transmitted infection (STI) that affects most people in the United States today is: a. Herpes simplex virus type 2 (HSV-2). b. Human papillomavirus (HPV). c. Human immunodeficiency virus (HIV). d. Cytomegalovirus (CMV).
b. Human papillomavirus (HPV).
Which is the best strategy the nurse manager should include when working to reduce health care disparities on a medical-surgical unit? a. Less diverse workforce b. Increase interpreter availability c. Authoritarian leadership d. Annual staff training
b. Increase interpreter availability
The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? a. Have the patient take a mid-morning nap. b. Keep window blinds open during the day. c. Provide hourly orientation to time and place. d. Move the patient to a quiet room in the afternoon.
b. Keep window blinds open during the day.
A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.
b. Maintain a consistent daily routine for the patient's care.
The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? a. Suggest that a long-term care facility be considered. b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. d. Suggest that the spouse consult with the physician for antianxiety drugs. e. Ask the spouse what she knows and has considered about dementia care options.
b. Offer ideas for ways to distract or redirect the patient. c. Teach the spouse about adult day care as a possible respite. e. Ask the spouse what she knows and has considered about dementia care options.
A 37-year-old heterosexual African-American man has come for his annual health screening. Which test must the nurse ensure is ordered for this patient? a. Human papilloma virus (HPV) b. Prostate-specific antigen (PSA) c. HIV d. Venereal disease research laboratory (VDRL)
b. Prostate-specific antigen (PSA)
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had a fractured hip repair 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.
b. Remind the patient frequently about being in the hospital.
A patient seen in the outpatient clinic is diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.
b. Schedule the patient for more frequent appointments.
Which topics will the nurse include when preparing to teach a patient with recurrent genital herpes simplex (select all that apply)? a. Infected areas should be kept moist to speed healing. b. Sitz baths may be used to relieve discomfort caused by the lesions. c. Genital herpes can be cured by consistent use of antiviral medications. d. Recurrent genital herpes episodes usually are shorter than the first episode. e. The virus can infect sexual partners even when you do not have symptoms.
b. Sitz baths may be used to relieve discomfort caused by the lesions. d. Recurrent genital herpes episodes usually are shorter than the first episode. e. The virus can infect sexual partners even when you do not have symptoms.
Which of the following statements made by the charge nurse indicate appropriate delegation? (Select all that apply.) a. The LPN can delegate dressing changes to the nursing assistant. b. The LPN can administer a DPT immunization to a child. c. The LPN can add a dose of chemotherapy to an existing IV infusion. d. The nursing assistant can transfer a paraplegic patient from a wheelchair to the bed. e. The nursing assistant can assess vital signs on a patient 15 minutes after the transfusion has been started.
b. The LPN can administer a DPT immunization to a child. d. The nursing assistant can transfer a paraplegic patient from a wheelchair to the bed.
A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective? a. The medication will become effective immediately. b. The medication may take up to 12 weeks to become effective. c. The medication may take up to 6 weeks to become effective. d. The medication may take up to 4 weeks to become effective.
b. The medication may take up to 12 weeks to become effective.
The U.S. Centers for Disease Control and Prevention (CDC) recommends that HPV be treated with client-applied: a. Miconazole ointment. b. Topical podofilox 0.5% solution or gel. c. Penicillin given intramuscularly for two doses. d. Metronidazole by mouth.
b. Topical podofilox 0.5% solution or gel.
A patient admitted with chest pain is also found to have positive Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody absorption (FAT-Abs) tests, rashes on the palms and the soles of the feet, and moist papules in the anal and vulvar area. Which action will the nurse include in the plan of care? a. Assess for arterial aneurysms. b. Wear gloves for patient contact. c. Place the patient in a private room. d. Apply antibiotic ointment to the perineum.
b. Wear gloves for patient contact.
A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. a diagnosis of AD is made only after other causes of dementia are ruled out. c. new drugs have been shown to reverse AD deterioration dramatically in some patients. d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the diagnosis of AD.
b. a diagnosis of AD is made only after other causes of dementia are ruled out.
A patient with gonorrhea is treated with a single IM dose of ceftriaxone (Rocephin) and is given a prescription for doxycycline (Vibramycin) 100 mg bid for 7 days. The nurse explains to the patient that this combination is prescribed to a. prevent reinfection during treatment. b. treat any coexisting chlamydial infection. c. eradicate resistant strains of N. gonorrhoeae. d. prevent the development of resistant organisms.
b. treat any coexisting chlamydial infection.
A 48-yr-old male patient who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. In responding to the patient, the nurse explains that a. women do not develop gonorrhea infections but can serve as carriers to spread the disease to men. b. women may not be aware they have gonorrhea because they often do not have symptoms of infection. c. women develop subclinical cases of gonorrhea that do not cause tissue damage or clinical manifestations. d. when gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs
b. women may not be aware they have gonorrhea because they often do not have symptoms of infection.
A day shift nurse has come into work and notices that the glucometers were not tested overnight as they typically are. What is the best way for the nurse to question the nurse assistant in order to give feedback? a. "Why didn't you test the glucometers?" b. "What did you do last night?" c. "How was your night? I noticed the glucometers weren't tested." d. "Couldn't you have asked one of the nurses to check the glucometers if you were busy?"
c. "How was your night? I noticed the glucometers weren't tested."
After the nurse has taught a patient with a newly diagnosed sexually transmitted infection (STI) about expedited partner therapy, which patient statement indicates that the teaching has been effective? a. "I will tell my partner that it is important to be examined at the clinic." b. "I will have my partner take the antibiotics if any STI symptoms occur." c. "I will make sure that my partner takes all of the prescribed medication." d. "I will have my partner use a condom until I have finished the antibiotics."
c. "I will make sure that my partner takes all of the prescribed medication."
Which statement by a 24-yr-old patient indicates that the nurse's teaching about management of primary genital herpes has been effective? a. "I will use acyclovir ointment on the area to relieve the discomfort." b. "I will use condoms for intercourse until the medication is all gone." c. "I will take the acyclovir (Zovirax) every 8 hours for the next week." d. "I will need to take all of the medication to be sure the infection is cured."
c. "I will take the acyclovir (Zovirax) every 8 hours for the next week."
A patient who is dehydrated has been experiencing confusion. The daughter is concerned about taking the patient home in a confused state. What statement by the nurse is correct? a. "Don't worry; the patient should be fine once they are in a familiar environment." b. "I can make a referral for a home health aide to assist with the patient." c. "Once the dehydration is corrected, the patient's confusion should improve." d. "I can show you how to care for the patient once you return home."
c. "Once the dehydration is corrected, the patient's confusion should improve."
Which of the following represents appropriate feedback for an assignment to an LPN? a. "Did you understand the assignment that you received in the staff report?" b. "Have you completed the urinary catheterization and care of the new patient?" c. "The patient in Room 430 looks much better, and you did a good job of making the patient comfortable." d. "I know you are busy; however, you need to get caught up with your pain medications."
c. "The patient in Room 430 looks much better, and you did a good job of making the patient comfortable."
A patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.
c. loss of recent and long-term memory.
The nurse is sitting with the family of a patient who has just received the diagnosis of dementia. The family asks for information on what treatment will be needed to cure the condition. What is the nurse's best response? a. "Hormone therapy will reverse the condition." b. "Vitamin C and zinc will reverse the condition." c. "There is no treatment that reverses dementia." d. "Dementia can be reversed with diet, exercise, and medications."
c. "There is no treatment that reverses dementia."
When a 31-yr-old male patient returns to the clinic for follow-up after treatment for gonococcal urethritis, a purulent urethral discharge is still present. Which question will the nurse ask to identify a possible cause of recurrent infection? a. "Did you take the prescribed antibiotic for a week?" b. "Did you drink at least 3 quarts of fluids every day?" c. "Were your sexual partners treated with antibiotics?" d. "Do you wash your hands after using the bathroom?"
c. "Were your sexual partners treated with antibiotics?"
A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad right now?" b. "How is your self-image?" c. "What did you eat for lunch?" d. "Where were you were born?"
c. "What did you eat for lunch?"
26. The nurse should know that once human immunodeficiency virus (HIV) enters the body, seroconversion to HIV positivity usually occurs within: a. 6 to 10 days. b. 2 to 4 weeks. c. 6 to 8 weeks. d. 6 months.
c. 6 to 8 weeks.
The nurse is making assignments for the team. There are two LPNs and a nursing assistant on the team. Which of the following assignments would the nurse choose for him/herself? a. A patient with left-sided paralysis who needs help with bathing b. A patient with a chest tube who is ambulating in the hall c. A patient receiving chemotherapy for bone cancer d. A patient receiving tube feedings with a J-tube
c. A patient receiving chemotherapy for bone cancer
The school nurse is developing a curriculum for a junior human sexuality class. In order to provide the most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy for preventing sexually transmitted infections (STIs)? a. A vaccine to prevent HPV infection b. HIV screening c. Abstinence d. The male condom
c. Abstinence
The nurse who has been hired to work on an oncology unit identifies which group of women as being at highest risk of developing breast cancer? a. African b. Caucasian c. Asian d. Hispanic
c. Asian
When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? a. Check the patient's orientation to time and date. b. Obtain a list of the patient's prescribed medications. c. Ask the person to use a clock drawing to indicate a specific time. d. Determine the patient's ability to recognize a common object such as a pen.
c. Ask the person to use a clock drawing to indicate a specific time.
An experienced nursing assistant could be assigned by the nurse to do which of the following? a. Help teach new diabetic clients to give themselves injections. b. Report on quality and quantity of urine, and adjust drip rate on continuous bladder irrigation. c. Assist the client to obtain a clean-catch urine specimen. d. Chart the dietary intake of a client with an eating disorder.
c. Assist the client to obtain a clean-catch urine specimen.
The drug of choice for treatment of gonorrhea is: a. Penicillin G. b. Tetracycline. c. Ceftriaxone. d. Acyclovir.
c. Ceftriaxone.
When evaluating a patient for sexually transmitted infections (STIs), the nurse should be aware that the most common bacterial STI is: a. Gonorrhea. b. Syphilis. c. Chlamydia. d. Candidiasis.
c. Chlamydia.
Which task could a staff nurse delegate to a certified nursing assistant (CNA)? a. Evaluating a patient's response to pain b. Making rounds with a physician c. Feeding a stroke patient who has minimal dysphagia d. Assessing a patient's central venous line site
c. Feeding a stroke patient who has minimal dysphagia
Which diagnostic test is used to confirm a suspected diagnosis of breast cancer? a. Mammogram b. Ultrasound c. Fine-needle aspiration (FNA) d. CA 15.3
c. Fine-needle aspiration (FNA)
Which of the following tasks can the nurse safely delegate to the nursing assistant? a. Assessing the patients who are being discharged later today b. Giving discharge instructions to a patient c. Helping a patient select food according to the specified diet d. Educating the patient on what foods to eat for his/her diet plan
c. Helping a patient select food according to the specified diet
An older adult who is cognitively impaired is admitted to the hospital with pneumonia. Which sign or symptom would the nurse expect to be exhibited by the patient? a. Severe headache b. Flank pain c. Increased confusion d. Decreased blood glucose
c. Increased confusion
The nurse providing education regarding breast care should explain to the woman that fibrocystic changes in breasts are: a. A disease of the milk ducts and glands in the breasts. b. A premalignant disorder characterized by lumps found in the breast tissue. c. Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women during menstrual cycles. d. Lumpiness accompanied by tenderness after menses.
c. Lumpiness with pain and tenderness found in varying degrees in the breast tissue of healthy women during menstrual cycles.
Which hospitalized patient will the nurse assign to the room closest to the nurses' station? a. Patient with Alzheimer's disease who has long-term memory deficit b. Patient with vascular dementia who takes medications for depression c. Patient with new-onset confusion, restlessness, and irritability after surgery d. Patient with dementia who has an abnormal Mini-Mental State Examination
c. Patient with new-onset confusion, restlessness, and irritability after surgery
A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? a. Reorient the patient several times daily. b. Have the family bring in familiar items. c. Place the patient in a room close to the nurses' station. d. Ask the patient why the wandering episodes have occurred.
c. Place the patient in a room close to the nurses' station.
A male patient who has a profuse, purulent urethral discharge with painful urination is seen at the clinic. Which information will be most important for the nurse to obtain? a. Sexual orientation b. Immunization history c. Recent sexual contacts d. Contraceptive preference
c. Recent sexual contacts
The nurse is caring for a 44-year-old married woman who is complaining of painful intercourse and incontinence due to prolapse of reproductive organs. Clinical evaluation reveals that the patient has a cystocele. Which treatment option is most appropriate for this patient? a. Pelvic floor training b. Vaginal pessaries c. Surgical correction d. Lifestyle changes
c. Surgical correction
Which statements related to sexual dysfunction are correct? (Select all that apply.) a. Biological factors play a more significant role than psychologic factors. b. Sexual dysfunction is more prevalent among men than women. c. The best predictor of sexual health is emotional well-being. d. The patient with sexual dysfunction is at risk for anxiety and depression. e. Sexual dysfunction remains uncommon.
c. The best predictor of sexual health is emotional well-being. d. The patient with sexual dysfunction is at risk for anxiety and depression.
The nurse is reviewing new medication orders for several patients in a long-term care facility. Which patient does the nurse recognize as being at the highest risk for having cognitive impairment related to prescribed medications? a. The patient prescribed an antibiotic for a urinary tract infection. b. The patient prescribed a cholinesterase inhibitor for early Alzheimer's disease. c. The patient prescribed a beta-blocker for hypertension. d. The patient prescribed a bisphosphonate for osteoporosis.
c. The patient prescribed a beta-blocker for hypertension.
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Ask about a family history of dementia. b. Administer the Mini-Mental Status Exam. c. Use the Confusion Assessment Method tool. d. Obtain a list of the patient's usual medications.
c. Use the Confusion Assessment Method tool.
The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to a. reorient the patient to time, place, and person. b. administer a PRN dose of lorazepam (Ativan). c. assess for factors that might be causing discomfort. d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.
c. assess for factors that might be causing discomfort.
When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.
c. choose a place without distracting stimuli.
A patient is diagnosed with primary syphilis during her eighth week of pregnancy. The nurse will plan to teach the patient about the a. likelihood of a stillbirth. b. plans for cesarean section c. intramuscular injection of penicillin. d. antibiotic eye drops for the newborn.
c. intramuscular injection of penicillin.
In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse? a. A recently divorced 50-year-old woman b. A Hispanic teenage girl c. A 30-year-old African-American male d. An individual with intellectual or developmental disabilities
d. An individual with intellectual or developmental disabilities
The Delegation Decision Tree, which was prepared and adopted by the ANA and NCSBN, has specific steps. Identify the steps in this Decision Tree. (Select all that apply.) a. Monitoring b. Surveillance and supervision c. Read back and response d. Assessment and planning e. Evaluation f. Communication
d. Assessment and planning. f. Communication b.Surveillance and supervision e. Evaluation
The nurse has a full assignment. The charge nurse adds a newly admitted patient who will require close monitoring. Which task can the nurse delegate to the CNA who is co-assigned to the same patients? a. Teaching insulin self-administration b. Updating a care plan c. Evaluating goal attainment for a patient who is learning to walk with a below-the-knee prosthesis d. Bathing an unconscious patient
d. Bathing an unconscious patient
The nurse providing care in a women's health care setting must be aware regarding which sexually transmitted infection that can be successfully treated and cured? a. Herpes b. Acquired immunodeficiency syndrome (AIDS) c. Venereal warts d. Chlamydia
d. Chlamydia
A new nurse requires further teaching when failing to identify which practice as a health disparity? a. Annual mammogram b. Early prenatal care c. Blood pressure screening d. Frequent fast food meals
d. Frequent fast food meals
The nurse has just given a patient an opioid medication for pain relief. Because the nurse must leave the unit for lunch and a 1-hour meeting, the task of evaluating the patient's response to the pain medication must be delegated. To whom should the nurse delegate this responsibility? a. Nursing assistant b. Student nurse c. Licensed practical nurse d. Nurse manager
d. Nurse manager
After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? a. Patient who has not had a bowel movement for 5 days b. Patient who has a stage II pressure ulcer on the coccyx c. Patient who is refusing to take the prescribed medications d. Patient who developed a new cough after eating breakfast
d. Patient who developed a new cough after eating breakfast
The nurse is developing a care plan for a patient newly admitted to a unit that cares for patients with cognitive impairment. What is an important component of care for the patients on this unit? a. Allow food selections from a menu with several choices. b. Schedule frequent field trips off the unit for cognitive stimulation. c. Plan for attendance at activities with several other patients on the unit. d. Plan for a structured daily routine of events and caregivers.
d. Plan for a structured daily routine of events and caregivers.
A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time? a. Massage b. Meditation c. Guided imagery d. Relaxation breathing
d. Relaxation breathing
The two primary areas of risk for sexually transmitted infections (STIs) are: a. Sexual orientation and socioeconomic status. b. Age and educational level. c. Large number of sexual partners and race. d. Risky sexual behaviors and inadequate preventive health behaviors.
d. Risky sexual behaviors and inadequate preventive health behaviors.
What are potential causes of performance inadequacies? a. The person to whom the task was assigned had appropriate educational qualifications to complete the task. b. The task was assigned to a person capable of carrying out the assignment. c. The person who delegated the task confirmed the recipient's ability to perform the task. d. The person to whom the task was assigned did not understand what the task involved.
d. The person to whom the task was assigned did not understand what the task involved.
A registered nurse is feeling overwhelmed. Which of the following would be most appropriate for the registered nurse to delegate to an LPN? a. An initial assessment on a new patient b. Educational teaching on diabetes management c. Creating a care plan for a patient d. Updating the care plan for a patient who is post-op day 2
d. Updating the care plan for a patient who is post-op day 2
Determine how the registered nurse's role is different from that of the LPN in the assessment of the patient. a. Collects data during the health history and physical exam b. Contributes to the development of the care plan c. Assist in updating the care plan d. Uses findings from the assessment to create a care plan
d. Uses findings from the assessment to create a care plan
The recommended treatment for the prevention of human immunodeficiency virus (HIV) transmission to the fetus during pregnancy is: a. Acyclovir. b. Ofloxacin. c. Podophyllin. d. Zidovudine.
d. Zidovudine.
The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain at the patient's bedside and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.
d. assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.
A patient in the sexually transmitted infection (STI) clinic tells the nurse that she is concerned she may have been exposed to gonorrhea. To determine whether the patient has gonorrhea, the nurse will plan to a. interview the patient about symptoms of gonorrhea. b. take a sample of cervical discharge for Gram staining. c. draw a blood specimen or rapid plasma reagin (RPR) testing. d. obtain secretions for a nucleic acid amplification test (NAAT).
d. obtain secretions for a nucleic acid amplification test (NAAT).
