Week Two- Documenting, Vitals, Wound Care, & Pain
A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality. A. True B. False
A. True
Which instruction might the nurse give to the NAP to ensure that a wound culture specimen will be transported properly? A. "Wear sterile gloves when holding the specimen" B. "Take this specimen to the lab immediately" C. "Borrow a specimen collection kit from another unit if we're out of them" D. "Keep the specimen tube horizontal"
B. "Take this specimen to the lab immediately"
A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? A. Pulse B. Respirations C. Temperature D. Blood pressure
C. Temperature
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response? A. "Let me get that for you." B. "I am sorry I can't access that information." C. "The provider will need to give permission for you to review." D. "Only authorized persons are allowed to access client records."
D. "Only authorized persons are allowed to access client records."
When opening a JP drain, which issue should the NAP report immediately to the nurse as a potential abnormality? A. The drainage is odorless. B. The drainage is straw colored. C. The patient doesn't like looking at the drainage tubing. D. The amount of drainage was greater today than yesterday.
D. The amount of drainage was greater today than yesterday.
A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? A. serous B. purulent C. sanguineous D. serosanguineous
D. serosanguineous
Which question might the nurse ask the patient when an aerobic wound culture has been ordered? A. "Do you have any pain at the wound site?" B. "Have you ever collected a specimen from your wound before?" C. "Have you had any trouble breathing?" D. "Have your blood counts been high recently?"
A. "Do you have any pain at the wound site?"
The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? A. 40% of the circumference of the limb to be used B. 60% of the circumference of the limb to be used C. 70% of the circumference of the limb to be used D. 50% of the circumference of the limb to be used
A. 40% of the circumference of the limb to be used
A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? A. Tearing of a structure from its normal position B. Puncture of the skin C. Tearing of the skin and tissue with some type of instrument; tissue not aligned D. Cutting with a sharp instrument with wound edges in close approximation with correct alignment
A. Tearing of a structure from its normal position
A stage 3 pressure injury requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False
A. True
Blood vessels in the skin dilate to dissipate heat. A. True B. False
A. True
The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? A. 60 B. 80 C. 140 D. 200
B. 80
The nurse is assessing a client's surgical wound after abdominal surgery and sees viscera protruding through the abdominal wound opening. Which term best describes this complication? A. Fistula B. Evisceration C. Dehiscence D. Hemorrhage
B. Evisceration
The nurse is caring for a patient who reports feeling light headed and "woozy". The nurse checks the patient's pulse and finds that it is irregular. The patient's blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? A. Apply more pressure to the radial artery to feel pulse. B. Perform an apical/radial pulse assessment. C. Call the health care provider immediately D. Obtain arterial blood gases.
B. Perform an apical/radial pulse assessment.
A patient who has bone cancer is most likely experiencing which of the following types of pain? A. Cutaneous B. Somatic C. Visceral D. Referred
B. Somatic
The patient is found unresponsive and not breathing. Which pulse site will the nurse use? A. Radial B. Apical C. Carotid D. Brachial
C. Carotid
Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? A. Morphine B. hydromorphone C. gabapentin D. lorazepam
C. gabapentin
The client is self-monitoring blood pressure at home and reports that every reading is 150/90 mmHg. What is the priority nursing intervention? A. Ask the client to demonstrate self-blood pressure assessment B. Provide the client with a larger blood pressure cuff C. Recommend lower sodium in the client's diet D. Report readings to primary care provider
A. Ask the client to demonstrate self-blood pressure assessment
Which action would the nurse take to reduce the risk of wound infection when collecting a specimen for culture? A. Collect the specimen while wearing sterile gloves. B. Collect the specimen after washing the wound with sterile water. C. Collect the specimen before cleansing the wound. D. Collect the specimen after administering prescribed pain medication.
A. Collect the specimen while wearing sterile gloves.
Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? A. Contusion B. Abrasion C. Laceration D. Avulsion
A. Contusion
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? A. Elevating and supporting the stump B. Exerting equal, but not excessive, tension with each turn of the bandage C. Wrapping distally to proximally D. Keeping the bandage free of gaps between turn
A. Elevating and supporting the stump
After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for the nursing assistive personnel to position the patient for a sterile dressing change? A. Interlocking he fingers and keeping the hands above waist level. B. Keeping the arms at the sides, with elbows bent and gloved hands pointing up. C. Leaving the room momentarily. D. Stepping back from the bedside where the NAP is working
A. Interlocking he fingers and keeping the hands above waist level.
While preparing supplies on a sterile field, a gauze pad falls off the sterile field. What should the nurse do? A. Nothing. B. Create a new sterile field. C. Use sterile forceps to move the gauze pad toward the center of the sterile field D. Dispose of the gauze before continuing the procedure.
A. Nothing
The patient with heart failure is restless with a temperature of 102.2. What action will the nurse take? A. Place the patient on oxygen. B. Encourage the patient to cough. C. Restrict the patient's fluid intake. D. Increase the patient's metabolic rate.
A. Place the patient on oxygen
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient's pain? A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. B. Use a distraction technique to divert the patient's attention during the procedure. C. Position the patient comfortably before the intervention. D. Thoroughly explain the procedure to the patient.
A. Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.
During hospitalization, the client has developed shortness of breath with edema. What action should the nurse take? A. Revise the plan of care. B. Involve the family in changes. C. Implement changes in the current interventions. D. Review the nursing care plan.
A. Revise the plan of care.
A nurse is caring for a patient who has a temperature reading of 100.4. The patient's last two temperature readings were 98.6 and 96.8. What actions will the nurse take? A. Wait 30 minutes and recheck the patient's temperature B. Assume that the patient has an infection and order blood cultures C. Encourage the patient to move around to increase muscular activity. D. Be aware that temperatures this high are harmful and affect patient safety.
A. Wait 30 minutes and recheck the patient's temperature
Which nursing action demonstrates proper procedure when the collection of a wound culture specimen? A. Wearing clean gloves to remove soiled dressings. B. Using a circular motion to cleanse the wound before collecting the specimen. C. Completing the lab requisition form in a timely manner after collecting the specimen. D. Sending the specimen to the lab within 30 minutes of collecting it.
A. Wearing clean gloves to remove soiled dressings.
When are sterile nonlatex gloves recommended for a sterile procedure? A. When there is a possible sensitivity issue B. When the staff member prefers them C. When latex gloves are not conveniently available D. When the patient prefers them
A. When there is a possible sensitivity issue
Which direction to nursing assistive personnel (NAP) would help to maintain a sterile field while conducting a sterile procedure? A. "Please see to it that nothing contaminates this sterile field while I get some additional supplies." B. "I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing." C. "Hand me the item closest to the edge of the sterile field." D. "Place a sterile drape over these supplies for a moment while I answer my other patient's call light."
B. "I'd like you to make sure that the patient doesn't reach toward the sterile field while I'm changing the dressing."
The best judge of the existence and severity of a patient's pain is the physician or nurse caring for the patient. A. True B. False
B. False
A patient has the right to obtain, review, and revise the patient information in his or her health record. A. True B. False
B. False. They are able to review, but not revise.
The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? A. Allow the patient to breathe into a paper bag. B. Use oxygen cautiously in this patient. C. Administer high levels of oxygen. D. Give CO2 via a mask.
B. Use oxygen cautiously in this patient.
Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? A. Begin antibiotic therapy before the dressing change. B. Use the appropriate PPE C. Adhere to sterile technique during the intervention D. Complete the dressing change in an effective, timely way.
B. Use the appropriate PPE
A client's record can be more accurate if the nurse: A. Charts at least every 6 hours. B. Uses point-of-care documentation. C. Summarizes client care at the end of the shift. D. Delegates charting appropriately.
B. Uses point-of-care documentation.
A sedated patient is frequently drowsy and drifts off during his conversation with the nurse. What number on the sedation scale best describes this patient? A. 1 B. 2 C. 3 D. 4
C. 3
When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? A. After performing hand hygiene at the start of the procedure. B. Before removing the inner dressing. C. After removing the original dressing materials and performing hand hygiene a second time. D. Just before cleansing the wound with sterile water.
C. After removing the original dressing materials and performing hand hygiene a second time.
Which action would the nurse perform first when preparing to apply sterile gloves? A. Perform hand hygiene. B. Place the package on a stable, flat surface. C. Assess the glove packaging for wetness or tears. D. Open the outer packaging.
C. Assess the glove packaging for wetness or tears.
Which factor is not known to cause false blood pressure readings? A. Eating B. Having the client's legs crossed at the knee C. Being in a warm environment D. Smoking
C. Being in a warm environment
Which action would minimize the risk of infection when placing prepackaged supplies on an established sterile field. A. Wear clean treatment gloves. B. Collect supplies with sterile gloves to avoid contamination. C. Do not allow the wrapper to touch the sterile field. D. Place the supplies in the 1-inch perimeter of the sterile field.
C. Do not allow the wrapper to touch the sterile field.
Which modulator of pain is thought to reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons? A. Endorphins B. Dynorphins C. Enkephalins D. Nociceptors
C. Enkephalins
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? A. Primary intention B. Tertiary intention C. Secondary intention D. Malnutrition
C. Secondary intention
What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands? A. Using powdered sterile gloves B. Keeping the fingernails trimmed and smoothly filed C. Selecting the proper glove size D. Drying the hands thoroughly before applying the gloves
C. Selecting the proper glove size
A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure? A. Smoking increases BP for up to 3 hours. B. Caffeine increases BP for up to 15 minutes. C. Smoking result in vasoconstriction, falsely elevating BP. D. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.
C. Smoking result in vasoconstriction, falsely elevating BP.
Which protocol does not vary among institutions? A. Acceptability of wearing artificial nails in patient care areas. B. Use of impervious transparent dressings to cover open lesions on nurse's hands during sterile procedures. C. Use of sterile gloves for sterile procedures. D. Sterile gloves are only available in "one size fits all"
C. Use of sterile gloves for sterile procedures.
In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase
C. proliferation phase
Which following pain assessment tool is recommended for use with neonates ages 0 to 6 months? A. Oucher pain scale B. Wong-Baker FACES C. FLACC pain scale D. CRIES pain scale
D. CRIES pain scale
What is the nursing action to set up suction for a Hemovac drainage system? A. Set the suction to the lowest level possible. B. The hemovac is always set to medium suction. C. Connect to the wall on intermediate suction. D. Compress the hemovac, creating suction.
D. Compress the hemovac, creating suction.
What is the nurse's best response when additional drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago? A. Notify the surgeon of the bleeding. B. Remove the dressing and assess the wound. C. Assess the patient for signs of shock. D. Further assess the patient and the wound.
D. Further assess the patient and the wound.
Which wound complication is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration
D. Maceration
The nurse is placing supplies on a sterile field that is being prepared for a dressing change. Which action is likely to contaminate the field? A. Placing a role of sterile tape on the field. B. Holding a prepackaged sterile item in the nondominant hand while opening it. C. Adding supplies that will expire in 2 days. D. Placing the needed supplies near the back of the sterile field.
D. Placing the needed supplies near the back of the sterile field.
A patient requires all of the following interventions. Which one would the nurse perform last? A. Change the dressing on the patient's newly established suprapubic catheter. B. Administer the patient's prescribed medication. C. Offer the patient a bedpan. D. Position the patient for maximum comfort and ease of breathing.
D. Position the patient for maximum comfort and ease of breathing.
What dual purpose does an audit serve? A. Communication and evaluation B. Knowledge and quality C. Education and confidentiality D. Quality assurance and reimbursement
D. Quality assurance and reimbursement
The healthcare provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first? A. Explain the purpose of the test to the patient. B. Assess the level of the patient's pain at the wound site. C. Assess the patient for signs and symptoms of infection. D. Review the type of order to determine the type of specimen to be collected.
D. Review the type of order to determine the type of specimen to be collected.
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? A. The patient has a fever B. The patient has possible hemorrhage or bleeding. C. The patient has chronic obstructive pulmonary disease (COPD) D. The patient has calcium channel blockers or digitalis medication prescriptions.
D. The patient has calcium channel blockers or digitalis medication prescriptions.
A nurse is caring for a client whose injured cells are releasing chemicals such as prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing? A. Perception B. Transmission C. Modulation D. Transduction
D. Transduction
Which action would minimize the risk for cross-contamination while cleansing an infected abdominal wound? A. Cleansing the wound with sterile water. B. Blotting the incision with dry gauze. C. Wearing sterile gloves to cleanse the wound. D. Using a new gauze pad for each stroke while cleansing the wound.
D. Using a new gauze pad for each stroke while cleansing the wound.
What is the proper method for cleansing the evacuation port of a wound drainage system? A. Cleanse it with normal saline. B. Wash it with soap and warm water. C. Rinse it with sterile water. D. Wipe it with an alcohol sponge.
D. Wipe it with an alcohol sponge.
A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: A. to decrease dead space by decreasing drainage. B. to provide a sinus tract for drainage. C. to divert drainage to the peritoneal cavity. D. to provide drainage for bile.
D. to provide drainage for bile.
How should the nurse position the head of the bed for a client receiving epidural opioids? A. Flat B. Trendelenburg C. Elevated 30 degrees D. Reverse Trendelenburg
C. Elevated 30 degrees
An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: A. Prickly heat B. Lanugo. C. Milia. D. Acne vulgaris.
C. Milia.
The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief? A. Acknowledge the pain as the client reports it and administer pain medication as prescribed. B. Take the client's vital signs often to observe for changes that may indicate pain. C. Report the client to the health care provider for seeking drugs. D. Observe the client's behavior when the nurse is not with the client.
A. Acknowledge the pain as the client reports it and administer pain medication as prescribed.
A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered? A. PRN order B. one-time order C. stat order D. standing order
A. PRN order
Assessment of the pulse amplitude is accomplished by: A. Palpating the flow of blood through an artery. B. Auscultating the area of the left ventricle. C. Palpating the area of the left ventricle. D. Auscultating the flow of blood through an artery.
A. Palpating the flow of blood through an artery.
The normal adult temperature obtained through the oral route ranges from: A. 96.6°F to 98.6°F (35.9°C to 37.0°C). B. 97.6°F to 99.6°F (36.4°C to 37.6°C). C. 98.6°F to 100.4°F (37.0°C to 38.0°C). D. 98.2°F to 100.2°F (36.8°C to 37.9°C).
B. 97.6°F to 99.6°F (36.4°C to 37.6°C).
The nurse assesses a client admitted with multiple trauma including basilar skull fracture and rhinorrhea (drainage from nose), bilateral otorrhea (drainage from ear), and multiple fractures requiring a full body cast. The client is on a 40% Venturi oxygen mask. What is the best way to evaluate the client's temperature? A. Axillary B. Oral C. Tympanic D. Temporal artery
D. Temporal artery
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate? A. "Any information that can identify a person is considered a breach of client privacy." B. "You may continue to post about a client, as long as you do not use the client's name." C. "All aspects of clinical practice are confidential and should not be discussed." D. "The information being posted on social media is inappropriate. Make sure to discuss information about clients privately with friends and family."
"Any information that can identify a person is considered a breach of client privacy."
A nurse is documenting client care using the SOAP format. Place the statements listed below in the order that the nurse would record them. A. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature. B. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. C. Fever, possible urinary tract infection D. "I don't feel well. I've been urinating often, and it burns when I urinate."
1. "I don't feel well. I've been urinating often, and it burns when I urinate." 2. Abdomen soft non-tender. Urine dark yellow and cloudy. Temperature 100.8 degrees F. Indwelling urinary catheter removed 2 days ago. 3. Fever, possible urinary tract infection 4. Notify Dr. Phillips of fever and client complaints. Encourage fluids, continue to monitor temperature.
The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options. A. Place the Doppler tip in the gel and move it around until hearing the pulse. B. Inflate the cuff while continuing to use the Doppler device on the artery. C. Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. Wrap the cuff around the limb smoothly and snugly, and fasten it. D. Note the point on the gauge where the pulse disappears. E. Place a small amount of conducting gel over the artery.
1. Center the bladder of the cuff over the artery, lining the artery marker on the cuff up with the artery. Wrap the cuff around the limb smoothly and snugly, and fasten it. 2. Place a small amount of conducting gel over the artery. 3. Place the Doppler tip in the gel and move it around until hearing the pulse. 4. Inflate the cuff while continuing to use the Doppler device on the artery. 5. Note the point on the gauge where the pulse disappears.
Which statement regarding FOCUS charting is most accurate? A. The charting focuses on client strengths, problems, or needs. B. The charting focuses on the injury or illness only. C. Problem, intervention, evaluation (PIE) charting is used with FOCUS charting. D. Each note should include each section of the data, action, response (DAR) format of charting.
A. The charting focuses on client strengths, problems, or needs.
Changes in the rate and depth of inhalation and exhalation are brought about by the inhibition or stimulation of the respiratory muscles by respiratory centers in the medulla and pons. A. True B. False
A. True
One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care. A. True B. False
A. True
The normal pulse rate for adolescents and adults ranges from 60 to 100 beats/min. A. True B. False
A. True
The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point? A. reviewing and revising the pain management treatment plan B. beginning pain medications before the pain is too severe C. administering a placebo and performing a reassessment of the pain D. judging whether the client is in pain or is just depressed
A. reviewing and revising the pain management treatment plan
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication? A. "It seems like this client has fluid volume overload." B. "I think the client would benefit from intravenous furosemide." C. "I am calling because the client receiving blood has developed dyspnea and had crackles." D. "This client has a medical history of heart failure."
B. "I think the client would benefit from intravenous furosemide."
A nurse is assessing the respiratory rate of a sleeping 28-day-old infant. What would the nurse document as a normal finding? A. 80-100 breaths/min B. 30-60 breaths/min C. 12-20 breaths/min D. 60-80 breaths/min
B. 30-60 breaths/min
A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? A. Notify the surgeon STAT B. Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement C. Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon D. Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon
B. Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement
What is the term for the heat that is lost when a person goes out in the cold without a hat? A. Convection B. Radiation C. Evaporation D. Conduction
B. Radiation
An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug? A. The client experiences respiratory depression after the drug takes effect. B. The client exhibits restless, uncharacteristic behavior after receiving the drug. C. The client is unable to sleep without medication the following night. D. In the morning, the client is unable to identify his location or the day of the week.
B. The client exhibits restless, uncharacteristic behavior after receiving the drug.
The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? A. The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. B. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. C. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain. D. The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain.
B. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.
The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? A. The nurse packs the wound cavity tightly with dressing material. B. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. C. The nurse uses wet-to-dry dressings continuously. D. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown.
B. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.
A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as A. "You will need more pain medication as the days progress." B. "Your present pain is worse because you had your packing removed." C. "Acute pain tends to increase during the day and is called a routine pain response" D. "I will call your doctor because you may have loosened sutures when walking."
C. "Acute pain tends to increase during the day and is called a routine pain response"
The nursing student is discussing the need for a care plan with the instructor. What is the most appropriate explanation by the instructor for nursing care plan development? A. "The care plan is the only way for nurses to document what they do." B. "The care plan provides additional documentation about the work of the nurse." C. "The care plan is required for every client by The Joint Commission." D. "The care plan shows the medical diagnosis for the client."
C. "The care plan is required for every client by The Joint Commission."
The nurse is providing in-home care for a client recently prescribed antihypertensive medication. Upon evaluation the nurse obtains a blood pressure reading of 92/58 mm Hg and alerts the provider. In which manner will the nurse execute verbal orders from provider? A. The nurse can implement care once written orders are received from the provider. B. The client must be stabilized before the nurse can obtain any orders from the provider. C. The nurse can accept verbal orders to provide immediate care and record once the client is stable. D. The provider can input orders remotely into the EHR system for the nurse to retrieve.
C. The nurse can accept verbal orders to provide immediate care and record once the client is stable.
The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? A. Use the Bell side of the stethoscope to listen. B. Ask another student nurse to check it for him. C. Use the Doppler ultrasound device. D. Connect the client to the oxygen saturation monitoring device.
C. Use the Doppler ultrasound device.
Which documentation by the nurse best supports the PIE charting system? A. Vomiting 250 mL undigested food, states abdominal pain, blood pressure 114/68 mm Hg B. States nauseated, vomiting 250 mL undigested food, hypoactive bowel sounds, antiemetic given C. Vomiting 250 mL undigested food, antiemetic given, no further vomiting D. Blood pressure 88/42 mm Hg, 500 mL IV fluids given, no statements of nausea
C. Vomiting 250 mL undigested food, antiemetic given, no further vomiting
When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should: A. assume the client does not need medication. B. ask the client's family if he ever uses pain medicines. C. actively solicit information about the client's pain level. D. document the client's lack of medication.
C. actively solicit information about the client's pain level.
The action of ibuprofen is to: A. enhance the endorphins of the CNS. B. provide opioid pain relief C. have an antiprostaglandin effect on the CNS. D. close the gate of the A-delta fibers
C. have an antiprostaglandin effect on the CNS.
The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate? A. "The benefit of CBE is that it demonstrates whether high-quality care is given." B. "CBE is the best way to protect against lawsuits." C. "CBE is a relatively new format of documentation in electronic health records." D. "The benefit of CBE is less time needed on computer charting."
D. "The benefit of CBE is less time needed on computer charting."
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? A. 0300 B. 1100 C. 1500 D. 1700
D. 1700
A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. B. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. C. A Penrose drain is a closed drainage system that is connected to an electronic suction device. D. A Penrose drain promotes passive drainage into a dressing.
D. A Penrose drain promotes passive drainage into a dressing.
Which pulse site is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. Brachial
D. Brachial
The nurse is caring for a client with hypertension, and only documents a blood pressure of 170/100 mmHg when all other vital signs are normal. This reflects what type of documentation? A. SOAP B. Narrative C. Focus D. Charting by exception
D. Charting by exception
The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? A. Notify the wound care nurse B. Change the dressing C. Notify the health care provider D. Document the findings
D. Document the findings
A nurse walks into the room of a client, who is to be discharged, and notes the client appears to be sleeping. The nurse observes the client's breathing pattern. The client is not breathing; then appears to breathe with the depths of the respirations appearing to increase, then decrease; and then stops breathing again. Which action should the nurse prioritize? A. Raise the head of the bed to 90 degrees B. Obtain a full set of vitals C. Place the client on oxygen D. Notify the health care provider
D. Notify the health care provider
The nurse is assessing an adult who has a pulse rate of 150 beats/min. Which action should the nurse take next? A. Obtain the client's blood pressure B. Assess the client for allergic reaction C. Administer epinephrine immediately D. Notify the health care provider of tachycardia
D. Notify the health care provider of tachycardia
A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? A. Stop removing staples and apply an abdominal pad over the incision. B. Apply an occlusive pressure dressing after removing the staples. C. Apply adhesive wound closure strips after each staple is removed. D. Stop removing staples and inform the surgeon
D. Stop removing staples and inform the surgeon
A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? A. The blood pressure is elevated B. A baseline pulse rate is needed C. The carotid pulse is bounding D. The radial pulse is too difficult to obtain
D. The radial pulse is too difficult to obtain.
A nurse is explaining to a nursing student why blood pressure is a frequently used assessment parameter in a wide variety of care settings. What can be inferred from an assessment of a client's blood pressure? A. The amount of oxygen available to tissues throughout the body B. The volume of the venous system relative to the volume of the arterial system C. The size of the client's heart muscle D. The resistance that the client's heart must overcome when pumping blood
D. The resistance that the client's heart must overcome when pumping blood
The nurse is performing a telephone follow-up with parents whom she taught to monitor their newborn's BP and pulse at home. Which results reported by the parents would indicate that the parents are performing the technique correctly and there is no cause for concern? A. 70/40 mmHg and 145 bpm B. 120/80 mmHg and 60 bpm C. 90/50 mmHg and 85 bpm D. 102/80 mmHg and 60 bpm
A. 70/40 mmHg and 145 bpm
The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply. A. After introductions, the nurse states the client name, room number, and problem. B. The nurse asks the health care provider to comment on the present situation before giving recommendations. C. The nurse asks the health care provider to describe the admitting diagnosis of the client. D. The nurse states that the client's condition "could be life-threatening." E. The nurse reads back the physician's new orders at the conclusion of the call. F. The nurse asks the health care provider to estimate the discharge date for the client.
A. After introductions, the nurse states the client name, room number, and problem. B. The nurse states that the client's condition "could be life-threatening." E. The nurse reads back the physician's new orders at the conclusion of the call.
The nurse is talking to an older adult client who performs home blood pressure monitoring (HBPM) and finds that recently her BP measurements have consistently been low. Which factors may contribute to causing this client's BP to be falsely decreased? Select all that apply. A. Applying too wide a cuff B. Applying a cuff that is too narrow C. Assessing the BP immediately after exercise D. Releasing the valve rapidly E. Using cracked or kinked tubing
A. Applying too wide a cuff D. Releasing the valve rapidly E. Using cracked or kinked tubing
A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation? A. Attach a copy of the incident report to the chart. B. Fill out an incident report. C. Stop the infusion and document the time. D. Report the error to the primary provider.
A. Attach a copy of the incident report to the chart.
The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order? A. Confused to time and place B. Right shoulder immobilizer in place C. Rates pain as 8 on a 0 to 10 scale D. B/P 178/92 and pulse 118
A. Confused to time and place
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A. Identifying risks and ensuring future safety for clients. B. Gauging the nurse's professional performance over time. C. Protecting the nurse and the hospital from litigation. D. Following up the incident with other members of the care team.
A. Identifying risks and ensuring future safety for clients.
A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply. A. Observe the client B. Use the Wong-Baker FACES pain rating scale. C. Ask the parent if the client is in pain D. Ask the client to describe the pain E. Use the numeric rating scale
A. Observe the client B. Use the Wong-Baker FACES pain rating scale. D. Ask the client to describe the pain
Which actions should the nurse take before making an entry in a client's record? Select all that apply. A. Reviewing the agency's list of approved abbreviations B. Choosing the charting format that the nurse prefers C. Locating clients' files within an electronic health record system D. Identifying the form appropriate to be used for documenting E. Checking that clients' names are not identified within the chart forms
A. Reviewing the agency's list of approved abbreviations C. Locating clients' files within an electronic health record system D. Identifying the form appropriate to be used for documenting
A nurse working in a rural setting is documenting care using a paper format. The nurse records the routine care, normal findings, and client problems in a narrative note. The nurse reviews the physician's information in the physician's progress notes. The nurse is using which method of documentation? A. Source-oriented B. Problem-oriented C. PIE charting D. Charting by exception
A. Source-oriented
The nurse is caring for client prescribed morphine who is experiencing constipation. What intervention should the nurse recommend to the client? (Select all that apply.) A. Stool softner B. Increase fluids C. Enema D. Increase protein E. Increase fiber
A. Stool softner B. Increase fluids E. Increase fiber
A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first? A. Stop the PCA pump B. Administer naloxone. C. Increase the primary IV rate. D. Notify the physician
A. Stop the PCA pump
The nurse is interviewing a newly admitted client. Quoting statements made by the client will help in maintaining what type of assessment data? A. Subjectivity B. Objectivity C. Organization D. Reimbursment
A. Subjectivity
The nurse prepares to take a temperature of a client admitted with a myocardial infarction. The client is eating breakfast. Which action should the nurse choose? A. Take the temperature using the axillary route. B. Wait 3 to 5 minutes after breakfast to take the oral temperature. C. Assess the temperature using the rectal route. D. Cleanse the temporal artery thermometer to prevent a false high reading.
A. Take the temperature using the axillary route.
A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action? A. Teach the client to perform deep-breathing and coughing exercises. B. Arrange for a high-protein, low-residue diet. C. Apply sequential compression stockings. D. Encourage the client to drink an 8-oz glass of water every 2 hours.
A. Teach the client to perform deep-breathing and coughing exercises.
The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed? A. Assess blood pressure B. Assess temperature C. Let the patient sleep D. Call the health care provider
B. Assess temperature
A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain? A. Chronic pain B. Acute pain C. Referred pain D. Limited pain
C. Referred pain
A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? A. "It is because of the closely woven dark fabric wrapped around the baby." B. "It is because of the immature ability to regulate temperature in general." C. "It is common for newborns to have body temperatures less than 36.4°C (97.6°F)." D. "The baby is showing how it is adapting to the environmental temperature."
B. "It is because of the immature ability to regulate temperature in general."
A nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as? A. A never event B. A variance C. An audit D. A sentinel event
B. A variance
A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse? A. Administer the medication when the client's blood pressure is > 140/90. B. Administer the medication if respiratory rate is > 9. C. Administer the medication when the client's heart rate is < 90. D. Administer the medication when the client's heart rate is > 80.
B. Administer the medication if respiratory rate is > 9.
The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? A. The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. B. The nurse meets with nurses or other health care professionals to discuss some aspect of client care. C. The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. D. The nurse sends or directs someone to take action in a specific nursing care problem.
B. B. The nurse meets with nurses or other health care professionals to discuss some aspect of client care.
A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse? A. Discard the swab and inform the health care provider that the wound is too infected to culture B. Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab C. Obtain the swab and then clean the wound D. Obtain the swab as prescribed and send it to the lab for culture
B. Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab
The nurse is caring for a 72-year-old client who has a history of asthma and hypertension and recently had some medication changes. Which action should the nurse prioritize after noting the client has a diminished appetite with reports of nausea as well as dizziness upon standing? A. Assess for infection B. Evaluate new cardiovascular medications C. Obtain complete vital signs D. Institute precautions against falling
B. Evaluate new cardiovascular medications
While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant? A. Braden scale B. FLACC scale C. FACES scale D. Apgar score
B. FLACC scale
A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse likely document the results? A. Progress note B. Graphic sheet C. Admission nursing assessment D. Medical record
B. Graphic sheet
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? A. Increased temperature B. Increased pulse rate C. Increased respiration rate D. Increased blood pressure
B. Increased pulse rate
Which is a drawback to the type of documentation known as charting by exception? A. Interference with standardized assessments B. Issues related to high-quality care should a negligence claim arise C. Increased time required to document information D. Less interdisciplinary communication
B. Issues related to high-quality care should a negligence claim arise
A cancer client's care plan includes the use of a transcutaneous electrical nerve stimulation (TENS) unit. Which action should be included in the plan? A. Water should be kept far from the client to reduce the risk of electrocution. B. The unit should be turned off whenever repositioning the electrodes. C. TENS should not be used if the client is being treated with opioid analgesics. D. Unlicensed assistive personnel (UAP) may apply the device, if necessary.
B. The unit should be turned off whenever repositioning the electrodes.
A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? A. Apply moist dressing B. Wound irrigation C. Debridement D. Gentle cleansing
B. Wound irrigation
A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? A. "This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction." B. "The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." C. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." D. "The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider."
C. "The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."
A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting? A. Problem, intervention, evaluation (PIE) charting B. Variance charting C. Charting by exception (CBE) D. FOCUS charting
C. Charting by exception (CBE)
The nurse identifies the auscultatory gap while taking the client's blood pressure. What should the nurse do next? A. Use the bell of the stethoscope to listen for the diastolic sound. B. Record the reading in the chart. C. Inflate the cuff about 30 mm Hg above the auscultatory gap. D. Inflate the cuff about 10 mm Hg above the auscultatory gap.
C. Inflate the cuff about 30 mm Hg above the auscultatory gap.
Which method of documentation is unique in that it does not develop a separate care plan but instead incorporates the care plan into the progress notes? A. Source-oriented records B. Problem-oriented records C. PIE (problem, intervention, evaluation) D. Focus charting
C. PIE (problem, intervention, evaluation)
The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use? A. Palpate both arteries at the same time. B. Measure the rate for 1 full minute. C. Palpate one artery at a time. D. Measure the rate for 30 seconds and multiply by 2.
C. Palpate one artery at a time.
A client with the history of systemic lupus erythematosus underwent a surgical repair of a right inguinal hernia. The client now presents to the emergency department with the report that the incision appears to have opened. Which action should the nurse prioritize after performing the focused assessment? A. Collect drainage from skin for culture and sensitivity testing B. Administer ibuprofen for pain C. Question the use of Prednisone D. Request a stronger pain medication
C. Question the use of Prednisone
Three days after surgery, a client continues to have moderate to severe incisional pain. Based on the gate-control theory, what action should the nurse take? A. Administer pain medications in smaller doses but more frequently. B. Decrease external stimuli in the room during painful episodes. C. Reposition the client and gently massage the client's back. D. Advise the client to try to sleep following administration of pain medication.
C. Reposition the client and gently massage the client's back.
The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate? A. If a client is experiencing adverse effects, a peripheral IV line should be inserted to allow immediate administration of emergency drugs, if warranted. B. The nurse should expect slight resistance during the removal of the epidural catheter. C. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min. D. If the client develops a headache, an opioid analgesic may be administered along with the epidural analgesia.
C. The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.
A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify? A. Preferred site for temperature assessment. B. The client's nutritional status. C. The client's most recent temperature. D. The client's wellness goals.
C. The client's most recent temperature.
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson-Pratt drain? A. Allowed the Jackson-Pratt drain to hang freely to avoid any kinks in the tubing. B. Apply an abdominal binder over the entire wound and drain to support the site. C. Tape the drain to the dressing material securely below the level of the wound. D. Secure the drain to the client's gown with a safety pin below the level of the wound.
D. Secure the drain to the client's gown with a safety pin below the level of the wound.
A client was recently hospitalized. To process insurance payment, the insurance company requested access to the client's payment information. What is the most appropriate response to maintain client privacy? A. Do not release any information to the insurance company. B. Refer the insurance agency directly to the client. C. Release the full medical record to expedite payment. D. Use minimum disclosure policy to release the information.
D. Use minimum disclosure policy to release the information.
A client's risk for the development of a pressure injury is most likely due to which lab result? A. glucose 110 mg/dL B. sodium 135 mEq/L C. hemoglobin A1C 7% D. albumin 2.5 mg/dL
D. albumin 2.5 mg/dL
A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? A. monitoring for pallor and mottled appearance of the wound B. assessing for impaired blood flow to the area of evisceration. C. contacting the surgeon D. applying sterile dressings with normal saline over the protruding organs and tissue
D. applying sterile dressings with normal saline over the protruding organs and tissue
The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply. A. Include V.O. with the health care provider's name on the prescription. B. Record the date and time of the prescription. C. Read back the prescription. D. Have the health care provider review and sign the prescription during the emergency. E. Record the prescription on the pharmacy discrepancy sheet.
Include V.O. with the health care provider's name on the prescription. B. Record the date and time of the prescription. C. Read back the prescription.