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Nursing 102 Final
| Question | Answer |
|---|---|
| A nurse is meeting a patient for the first time for the admission interview. there are eight family members sitting around the patients bed. after introductions, the most appropriate nursing action is to: 1. ask the family members to leave immediately 2. | 4. ask the patient if he/she wants a family member present |
| a nurse is seeing patients in the outpatient clinic who are asian american. a patient for this cultural group who incorporates traditional health practices may use a: 1. herbalist 2. curandero 3. root worker 4. medicine man | 1. herbalist |
| a nurse recognizes the physiological characteristics of cultural groups may affect overall health and that there may be an increased prevalence of particular disease processes with certain group. In working with Native Americann people, the nurse is alert | diabetes mellitus |
| the community center where a nurse volunteers has a culturally diverse population. the nurse wants to promote communication with all the patients from different cultures. a beneficial technique for the nurse is to: | explain nursing terms that are used |
| a patient expresses to the nurse that traditional Western or American practices are used in the home for health promotion. the nurse expects that the patient will use: 1. acupuncture 2. guided imagery 3. aromatic therapy 4. over the counter meds | 4. over the counter meds |
| when working with an interpreter for a patient who speaks another language, the nurse should: 1. direct questions to the interpreter 2.expect word for word translation 3. ensure interpreter speaks same dialect4.ask interpreter evaluate nonverbal behavoirs | 3. ensure interpreter speaks same dialect |
| when asking patient specifically about his/her social organization,a nurse will focus on the patients:1.posistion in family hierarchy 2.preferred manner of communication 3.age at time of immigration 4.dietary practices | 1. position in family hierarchy |
| a nurse is working with a patient who's Muslim. the are foods that are prohibited(Haram),and the nurse recognizes that this will include:1.pork 2.fish 3.fresh fruit 4.vegetables | 1.Pork |
| An Orthodox Jewish patient has just died. The nurse anticipates:1.a request for autopsy 2.preparation of cremation 3.refusal to move body 4.scheduling immediate burial | 4. scheduling for immediate burial |
| when working with patients of other cultures, a nurse anticipates tat a curandero may be sought for a patient who is: 1.Hispanic 2.Chinese 3.African 4.Korean | 1. Hispanic |
| Patient admitted to a medical center for surgery to repair a fractured hip. Upon reviewing the patients admission history, a nurse finds that the patient attends religious services routinely. the nurse supports the pats spiritual needs by stating: | "Is there any way that i may be able to help with your spiritual needs." |
| A patient who is of the Jewish faith is admitted to the long term care facility. a nurse seeks to provide support of the usual health practices that are part of this religion. the nurse learns that one component of usual Jewish tradition states: | no euthanasia should be used |
| while caring for a patient in the ICU,the patient has a cardiac arrest.The patient is successfully resuscitated.After this near death experience,the patient is progressing physically,but appears withdrawn and concerned.The nurse assist by stating: | "If you would like to talk about you experience, I will stay with you." |
| For a patient with a diagnoses of chronic disease,a nurse wishes to encourage feelings of hope.The nurse recognizes that hope provides: | meaning and purpose for patient |
| A nurse is reviewing the plan of care, for a 66 year old home care patient who's experiencing the beginning stages of Alzheimers. Nurse believes they may need to be assessed for spiritual needs based on: | Ineffective individual coping |
| According to Erkison's stages of psychosocial development, with regard to spiritual beliefs its expect that a 6year old will:1.begin to ask about God or supreme being 2.spiritual well being provided by parents 3.interpret meanings literally | begin to ask about God or supreme being |
| A nurse recognizes that a group whose members may reject modern medicine based on religious beliefs is: 1.Hindu 2.Islamic 3.Catholic 4.Navajo | 4.Navajo |
| According to Erikson's stages of psychococial development, with regard to spiritual beliefs it's expected that a middle age person will begin to: | review value systems during crisis |
| A nurse recognizes which of the following age-groups are most vulnerable to identity stressors? 1.Infancy 2. Preschool 3. Adolescence 4. Middle-aged adulthood | 3. Adolescence |
| An adolescent has gone to the nurse's office in a school to discuss some personal issues. The nurse wishes to determine the sexual health of this adolescent. The nurse begins by asking: | "Do you have any concerns about sex or your body's development?" |
| During an interview and physical assessment of female patient in the clinic, a nurse finds that the patient has multiple laceration and bruises and that she has experienced headaches and difficulty sleeping. The nurse suspects: | Physical and/or sexual abuse |
| A patient has gone to family planning center for assistance in selecting a birth control method. She asks the nurse about contraception that requires a prescription. the nurse responds by discussing:1.Condoms2.abstinence3.spermicides 4.birth control pills | 4. birth control pills |
| A pateint is admitted to coronary care unit after acute myocardial infarction.He tells the nurse,"I won't be able to do what I used to at the hardware store."The nurse recognizes that the patient is experiencing problem with the self-concept component of: | Role |
| An adolescent patient just as been diagnosed with scoliosis and will need to wear a corrective brace. She tells the nurse angrily,'I dont know why i have to have this stupid problem!" The nurse responds most appropriately by saying: | "Tell me what you do when you get angry and upset." |
| During an initial assessment at an outpatient clinic, a nurse wants to determine a patients perception o identity. The nurse asks the patient: 1."What's your usual day like?" 2."How would you describe yourself?" 3."what activities do you enjoy at home" | 2. " How would you describe yourself?" |
| A patient has been in the rehab facility for several weeks after CVA..Although able he wont participate in grooming and now refusing visitors. At this point the nurse intervenes by: | Contacting the physician to discuss a psychological consulatation |
| A nurse is working with a patient who has had a colostomy. The patient asks about resuming a sexual relationship with a partner. the nurse begins by determining. | How comfortable the patient and the partner are in communicating with each other |
| A nurse who's using Erikson's theory expects that 5 year old boy will begin to:1.accept body changes & maturation 2.incorporate feedback from peers into his personality3.distinguish himself from the environment around him4.identify w/specific gender group | 4. identify with a specific gender group |
| a patient asks a nurse about prescription for tadalafil(Cialis). the nurse recognizes, however,that this drug is contraindicated for the patient who's taking:1.antibitotics 2.beta blockers 3.antihitamines 4.NSAIDS | 2. Beta Blcokers |
| A nurse is aware that which of the following strategies is appropriate for teaching a patient for promotion of a positive sexual experience? | discusing side effects of medications that my alter responsiveness |
| Correction is required i a new nurse in the womens clinic is observed: | Discussing findings with the patient in the exam room |
| Which of the following is anticipated as a sexual change related to the aging process? | decreased time for maintenance of an erection |
| During an initial assessment at an outpatient clinic, a nurse wants to determine a patients level of self esteem. the nurse ask the patient: | "How do you feel about yourself?" |
| A patient has been hospitalized with a serious systemic infection. if the patient is in the resistance stage of the general adaptation syndrome and moving toward recovery.the nurse expects that a patient will demonstrate: | stabilization of hormone levels |
| while working in a psychiatric emergency department, a nurse is a alert to patients who are having severe difficulty in coping. a priority for the nurse is the safety of the patient and others;therefore,the nurse asks patients: | "Are you thinking of harming yourself?" |
| As a result of a patients health problem, the family is experiencing economic difficulty and demonstrating signs of crisis. as part of crisis intervention, a nurse: | refers the patient for financial assistance |
| A nurse working for the surgical unit notes that a patient has been exhibiting nervous behavior the evening before a surgical procedure to assess the degree of stress that the patient is experiencing, the nurse asks: | "You seem anxious. Would you like to talk about the surgery?" |
| A nurse notes that a patient is experiencing a stress reaction. to determine how the patient may cope with the event, the nurse should ask: | "Have you dealt with this reaction before?" |
| 80 year old patient was admitted to hospital with diagnoses of pneumonia.the patient is very lethargic¬ communicating,&the patients respiration are extremely labored. the nurse assesses that the patient is experiencing the general adaptation stage of: | exhaustion |
| a patient complaints of fatigue and general uneasiness. the patient believes that the symptoms may be related to the increased amount of work thats expected in the job. the nurse initially recommends that patient should attempt to reduce or control stress | employing relaxation techniques, such as deep breathing |
| according to general adaptation syndrome,a nurse expects which of the following signs as part of an alarm reaction? 1.pupil dilation 2.decreased blood glucose levels 3.decreased heart rate 4.stabilized hormone levels | 1.pupil dilation |
| a nurse identifies that a patient is under stress. To determine the patients perception of the stress, the nurse should ask: | "what does the situation meant to you?" |
| Which of the following patient observations does a nurse associate with ego-defense mechanism of conversion? | having difficulty sleeping |
| a patient has been having a hard time at home. he goes outside and begins to yell about the car and starts kicking the tires. this is an example of which of the following ego-defense mechanism? 1.displacement 2.compensation 3.identification 4.denial | 1.displacement |
| A nurse wants to assess whether a patient is using maladaptive coping strategies. the patient should be asked specifically about his/her: 1.dietary intake 2.social activities 3.cigarette smoking 4.exercise plan | 3.cigarette smoking |
| A nurse is working with a patient who has been diagnosed with a terminal disease. The patient, who is moving into Kubler-Ross's denial stage of grieving, may respond: | "I think that the diagnostic tests are wrong, and they should be redone." |
| While working with young children in a day care center, a nurse responds to instances that occur in their lives. toddlers at the center generally experience loss and grief associated with: | separation from parents |
| in senior citizen center, a nurse is talking with a group of older adults. the recurrent them associated with loss for this age-group is a : | change in status, role, and lifestyle |
| a nurse who has recently graduated from nursing school is employed by an oncology unit. there are a number of patients who will not improve and will need assistance with dying. the nurse prepares for this experience by: | identifying his or her own feelings about death and dying |
| a patient has had a long illness and is now approaching the end stages of his life. to assist this patient to meet his need for self-worth and support during this time, the nurse: | Plans to visit the patient regularly throughout the day |
| the spouse of a patient who has just died is having more frequent episodes of headaches and generalized joint pain. the initial nursing intervention for this individual is to: | sit with the patient and encourage discussion of feelings |
| a patient is experiencing a very serious illness that may not be curable. the nurse promotes hope for this patient in the affiliative dimension when | encouraging the development of supportive relationships |
| a patient in the long term care facility is to receive palliative care measures only during the end stages of terminal illness. the nurse anticipates that this will include: | pain relief measures |
| a patient arrives for outpatient tells the nurse that she is experiencing periods of nausea. the nurse promotes patient comfort by providing: | ginger ale |
| the loss of a known environment is associated with: 1.being hospitalized for several days 2.death of pet 3.amputation of right leg 4.recent burglary in the home | 1.being hospitalized for several days |
| of the following a situational loss occurs when a: 1.parents require of physical assistance 2.family friend dies 3.child goes to college 4.job demotion and pay reduction occure | 4.job demotion and pay reduction occur |
| an individual in Bowlby's second phase of mourning yearning, and searching may be expected to: | experience emotional outbursts and sobbing |
| A nurse recognizes exaggerated grief in the person who: | cannot function and is overwhelmed, with resulting substance abuse or phobia |
| a nurse manager observes a new staff nurse performing care of the body after death. which one of the following interventions requires correction and further instructions? | the patients remaining personal items are discarded. |
| an expected outcome for patient with an auditory deficit should include:1.minimiizing use of affected sense 2.preventing additional sensory losses 3.promoting the patients acceptance of dependency 4.controlling the environment to reduce sensory stimuli | 2.preventing additional sensory loss |
| a nurse is working with patients at the senior day care center and recognizes that changes in sensory status may influence the older adults eating patterns. for patients who are experiencing changes in their dietary intake,the nurse will assess for: | XEROSTOMIA |
| Parents arrive at the pediatric clinic with their 1 1/2 year old child. The parents ask the nurse if there are signs that may indicate that the child is not able to hear well. the nurse explains to the parents that they should be alert to the child: | having delayed speech development |
| a nurse is assessing a patent for a potential gustatory impairment. this may be indicated if the patient has a(n): | weight loss |
| which of the following is a priority safety measure in the acute care environment for apateint with a sensory deficit? | orienting the patient to the surroundings |
| a responsive patient had eye surgery, and patches have been temporarily placed on both eyes fr protection. the evening meal has arrived, and the nurse will be assisting the patient. in the circumstance, the nurse should: | orient the patient to the locations of the foods on the plate and provide the utensils |
| after a CVA a patient is found to have receptive aphasia. the nurse may assist the patient with communication by: | using system of simple gestures and repeated behaviors |
| a patient has been diagnosed with glaucoma. the nurse anticipates that the patient will report a history of: | painless loss of peripheral and central vision |
| a mother is taking her newborn for his first physical exam. she expresses concern becuase during her pregnancy she may have been exposed to an infectious disease, and the babys hearing could be affected. the nurse inquires if the patient was exposed to: | rubella |
| for a patient with a hearing deficit, the best way fo the nurse to communicate is to: | use visible facial expression |
| the daughter of an older woman expresses her concern that while she is at work her mother, recently diagnosed with alzheimers, has been found wandering around the neighborhood is a disoriented state. this family may benefit from the services of a: | adult day care center |
| while working community health agency,a nurse visits older adult patient whos having difficulty performing ADLs in her own home.patient recognizes that she needs some supervision with medications.in discussions with thispatient,nurse refers patient to an: | assisted living facility |
| a patient is discharged from a mdical unt and requires more constant nursing care at a level above a nursing center or extended care facility. the nurse recognizes that this patient will be referred to an: | subacute care unit |
| a nurses next door neighbor has recently experienced some health problems. the neighbor visits the nurse to ask about Medicaid coverage. the nurse informs the neighbor that this program is: | a federally funded and state-regulated program for individuals of all ages with low income |
| a graduate of a nursing program is interested in the occupational health field. the graduate nure decides to pursue a position at:1.local medical center 2.a car manufacturing plant 3.urgent care center 4.physicians office | car manufacturing plant |
| patient being discharged from medical unit of the hospital.while working with patient,nurse identifies intermittent supervision will be required. the patient will also need to rent durable medical equipment for use in the home. nurse refer patient to: | home health agency |
| the family of a patient has requested that the hospice agency become involved with the patients care. the nurse recognizes that the services provided by hospice for this patient include: | provision of symptom management and comfort measures for the terminally ill |
| health care cost are generally reduced with: | treatment in an outpatient facility |
| an individual has health insurance coverage that offers an extremely limited choice of providers, with one health care organization to use and less access to specialists. the nurse recognizes that this individual is covered by an: | exclusive provider organization (EPO) |
| in a school health setting, the nurse expects to provide which service? 1.communicable disease prevention 2.physical assessment 3.chronic pain management 4.respite care | communicable disease |
| a nurse is assigned to prepare a teaching plan for a group of preschool age children. for this age group, the nurse includes: | guidelines for crossing the street or actions to take during a fire |
| children who are admitted to a hospital may be afraid about the hospitalization. to reduce the fear of school age children in an acute care environment, a nurse: | shows them the equipment that is to be used for procedures |
| during a clincal rotation a student nurse is observing children in a day care center. the student is asked to assist with the activities for the preschool age children. children in this age group are usually able to: | skip, throw, catch balls |
| a parent of an infant asks a nurse what the infant should be able to do at the end of the first year. the nurse identifies that the infant will be able to: | recognize his or her own name |
| parents of six month old infant are asking about the usual activities that can be expected of a child this age. a nurse informs the parents that a major milestone in gross motor development for a six month old infant is: | crawling on the abdomen |
| a nurse working with a group of young adults at the community cneter. there are many discussions about life and health issues. the nurse is aware that a health related concern for young adults is that: | faced paced lifestyles may place them at risk for illnesses or diabilities |
| a nurse is skeeing to evaluate the effectiveness of info provided to the parents of an infant. the nurse determines that teaching has been successful when the parents: | purchase a crib with slats that are less than 2 inches apart |
| when presenting a program for a group of individuals in their middle aged adult years, a nurse informs the members toe expect the following physical change | decrease in screen turgor |
| parents of a 3 1/2 year old boy are concerned when, after hospitalization,the boy begins to suck his thumb again. the boy had not sucked his thumb for over a year. a nurse informs the parent that: | the behavior should be ignored as it is common for a child to regress when anxious |
| an adolescent girl has gone to a family planning center for info about birth control. the patient asks a nurse what she should use to avoid getting pregnant. the nurse responds: | "what can you tell me about your past sexual experiences?" |
| a patient has gone to an outpatient obstetric clinic for a routine checkup. the patient asks a nurse what is happening with the baby now that she is in her second trimester. the nurse informs the patient that: | the brain is undergoing a tremendous growth spurt |
| for a patient in a nursing center, the nurse suspects the potentially reversible cognitive impairment of: | delirium |
| for a patient with a ng tube who has a painful, distended abdomen, the first most appropriate action by the nurse is to: | irrigate tube |
| a patient expresses a feeling of mild cramping during the administration of a saline enema. the nurse should first: | lower the bag to slow the infusion |
| a patient in a senior day care center is experiencing some constipation. a commonly prescribed medication is wetting agent or stool softener, such as: | docusate sodium |
| a nurse observes anursing assistant carrying out bowel retraining with a patient in the extended care facility. the nurse identifies that the assistant implements an incorrect procedure when: | restricting fluids with breakfast and lunch meals |
| for patients that have been prescribed extended bed rest, the prolonged immobility may result in reduced peristalsis and fecal impaction. a nurse is alert to one of the first signs of an impaction when the patient experiences: | overflow diarrhea |
| a patient has been admitted to an acute care unit with a diagnosis of biliary disease. when assessing the patients feces. the nurse expects that they will be: | white or clay colored |
| upon review of a patients lab results, a nurse notes that the patient is experiencing hypocalcemia. the nurse will plan to implement measures to prevent | constipation |
| a nurse is preparing to administer an enema to a 7-year-old child. when assembling the equipment, the nurse will prepare an enema of: | 400-500 mL of fluid |
| a nurse recognizes that the greatest challenge for skin care will be for a patient with an | ileostomy |
| a nurse evaluates that a patient has normal bowel sounds by auscultation all four quadrants and finding | 15 sounds per minute |
| a nurse instructs a patient whos taking an iron supplement that his stool may be | black and tarry |
| a nurse is caring for a patient with a Salem sump tube for gastric decompression. which of the following actions by the nurse requires correction | clamping off the blue lumen or air vent |
| a nurse recognizes the the intake of mineral oil to promote bowel elimination interferes with the absorption of: | vitamin A |
| further follow up is required if a patient informs the nurse that he uses: | tap water enemas |
| during a digital removal of a fecal impaction a nurse notes that the patient has bradycardia. the nurse should: | discontinue the procedure |
| in the teaching plan for a patient who will be having a fecal occult blood test, which of the following foods should e noted for producing a false positive result? | fish |
| A patient on the medical unit is scheduled to have a 24-hour urine collection to diagnose a urinary disorder. the nurse should: | note start time on the container |
| one of a nurse's assigned patients is experiencing urinary retention. the nurse anticipates a medication that may be ordered for this difficulty is: 1.propantheline 2.oxybutynin 3.bethanecol 4.phenylpropanolamine | 3.bethanecol |
| several patients in a long term care unit have indwelling urinary catheters in place. a nurse is delegating catheter care to the nursing assistant. the nurse includes instruction in: | cleansing about 4 inches along the length of catheter, proximal to distal |
| patient with recurrent uti ask nurse how they may be avoided.the nurse discusses with patient that selected foods may help prevent infections, while other foods may not. the nurse recommends that patient promote urinary acidity by avoiding: | orange juice |
| Prevention of infection is a patient outcome that is identified for a patient with a urinary alteration and an indwelling catheter. the nurse assists the patient to attain this outcome by: | performing peri care q8h and prn |
| a patient being seen at a urologist's office suffers from urge incontinence. the nurse anticipates that treatment for this difficulty will include: 1.Biofeedback 2.catheterization 3. cholinergic drug therapy 4.electrical stimulation | 1.biofeedback |
| A nurse notes that there is an order on a patients record for a sterile urine specimen. The patient has an indwelling urinary catheter. The nurse will proceed to obtain this specimen by: | using a syringe to withdraw urine from the catheter port |
| A patient had a laparoscopic procedure in the morning and is having difficulty voiding later that day. Before initiating invasive measures, the nurse intervenes by : | rinsing the perineal area with warm water |
| to determine the possibility of a renal problem, a patient is scheduled to have an intravenous pylelogram (IVP). Immediately after the procedure, a nurse will need to evaluate the patients response and be alert to: | an allergic reaction to the contrast material |
| A unit manager is evaluating the care that has been given to a patient by a new nursing staff member. The manager determines that the staff member has implemented an appropriate technique for clean-voided urine specimen collection if: | the specimen was collected after the initial stream of urine has been passed |
| A patient at the urology clinic is diagnosed with reflex incontinence. this problem was identified by patient's statement of experiencing: | no urge to void and being unaware of bladder fullness |
| A female patient has an order for urinary catheterization. A nursing student will be evaluated by the instructor on the insertion technique. the student is identified as implementing appropriate technique if: | The balloon is inflated before insertion to test its patency |
| A patient is diagnosed with prostate enlargement. The nurse is alert to specific indication of this problem when finding that the patient has: 1.chills 2.cloudy urine 3.polyuria 4.bladder distention | 4.bladder distention |
| Stress incontinence is associated with: 1. irritation of the bladder 2.neurological trauma 3.alcohol or caffeine ingestion 4.coughing or sneezing | 4. coughing or sneezing |
| For patients with diabetes mellitus, a nurse anticipates that the patients will experience: 1.dribbling 2.hesitancy 3.polyuria 4.hematuria | 3. polyuria |
| A nurse recognizes that one of the specific purposes of intermittent catheterization is for: | assessment of residual urine |
| A nurse notes that there is nor urine in a drainage bag since it was emptied a hour and half ago. The nurse should first: | check for kinks or bends in the tubing |
| A nurse manager is observing a new nurse staff member provide car for a patient with a condom catheter. The manger determines that correction and additional instruction are required for the new employee if the staff nurse is observed: | using adhesive tape to secure the catheter to the patient's penis |
| A patient who is taking pyridium needs to be instructed that a specific side effect of this medication is that: | the urine will turn orange |
| A nurse anticipates that a treatment option for a patient with functional incontinence will include: 1.Catheterization 2.bladder training 3.electrical stimulation 4.hormone replacement | 2. bladder training |
| A nurse is working with a patient who requires an increase in complete proteins in the diet. the nurse recommends: 1. milk 2. cereals 3.legumes 4.vegetables | 1. milk |
| Nurse talking with acommunity resident who has gone to health fair.The resident tells nurse that he takes a lot of extra vitamins every day. Because of the greater potential for toxicity, the resident is advised not to exceed the dietary guidelines for: | Vitamin A |
| A nurse is working with a patient who is a lactovegetarian. The food that is selected as appropriate for this dietary pattern is: 1.fish 2.milk 3.eggs 4.poultry | 2. milk |
| A patient states that he does not eat fish anymore. An appropriate follow-up question by the nurse is which of the following? | "What caused you to lose interest in fish?" |
| A nurse is preparing to insert a ng tube for enteral feedings. The nurse recognizes that this intervention is used when the patient: | Is not able to ingest foods |
| a nurse is preparing the enteral feeding for a patient who has a ng tube in place. The most effective method that the nurse can use to check for placement of a ng tube is to: | perform a pH analysis of aspirated secretions |
| A female patient who has gone to a family planning center is taking an oral contraceptive. This patient should increase vitamin b6 and niacin intake. The nurse recommends that the patient consume more: | whole grains |
| A patient has heard on tv that zinc is an important element in the bodys immune response. the patient asks the nurse what foods contain zinc. Because of its zinc content, the nurse recommends: | liver |
| A nurse is assigned to make home visits to a number of patients. Of the patients that the nurse visits, the patient with the greatest risk of nutritional deficiency is the patient with: | an alteration in dietary secretion |
| After surgery, a patient is having her dietary intake advanced. After a period of NPO, the patient is placed on a clear liquid diet. What food does the nurse request for the patient? 1.milk 2.soup 3.custard 4.popsicles | 4. popsicles |
| While completing an assessment during home visit,a nurse discovers that patient has a history of CHF and is taking digoxin 0.25 mg daily. Being aware that medications may influence the patients dietary patterns the nurse is alert to patient experienceing | anorexia |
| A patient on the unit has an enteral tube in place for feedings. When the nurse enters the room. the patient says that he is experiencing cramps and nausea. The nurse should: | decrease administration rate |
| Which of the following statements made by the parent of an infant indicates the need for additional teaching? | "I'll add a little honey to the baby's bottle to help him digest the formula." |
| A nurse instructs a patient who is a vegan to specifically include which supplement in the diet? 1.vitamin A 2.vitamin C 3. vitamin b12 4.niacin | 3. vitamin b12 |
| The individual with the highest percentage of water in the body is an: 1.infant 2.obese patient 3.lean patient 4.older adult | 1. infant |
| A patient with a gastrostomy has an excessive residual volume. The nurse should: | maintain the patient in high-fowler's position |
| A nurse is monitoring a patients lab reports. Which of the following, if decreased, is indicative of anemia? 1.BUN level 2.Creatine level 3.albumin level 4.hemoglobin level | 4. hemoglobin level |
| A nurse is instruction the family of a patient who is on an National Dysphagia Diet Task Force (NDDTF) dysphagia puree dietto include | mashed potatoes |
| A nurse recognizes that a patient on a low cholesterol diet requires of additional teaching if he indicates that he eats which of the following: 1.oatmeal 2.pastries 3.dried fruits 4.green peppers | 2. pastries |
| A realistic weight loss goal for the patient who is overweight is: 1. 1 lbs/week 2. 3 lbs/week 3. 5lbs/week 4. 7lbs/week | 1. 1lbs/week |
| To prevent the presence of E. coli in food, a nurse specifically instructs a patient and family to: | cook ground beef well |
| A nurse is visiting a patient in the home and notes that additional teaching is required if the patient is observed: | thawing frozen foods at room temperature |
| tube feedings are ordered for a patient with a ng tube. Unless the agency specifies otherwise, the nurse should: | begin with 150-250 mL at a time |
| Individuals have gone to the health fair to receive their free influenza vaccine. the nurse briefly discusses the medical backgrounds of the patients. the influenza vaccine will be withheld from the: | Woman with a hypersensitivity to eggs |
| A patient has a chest tube in place to drain bloody secretions from the chest cavity. when caring for a patient with a chest tube, a nurse should: | Have the patient cough if the tubing becomes disconnected |
| A nurse is making a home visit to a patient who has emphysema (COPD). Specific instruction to control exhalation pressure for this patient with an increased residual volume of air should include: | pursed-lip breathing |
| A patient has been admitted to a medical center with a respiratory condition and dyspnea. A number of medications are prescribed for the patient. For a patent with this difficulty, the nurse should question the order for: | Nacrotic analgesics |
| After a patient assessment, the nurse suspects hypoxemia. This is based on the nurse finding that the patient is experiencing: restlessness 2.bradypnea 3.bradycardia 4.hypotension | 1. restlessness |
| A patient has experienced some respiratory difficulty and is placed on oxygen via nasal cannula. A nurse assists the patient with this form of oxygen delivery by: | assessing the nares for breakdown |
| A patient is being seen in an outpatient medical clinic. A nurse has reviewed the patients chart and finds that there is a history of cardiopulmonary abnormality. this is supported by the nurses assessment of the patient having: | Splinter hemorrhages in the nails |
| A 65-year-old patient is seen in a physicians office for a routine annual checkup. As part of the physical exam, an ECG is performed. The ECG reveals a normal P wave,P-R interval,and QRS complex & a HR of 58bpm. The nurse evaluates the findings as: | sinus bradycardia |
| a patient is admitted to a medical center with a diagnosis of left ventricular CHF. A nurse is completing the physical assessment and is anticipating find that the patient has: | pulmonary congestion |
| A patient has just returned to the unit after abdominal surgery. A nurse is planning care for this patient and is considering interventions to promote pulmonary function and prevent complications. the nurse: | Demonstrates the use of flow-oriented incentive spirometer |
| nurse manager is evaluating care that is provided by a new staff nurse during the orientation period. One of the patients requires nasotracheal suctioning. and the nurse manger determines that the appropriate technique is used when the new staff nurse: | Applies intermittent suction for 10 seconds while the suction catheter is being removed |
| Chest tubes have been inserted into a patient after thoracic surgery. In working with this patient, a nurse should: | Coil and secure excess tuning next to the patient |
| A patient is being discharged home with an order for oxygen prn. in preparing to teach the patient and family, a priority for the nurse is to provide info on the: | use of the oxygen delivery equipment |
| In discrimination types of chest pain the a patient may experience, a nurse recognizes that pain associated with inflammation of the pericardial sac is noted the patient experiencing: | pain with inspiration |
| A nurse is checking a patient who has a chest tube in place and finds that there is constant bubbling in water-seal chamber. the nurse should: | tighten loose connections |
| For a patient who is receiving noninvasive ventilation and states that he feels claustrophobic, the nurse should: | demonstrate use of the quick-release straps |
| The patient is admitted with a diagnosis of COPD. The appropriate oxygen delivery method for this patient is a: | Nasal cannual with 1-2 L/min (28%) O2 |
| A nurse is completing a physical assessment of a patient with a history of a cardiopulmonary abnormality. A finding associated with hyperlipidemia is the patient having :1.Cyanosis 2.xanthelasma 3.petachiae 4.ecchymosis | 2. xanthelasma |
| A nurse is caring for an older adult patient in an extended care facility. the patient wears dentures, and the nurse delegated their care to the nursing assistant. the nurse instructs the assistant that the patients dentures should be: | brushed with a soft toothbrush |
| A nurse determines, after completing an assessment, that an expected outcome for a patient with impaired skin integrity will be that the: | skin remains dry |
| A patient has been hospitalized following a traumatic injury. the nurse is now able to provide hair care for the patient. The nurse includes: | Applying peroxide to dissolve blood in the hair and then rinsing with saline |
| While completing a patients bath, a nurse notices a red, raised skin rash on the patients chest. the next step for the nurse to take is to: | assess for any other areas of inflammation |
| A nurse is planning patient assignment with a nursing assistant. In delegating the morning care for a patient, the nurse expects the assistant to: | Wash the patients legs with long strokes from the ankle to the knew |
| A patient is receiving chemotherapy and is experiencing stomatitis. To promote comfort for this patient, a nurse recommends that the patient use: | normal saline rinse |
| For a patient with dry skin, a nurse should: 1.applying moisturizing lotion 2.use hot water for bathing 3.obtain dehumidifier 4.wash skin frequently | 1. apply moisturizing lotion |
| When integrating a culture considerations in to hygienic care, a nurse recognizes that Hindu or Muslim patients: | use left hand for bathing |
| Use of an electric razor is specifically indicated for a patient who is being treated with: 1.diuretics 2.antibiotics 3.anticoagulants 4.nacrotic analgesics | 3. anticoagulants |
| When making an occupied bed, the first step for a nurse is to: 1.cover patient w/bath blanket 2.position on far side of bed 3.explain procedure 4.adjust height of bed to waist level | 3. explain procedure to the patient |
| A clinical experience is planned for an acute care facility. The student nurse recognizes that his/her liability for patient care includes: | A shared responsibility with instructor, staff member(s), and health care agency |
| There has been serious flu epidemic among staff @ medical center.arrriving @work on the medical unit,nurse discovers that all other nursing staff members have called in sick &there are no other nurse available in facility. In this situation nurse should: | Document the situation and provide a copy to nursing administration |
| While a nurse is preparing to administer medication, the patient stats that he/she refuses the medication. the nurse know that the medication is important for the patient and proceeds with the injection of the meds. This is considered: | battery |
| The urgent care center in town is busy this evening. there are many walk in patients of different ages waiting for treatment. The nurse recognizes that in a nonemergency situation the individual who may give consent for a treatment is: | teenage parent |
| A nurse observes the following actions and recognizes that an invasion for patient privacy has occurred when another nurse: | shares patient data with other agency personnel not involved in the patients treatment |
| A nurse enters the room of a patient and observes that an incident has occurred. The situation is appropriately documented as follows: | "Patient found on floor. Laceration to forehead." |
| While working as a receptionist in a physician's office, a student nurse is offered the opportunity to provide an injection to one of the patients. the individuals liability is based upon the: | job description of a receptionist |
| A nurse has administered a medication to a patient with a documented allergy to that medication. A standard of care is applied when: | The nurse's action is compared to that of another nurse in similar circumstance |
| Of the following actions, which one is considered to be assault: 1.nurse threatens to administer med to patient who refuses 2.surgeon operates on wrong leg 3.nurse fails using septic technique 4.nursing assistant restrains confused patient | 1. nurse threatens to administer meds to a patient who refuses |
| National Organ Transplant Act allows for/or requires: | health care providers to ask family members to consider organ and tissue donation |
| a professional code of ethics include: 1.legal standards for practice 2.extensive details on moral principals 3.guidelines for approaching common ethical dilemmas 4.a collective statement of group expectations for behavoir | 4. a collective statement of group expectations for behavoir |
| By administering medication to a patient on a unit in an extended care facility, a nurse is applying the ethical principle of: 1.justice 2.fidelity 3.autonomy 4.beneficence | 4. Beneficence |
| A nurse has been working with a patient who had abdominal surgery. the patient is experiencing discomfort and has been calling for assistance often. the ethical principle of fidelity is demonstrated when the nurse: | Returns to assist the patient with breathing exercises as the agreed upon times |
| student nurse assgned work w/parents who refuse have medical treatment provided to there child.nurse has strong feelings for familys position,well as importance of medical treatment. the 1st step for nurse to take attempting resolve ethical dilemma is: | Gather all the facts |
| An example of advocacy in nursing practice is: 1.documenting care provided to a patient 2.giving meds to a patient 3.assessing the patients comfort level after surgery 4.contacting physician to discuss patients response to plan of care | 4.Contacting the physician to discuss patients response to the plan of care |
| The last phase in the processing of an ethical dilemma is to: 1.evaluate action take 2.consider treatment options 3.negotiate options and outcomes 4.identify the problem | 1. evaluate the action taken |
| At the tertiary level of prevention, a nurse would prepare an education program for a group requiring: 1.Chemotherapy 2. cardiac rehab 3.genetic screening 4. sex ed | 2. cardiac rehab |
| At the secondary level of prevention, what is the intervention that a nurse expects to assist with or provide instruction for? 1.Immunization 2.referral to outpatient therapy for monitoring 3.performance of biopsy 4. parent bathing newborn | 3. Performance of a biopsy |
| A nurse is working with a patient who is experiencing chronic joint pain. to assist the patient to manage or reduce the pain, the nurse decides to use a holistic health approach. With this in mind, the nurse specifically elects to include: | aroma therapy |
| A nurse is completing an assessment for a patient who has gone to a medical clinic. Variables that influence the patients health beliefs and practices are being determined. the nurse is aware that an internal variable for this patient is the: | Manner in which the patient deals with stress on the job and at home |
| A nurse recognizes that primary prevention is a critical aspect in health care. the target group for a program on hand hygiene for this level of prevention is: | fourth grade children at the elementary school |
| A nurse is leading a group of community members who are trying to quit smoking. In the precontemplation phase of health behavior change, the nurse anticipates that the group members will respond by: | `Expressing irritation when the topic of quitting is introduced |
| A young adult student has gone to the university's health center for a physical exam. The nurse conducting the initial interview is looking for a possible lifestyle risk factors. the nurse is specifically alerted to the students: | Mountain climbing hobby |
| According to Maslow's Hierarchy of needs, a patient's priority should be: 1.physical safety 2.psychological safety 3.self-esteem 4.adequate nutrition | 4. adequate nutrtion |
| To determine a patients stage in the process of changing behaviors in response to being diagnosed with diabetes, a nurse can conclude that the patient is in the maintenance stage on basic of what response? | "i take my insulin daily as ordered." |
| A nurse recognizes an environmental risk for illness upon learning that the patient: 1.Works in chemical plant 2.has history of heart disease 3.admits to intermittent substance abuse 4.older than 65 | 1. works in chemical plant |
| At the community health fair, a nurse is asked by one of the residents about the influenza vaccine. The nurse responds to the resident that the influenza vaccine is recommended for individuals who are: | health care workers |
| A nurse is preparing a room for a patient with tuberculosis. the specific aspect for this tier of Standard Precautions that is different than tier 1 is that care should include: | a private room with negative air flow |
| A nurse is preparing a teaching plan for patients about the hepatitis B virus. the nurse informs them that this virus may be transmitted by: | Blood products |
| A nurse is working on a unit with a number of patients who have infectious diseases. One of the most important methods for reducing the spread of microorganisms is: | hand hygiene before and after patient care |
| The assignment today for a nurse includes a patient with tuberculosis. In caring for a patient on droplet precautions, the nurse should routinely use: | particulate filtration masks and gowns |
| A nurse is caring for a patient who has a large abdominal wound that requires a sterile saline soak and dressing. While performing the care, the nurse drops the saline soaked 4x4 gauze near the wound on the patient's abdomen. The nurse: | throws the gauze away and prepares a new 4x4 gauze |
| A nurse is checking the lab results of a male patient admitted to the medical unit. the nurse is alerted to the presence of an infectious process based on the finding of: | WBCs: 16,000/mm3 |
| The individual most at risk for a latex allergy is the patient with a history of: 1.hypertension 2.CHF 3.diabetes mellitus 4.cholecystitis | 2. CHF |
| A nurse is working with a patient who has a deep laceration to the right lower extremity. to reduce a possible reservoir of infection, the nurse: | changes the dressing to the extremity when if becomes soiled |
| A nurse implements droplet precautions for the patient with: 1.pulmonary tuberculosis 2.varicella 3.rubella 4.herpes | 3. rubella |
| A patient who has had a transplant will require what type of isolation? 1.Contact 2.Airborne 3.droplet 4.Protective | 4. Protective |
| For a patient with hepatitis A, the nurse is aware that the disease is transmitted through: 1.feces 2.blood 3.skin 4.droplet nuclei | 1.Feces |
| a sign is indicative of a systemic infection resulting from a wound is: 1.Redness 2.Drainage 3.Edema 4.Fever | 4.Fever |
| There are small open wounds on the hands of the nurse. the nurse's most appropriate action is: | Using clean, disposable gloves for patient care |
| A nurse is aware that older adults are more susceptible to infection as a result of: | drying of the oral mucosa |
| A nurse is working in a facility that uses computerized documentation of patient info. to maintain patient confidentiality with the use of computerized documentation, the nurse should: | Log off the file or computer when not using the terminal |
| The nurses on a medical unit in an acute care facility are meeting to select a documentation format to use. the recognize that less fragmentation of patient data will occur if they implement: | Critical pathways |
| While care for a patient on the surgical unit, a nurse notes that the patients blood pressure has dropped significantly since the last measurement. The nurse shares this info immediately with the health care provider in a: | telephone report |
| Documentation of patient care is reviewed during the orientation to the facility. The new graduate nurse understands that the method for written documentation that is acceptable is: | beginning each entry with the time of the treatment or observation |
| A nurse has been very busy during the shift to get all of the patient care activities completed. while documenting one of the patients responses to a pain medication, the nurse mistakenly writes on the wrong patient charts. the nurse" | draws a straight line through the note and initials the error |
| A nurse is caring for a patient who has had abdominal surgery. Accurate and complete documentation of the care provided by the nurse is evident by the following notation: | "IV fluids increase to 100 mL per hour according to protocol." |
| A nurse is involved in patient care in an agency that uses military time for documentation which of the following represents 4:00 pm? | 1600 |
| A nurse would not expect to find which of the following in a problem oriented medical record? 1.Progress notes 2.narrative notes 3.SOAP notes 4.PIE notes | 2. Narrative notes |
| An appropriate action by a student nurse is demonstrated by: | reading the patients record in preparation for clinical care |
| A nurse enters a patients room and discovers a yellow poll on the bed under the patients pillow. the patient receives Lasix 40 mg daily. which of the following notations is appropriate to include on an incident/occurrence report? | "Yellow pill found on bed under pillow." |
| The nursing info that follows a more traditional format is the: 1.Protocol design 2.critical design 3.nursing process design 4.medical diagnosis design | 3. nursing process design |
| Which of the following statements made by a new staff nurse during change of sift report requires correction? | "The patient is uncooperative about doing his stoma care." |
| A patient tells a nurse that he feels anxious and afraid. The nurse responds by saying " I will stay here with you." The nurse is using the principle of effective communication know as: | availability |
| A patient states that he believes he may have cancer. The nurse tell him, "I wouldn't be concerned. I'm sure that the test will be negative." The response by the nurse demonstrates the use of: | false reassurance |
| A nurse is assigned to a young adult male patient. Gender sensitivities is demonstrated when the nurse: | use direct and indirect communication according to gender |
| A patient regularly visits a medical clinic. A nurse establishes a helping relationship with the patient. During the working phase of a helping relationship, the nurse: | encourages and helps the patient set goals |
| A nurse is interviewing a patient who is in the outpatient area. The nurse uses paraphrasing communication with the statement: | "If i understand you correctly, you are primarily concerned about your dizzy spells." |
| A patient tells a nurse that there are other people in the room that are watching her from under the bed. The nurse employs therapeutic communication when he/she: | identifies that there are no people under the bed |
| While speaking with a female patient, a nurse notes that she is frowning. The nurse wants to find out about possible concerns by: | Identifying that the patient is frowning |
| A patients condiction has deteriorated, and he has been transferred to the ICU. The roommate asks the nurss | "I recognize your interest in the patient, but i cannot share personal info with you without his permission." |
| A patient is experiencing aphasia as a result of CVA. to promote communication, a nurse plans to: | use visual clues, such as pictures and gestures |
| A patient is talking endlessly about problems in the past with arthritic pain, but the nurse need to get specific info for the admission assessment. The nurses best response is: | "You seem to have had difficulty managing the arthritis. What are you doing now for the pain?" |
| A nurse enters a room and finds the patient crying. The best action by the nurse is to: | sit quietly with the patient |
| A patient has visual impairment. In communicating with this patient, a nurse should | Caution the patient before any physical contact. |
| A nurse tells the patients family that recovery may be 'difficult." This may lead to an issue with: 1.pacing 2.clarity 3.relevance 4.connotation | 4.connotation |
| A cultural group that may perceive continuous eye contact as intrusive or threatening is: 1.Asian 2.Hispanic 3.African American 4.Northern European | 1. Asian |
| A nurse is working with a preschool age child. An appropriate communication technique to use with an individual in this agie group is: | sit or kneel down to be on the same level as the child |
| A patients blood sample was dropped on its way to the lab. the patient ask the nurse why blood needs to be drawn again for the same test. the nurses best response is: | "One of the vials was dropped and broke by mistake. We will make sure that this sample gets to the lab safely." |
| A nurse is evaluating communication skills used during an interaction with a newly admitted patient. Of the statements made, the nurse responded therapeutically with: | "I noticed that you didnt eat any of the lunch. Is there something bothering you?" |
| A nurse is discussing with her peers how much a patient matters to her. She states that she does not want the patient to suffer. The nurse is implementing the theory described by: | Patricia Benner |
| A patient was admitted to the hospital to have diagnostic tests to rule out a cancerous lesion in the lungs. The nurse is sitting with the patient in the room awaiting the results of the test. The nurse is demonstrating the caring behavior of: | providing presence |
| A nurse manager would like to promote more opportunities for the staff on the busy unit to demonstrate caring behaviors. The manager elects to implement: | Staff selection of patient assignments |
| A new graduate is looking at theories of caring. He selects Leininger's theory because it is most agreeable with his belief system. Leininger defines care as an: | improvement in the human condition using a transcultural perspective |
| A nurse is working with a patient who has been admitted to the oncology unit for treatment of a cancerous growth. This nurse is applying Swansons theory of caring and demonstrating the concept of maintaining belief when: | discussing how the radiation therapy will assist in decreasing the tumors size |
| A new graduate is assigned to a surgical unit where there are a large number of procedures to be performed during each shift. This nurse demonstrates a caring behavior in this situation by: | Seeking assistance before performing new or difficult skills |
| In example of the caring process of "enabling" is : | Assisting a patient during the birth of a child |
| A subdimension of Swanson's process of caring "doing for others as he/she would do for self" involves: | performing skillfully |
| In the Caring Assessment Tool, an example of mutual problem solving with a patient is when a nurse: | Discusses health issues with the patient and family |
| A nurse attempts to understand the specific cultural concerns of a patient and how they relate to his illness. What caring factor is applied: | Appreciation of unique meanings |
| Additional teaching is required if a nurse observes a nursing assistant working with an older adult patient and: | Addresses the patient as "Honey" |
| A patient is able to bear weight on one foot. the crutch walking gait that the nurse teaches this patient is the: | Three-point alternating gait |
| A nurse is working with a patient who is able only to minimally assist the nurse in moving from the bed to the chair. The nurse needs to help the patient stand. The correct technique for lifting the patient to stand and pivot to the chair is to: | Maintain a wide base with the feet |
| A nurse is assisting a patient who has been prescribed total bed rest to perform ROM exercises. The nurse performs the exercises by: | providing support for joints distal to the joint being exercise |
| A patient has experienced an injury to his lower extremity. The orthopedist has prescribed the use of crutches and a four point gait. The nurse instructs the patient using this gait to: | Move the right foot forward first |
| The patient had a CVA with resultant left hemipareis. The nurse is instructing the patient on the use of a cane for support during ambulation. The nurse instructs the patient to: | Use the can on the right side |
| A patient is admitted to the rehab facility for physical therapy after an automobile accident. To conduct an assessment of the patients body alignment, the nurse should begin by: | Putting the patient at ease |
| An average size female patient who resides in extended care facility requires assistance to ambulate down the hall. The nurse has noticed that the patient has some weakness on her right side. the nurse assists the patient to ambulate by: | Standing at her right side and using a gait belt |
| patient has cast on right foot & is being discharged home.Crutches will be used & patient has stairs manage outside and to get in the bedroom and bathroom. The nurse observes patient using correct techinique in using the crutches on stairs when patient: | advances the affected leg after moving the crutches when descending the stairs |
| A patient is getting up to ambulate for the first time since a surgical procedure. While ambulant in the hallway, the patient complains of severe dizziness. The nurse should first: | Lower the patient gently to the floor |
| One of the expected benefits of exercise is: 1.decreased diaphragmatic excursion 2.decreased cardiac output 3.increased fatigue 4.decreased resting heart rate | 4. decreased resting HR |
| A nurse selects which of the following for maintaining dorsiflexion of a patient: 1.Pillows 2.foot boots 3.bed boards 4.trochanter rolls | 2. Foot boots |
| A nurse recognizes that the position that is contraindicated for a patient who is at risk for aspiration is: 1.fowler's 2.lateral 3.sims' 4.supine | 4. supine |
| A patient had total hip replacement surgery an requires careful postoperative positioning to maintain the legs in abduction. the nurse will obtain a: 1.foot boot 2.trapeze bar. 3.bed board 4.wedge pillow | 4. wedge pillow |
| to prevent sudden infant death syndrome,a nurse instructs parents to: | Place the infant on the back or side to sleep |
| An older adult patient is being discharged home. The patient will be taking Lasix on a daily basis. A specific consideration for this patient is: | The location of the bathroom |
| While walking through a hallway in the extended care facility, a nurse notices smoke coming from a wastebasket in a patients room. upon closer investigation, the nurse identifies that there is a fire that is starting to flare up. The nurse should first: | Remove the patient from the room |
| A patient is newly admitted to the hospital and appears to be disoriented. There is a concern for the patients immediate safety. The nurse is considering the use of restraints to prevent an injury. The nurse recognize that the use of restraints requires: | physicians order |
| A nurse is completing admission histories for newly admitted patients to the unit. The nurse is aware that the patient with the greatest risk of injury: | has history of falls |
| a child has ingested a poisonous substance. The parent is instructed by the nurse to: | call the poison control center |
| Using the Morse Fall Scale, s nurse identifies what score for the patient with no history of falls, the presence of secondary diagnosis, use of a walker for ambulation with a weak gait, and awareness of his own limitations. | 40 |
| A restrain that may be used to prevent an adult patient from pulling on and removing tubes or an IV is an: | extremity restraint |
| An older adult patient in the extended care facility has been wandering outside of the room during the late evening hours. The patient has a history of falls. The nurse intervenes initially by: | Reassigning the patient to a room closer to the nursing station. |
| A parent with three children has gone to the outpatient clinic. The children range in age form 2 1/2-15 years old. A nurse is discussing safety issues with the parent. The nurse evaluates that further teaching is required if thee parent states: | "now my 2 1/2 year old can finally sit in the front seat of the care with me." |
| A viral disease that is spread through contaminated food or water is: 1.shigella 2.e. coli 3.listeria 4.hepatitis A | 4. Hepatitis A |
| After a CVA a patient is prescribed prolonged bed rest. During assessment, the nurse is especially alert to the presence of: | Warmth to the calf area |
| older adult patient had fractured hip repaired 2 days ago.patient is having more difficulty than expected in moving around, nurse is concerned about possible respiratory complications. IN assessing patient for possible atelectasis,nurse expects to find: | Asymmetrical breath sounds |
| For a patient who has been placed in a spica cast, the nurse remains alert to possible changes in the cardiovascular system as a result of immobility. the nurse may find that the patient has: | tachycardia |
| A possible compication for a patient who has been prescribed prolonged bed rest is thrombus formation. For the nurse to assess the presence of this serious problem, the nurse should: | Meausre the patients calf and thigh diameters |
| A patient was prescribed extended bed rest after abdominal surgery. the patient now has an order to be out of bed. the nurse should first: | Obtain the patients BP meausrements |
| A patient has been placed in skeletal traction and will be immobilized for an extended period of time. The nurse recognizes that there is a need to prevent respiratory complications and intervenes by: | encouraging deep breathing and coughing every hour |
| Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiological needs. A nurse recognizes a patients psychosocial needs when telling the patient the following: | "We can discuss the routine to see if there are any changes that we can make with you." |
| A patient is transferred to a rehab facility form the medical center after a CVA. The CVA resulted in severe right sided paralysis,& the patient is very limited mobility. To present complication of external hip rotation for this patient the nurse use a: | trochanter roll |
| A patient who has DVT is at risk for: 1.Atelectasis 2.Pulmonary emboli 3.Orthostatic hypotension 4.hypostatic pneumonia | 2. pulmonary emboli |
| The equipment that is used on a bed to assist a patient to raise the torso is a: 1.sandbag 2.bed board 3.trapeze bar 4.wedge pillow | 3. trapeze bar |
| For exercise, which of the following is appropriate for an immobilized older adult? | Gradual extended warm ups |
| If all of the following are prescribed, the best nursing strategy for the prevention of renal calculi is: | offering two liters of fluid per day |
| A nurse is instructing a patient on JROM and performance of shoulder abduction. The nurse correctly instructs the patient to: | raise the arm to the side to a position above the head |
| To prevent flexion, a nurse will obtain: 1.trochanter rolls 2.foot boots 3.sandbags 4.hand splints | 2. foot boots |
| A nurse is instructing a patient on ROJM and performance of forearm supination. The nurse correctly instructs the patient to: | Turn the lower arm and hand so the palm is up |
| A patient has weakness on the the upper and lower extremities and has been on bed rest for several days. Which of the following actions performed by the new staff nurse requires correction? | massaging the lower extremities |
| a patient is being instructed to perform dorisflexion of the foot. The nurse observes the patients ability to: | Move the foot so the toes point upward |
| To avodi pressure ulcer development for an immoblized patient at home, a nure recommends a surface to use on the bed. A surface type that is low cost and easy to use in the home is a: | foam overlay surface |
| For a patient in the extended care facility who has a nursing diagnoses of Impaired physical mobility, a nurse will implement: | maintenance of a position while in bed at 30 degrees or lower |
| A patient has experienced a traumatic injury that will require applications of heat. The nurse implement the treatment based on the principle that: | Patient response is best to minor temperature adjustment |
| a severely overweight patient has returned to the unit after having major abdominal surgery. When teh nurse enters the room, it is evident that the patient has moved or coughed and the wound has eviscerated. The nurse should immediately: | place sterile towels soaked in saline over the area |
| A patient with a knife protruding from his upper leg is taken into the emergency department. A nurse is waiting for the physician to arrive when a newly hired nurse comes to assist. The nurse delegates the new staff member to do all following asap except: | remove the knife to cleanse the wound |
| A nurse is assessing patients wound and notices that it has very minimal tissue loss and drainage. There are a number of dressing that may be used according to the protocol on the unit. The nurse selects: | transparent film |
| A nurse is completing an assessment of the patients skin integrity and identifies that an area is a full thickness wound with damage to the subcutaneous tissue. the nurse identifies this stage of ulcer formation as: | stage 3 |
| A patient has a large wound to the sacral area that requires irrigation. The nurse explains to the patient that irrigation wil be performed to; | remove debris from the wound |
| A nurse is working with an older audlt patient in an extended care facility. While turning the patient, the nurse notices that there is a reddened area on the patients coccyx. the nurse implements skin care that includes: | cleaning the area with mild soap, drying and applying a protective moisturizer |
| A patient has a wound to the left lower extremity that has minimal exudates and collagen formation. The nurse identifies the healing phase of this wound as: | proliferative phase |
| after neurosurgery, a nurse assesses the ptients bandage and finds that there is fresh bleeding coming from the operative site. the nurse describes this drainage to the surgeon as: | sanguineous |
| A patient has surgical wound on the right upper aspect of the chest that requires cleansing. The nurse implements appropriate aseptic technique by: | starting as the drainage site and moving outward with circular |
| A nurse is working in a physicians office and is asked by one of the patients when heat or cold should be applied. In providing an example the nurse identifies that cold therapy should b e applied for the patient with: | a newly fractured ankle |
| A patient will require the application of a binder to provide support to the abdomen. When applying the binder, the nurse uses the principle that: | the patient must maintain adequate ventilatory capaity |
| A nurse is aware that malnutrition places a patient at a greater risk for tissue damage. The patient with the greatest risk is the individual who: | experienced 7% weight loss in 4 months |
| The agent that is most effective and safest for cleaning a granular wound is: 1.acetic acid 2.normal saline 3.povidone iodine 4.hydrogen peroxide | 2. NS |
| A nurse is working with a patient who has a stage 3, clean ulcer with significant exudate. The nurse anticipates that which of the following dressings will be used: | hydrogel dressing |
| For a patients optimal nutritional intake that will promote formation of new blood vessels and collagen synthesis, the nurse plans to teach the patient to include sufficient intake of: | proteins |
| Individuals experience changes in their sleep patterns as they progress through the life cycle. A nurse assesses that a patient is experiencing bedtime fears. restlessness during the night, and nightmares. These behaviors are associated with: | preschoolers |
| A nurse is making rounds during the night to check on patients. When she enters one of the rooms at 3:00 a.m., She finds that the patient is sitting up in a chair. The patient tells the nurse that she is not able to sleep. The nurse should first: | ask about activities that have previously helped her sleep |
| A nurse is working on pediatric unit at the local hospital. A 4-year old boy is admitted to the unit. To assist this child to sleep, the nurse: | Reads to him |
| A patient is found to be awakening frequently during the night. There are a number of medications prescribed for this patient. The nurse determines that the medication that may be creating this patients particular sleep disturbance is the: | beta blocker |
| A nurse suspects that a patient may be experiencing sleep deprivation. This suspicion is validated by the nurses finding that the patient has: | blurred vision |
| A nurse is working in a sleep clinic that is part of the local hospital. In preparing to work with patients with different sleep nees, the nurse understands that: | warm milk before bedtime may help a patient sleep. |
| completing patient history&home assessment,nurse finds there are many prescriptions meds kept in bathroom cabinet. In determining possible areas that may influence sleep nurse looks for classification of meds that may suppress REM. The nurse looks for: | stimulant |
| newborn is taken to pediatricains office for the 1st physical exam.parents ask nurse when they can expect baby to sleep through night. The nurse response that,there maybe individual differences,infants usually develop a nighttime pattern of sleep age of: | 3 months |
| A nurse is working with older adults in the senior cneter. A group is discussing problems with sleep. The nurse recognizes that older adults: | Have a significant decline in stage 4 sleep |
| A patient with CHF is being discharged from the hospital to her home. The patient will be taking a diuretic daily. The nurse recognizes that, with this drug, the patient may experience: | nocturia |
| During a home visit, a nurse discovers that the patient has been having difficulty sleeping. To assist the patient to achieve sufficient sleep, an appropriate question the nurse might ask is the following: | "What kinds of things do you do right before bedtime?" |
| A patient has gone to the sleep clinic to determine what may be creating his sleeping problems. in addition, his partner is having sleep pattern interruptions. If this patient is experiencing sleep apnea, nurse may expect partner to identify that patient: | snores excessively |
| A nurse anticipates that the patient who is NREM stage 1 sleep is: 1.easily aroused 2.completely relaxed 3.having vivid,color dreams 4.reduced vital signs | 1. Easily aroused |
| A nurse is working with a patient who has a history of respiratory disease. The patient is expected to demonstrate: | need for extra pillows for comfort |
| To help promote sleep for a patient, a nurse recommends: | exercise about 2 hours before bedtime |
| An expected treatment for sleep apnea is: 1.biofeedback 2.full body massage 3.admistration of hypnotics 4.continuous positive airway pressure (CPAP) | 4. CPAP |
| At sleep aids, medications that are considered relatively safe to use are: 1.nonbenzodiazepines 2.barbituates 3.psychotropics 4.antihistamines | 1.nonbenzodiazepines |
| An expected observation of a patient in REM sleep is: 1.possible enuresis 2.sleep walking 3.loss of skeletal muscle tone 4.easy arousal from external noise | 3.loss of skeletal muscle tone |
| A parent asks the nurse what the appropriate amount of sleep is for her 11 year old child. The nurse responds correctly by informing the parent that children in this age group should average: | 10 hours/night |
| A patient is experiencing pain that is not being managed by analgesics given by the oral or IM routes. Epidural analgesia is initiated. The nurse is alert for a complication of this treatment and observes the patient for: | urinary retention |
| A patient had a laparoscopic procedure this morning and is requesting pain med. the nurse assesses the patients vital signs and decides to withhold the med based on the finding of: | respirations=10/minute |
| A nurse is working with an older adult population in the extended care facility. Many of the patients experience discomfort associated with arthritis and have analgesics prescribed. In administering an analgesic med to an older adult patient,nurse should: | give the med before activities or procedures |
| one of the patients that a nurse is working with on an outpatient basis at the clinic has rheumatoid arthritis. The patient has no known allergies to any medications, so the nurse anticipates that the physician will prescribe: | indomethacin |
| An adolescent has been carried to the sidelines of the soccer field after experiencing a twisted ankle. The level of pain is identified as low to moderate. The observes that the patient has: | diaphoresis |
| A nurse on the pediatric unit is finding that it is sometimes difficult to determine the presence and severity of pain in very young patients. The nurse recognizes that toddlers may be experiencing pain when they have: | disturbances in their sleep patterns |
| A patient on the oncology unit is experiencing sever pain associated with his cancer. Although analgesics have been prescribed and administered, the patient is having "breakthrough pain." The nurse anticipates that his treatment will include: | increase in the opioid dose |
| A patient is experiencing pain that is being treated with a fentanyl transdermal patch. The nurse advises this patient to: | applying heating pad over the site |
| A patient is experiencing sever pain and has been placed on a morphine drip. During the patients assessment, the nurse finds that the patients respiratory rate is 6 breaths/minute. The nurse anticipates that the patient will receive: | Naloxone |
| An assessment toll that allows for total freedom in identification of pain severity is the: | Brief Pain Inventory (BPI) |
| A nurse is working for an oncology unit in the medical center. All of the patients experience pain that requires management. The nurse should visit first with the patient who is also exhibiting signs of: | anxiety |
| For a patient with a consistent level of discomfort, the most effective pain relief is achieved with administration of analgesics: | Around the clock |
| A nurse anticipates that the patient with visceral pain will describe pain as:: 1.sharp 2.cramping 3.burning 4.shooting | 4.shooting |
| Which of the following orders would the nurse question for the patient who has an epidural infusion for pain relief? | tubing changes every 24 hours |
| A patient will be using an ambulatory infusion pump at home for analgesia. Additional teaching is required if the patent is observed: | clamping the catheter after the infusion |
| Because of the possible cardiovascular and neurological effects, which of the following analgesics orders for an older adult patient should be questioned: | acetaminophen |
| look at chapter 7,8,14 |
Created by:
bkate
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