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Exam #7

NCLEX questions

QuestionAnswer
Which Patient is at greatest risk for developing a pressure injury? 80 year old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence
A factor in skin problems common to older adults is: -nails become thin and more brittle -skin is less elastic and more fragile
Your patient has an area at the left trochanter that is reddened with slightly abraded skin. You would stage this as a __________ pressure injury stage 2 pressure injury
The extremities are washed from distal to proximal because this: promotes venous return to the heart
The primary reason some hospitals prefer a bag bath to a traditional bed bath is: infection control
When providing foot care for the diabetic patient, you must remember to: check for an order before trimming the nails straight across
Prevention of pressure injuries is promoted by: -changing the patient's position every 2 hours -keeping the heels of the immobile patient off the bed -using lift devices such as a trapeze bar to move patients
When instructing a patient scheduled for same day surgery, you tell him to: -bring only essential items to hospital -have someone available to take him home after the procedure -report to the same day surgery unit 1-2 hours before the scheduled procedure
In an acute care facility the person responsible for the initial nursing assessment is: the RN
Orders are verified and signed off by: The licensed nurse
If a patient brings credit cards, cell phone, and jewelry to the hospital, you can provide for their security by: -sending items home with the family -placing the contents in a valuables envelope to be stored in a safe
When transferring a patient to another facility, copies of pertinent medical records: must be faxed to the facility or must accompany the patient
What information should be included in a discharge summary? -patient's present condition -activity restrictions -diet to be followed
If a patient wants to leave AMA, the nurse: Explains that insurance may not pay his bill if he leaves
An autopsy may be required when: -a patient dies at the hands of another -a patient dies without being under a primary care provider's care outside the hospital -the cause of death is unknown
Your patient asks you what phytotherapy means. You respond that it refers to: herbs compounded into medicines
It is important to know whether a patient is using herbal therapies because: certain herbs can interact adversely with prescription drugs
Chiropractic therapy: -uses spinal manipulation to relieve pain and restore function -may be combined with exercise, ice, heat, and electrical stimulation massage
A patient who takes several herbs and supplements is scheduled for surgery in two weeks. The nurse should advise discontinuing: -garlic -omega 3 fatty acids -ibuprofen
A logical choice of a complimentary therapy for a person who has difficulty expressing her feelings might be: art therapy
An herb once commonly used in weight loss preparations and now banned by the FDA is: Ephedra
A similarity of roles for the scrub person and the circulating nurse is that they both: advise the team of breaks in sterile technique
When a patient arrives in the PACU with a surgical dressing, an intravenous infusion, and a urinary catheter, the priority action of the nurse is assessment of: airway patency
As part of a patient's immediate care in the PACU, the nurse would: -check vital signs every 15 minutes -assess adequacy of respirations -monitor the dressing -observe drainage from the NG tube -note the amount of urine output
A patient returns to his room after surgery. When he arrives, you notice that he is still groggy from anesthesia and that he has an IV running in one arm. As you help settle him in bed, you: -assess the IV for patency and correct fluid and rate -position to prevent aspiration while still groggy -take his vital signs every 15 minutes for one hour -reassure him that the surgery is over
If your fresh, postoperative patient has not voided within 8 hours of the surgery, you would first: assist the patient to attempt to void using measures to encourage voiding
The second day postoperatively, the NG tube is removed and an order is written for fluids as tolerated and a liquid diet. The patient is eager to try taking fluids. What should the nurse recommend that he do? start with small sips of water at first to see if they are retained
The patient has a PCA pump to be used for pain control. Should his pain not be adequately controlled with use of the pump, the nurse would first: -use non-pharmacologic comfort measures -be certain that none of the drainage tubes are kinked -encourage the use of distractions
On his 3rd postop day, a patient states that he does not feel well & that he has a lot more pain in the incision area. You inspect the incision & notice the lower end of it is very red. From these symptoms, you suspect that they have developed: a wound infection
Created by: ahoyyitbeaddi