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120 Cards in this Set
- Front
- Back
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When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, what phase of the nursing process is being used?
Planning Diagnosis Evaluation Implementation |
Implementation
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When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. What is this format called?
Concept map Critical pathway Clinical pathway Nursing care plan |
Concept map
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A nurse is providing care for a patient who had transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, but his urinary catheter is now occluded. The nurse is now planning to phone the patient's health care provider and communicate using the SBAR (Situation-Background-Assessment-Recommendation) format. Which statement is a component of communication using SBAR?
"What do you think could be causing this occlusion?" "I think that we should manually irrigate his catheter." "What do you know about this patient and his history?" "Could you please provide some direction for his care?" |
"I think that we should manually irrigate his catheter."
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What factor has been most clearly identified as an influence on the future of nursing practice?
Aging of the American population and increases in chronic illnesses Increasing birth rates coupled with decreased average life expectancy Increased awareness of determinants of health and improved self-care Apathy around health behaviors and the relationship of lifestyle to health |
Aging of the American population and increases in chronic illnesses
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A group of nurses have a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply)?
Consulting with the wound care and ostomy nurse The preferences of patients and their particular circumstances Nurses' expertise and their bodies of experience and knowledge The traditions that surround pressure ulcer practices on the unit Journal articles that address the care of patients with pressure ulcers |
Consulting with the wound care and ostomy nurse
The preferences of patients and their particular circumstances Nurses' expertise and their bodies of experience and knowledge Journal articles that address the care of patients with pressure ulcers |
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A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation?
The RN should first teach the LPN how to administer IV medications. Ultimate responsibility for the execution of the task now lies with the LPN. The RN is still accountable for the quality of care and procedures that the patient receives. The RN is responsible for observing and evaluating the administration of IV medications by the LPN. |
The RN is still accountable for the quality of care and procedures that the patient receives.
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Nurses deliver patient-centered care in collaboration with the interdisciplinary health care team within the framework of a care delivery model. In which care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines with a focus on continuity of care and interdisciplinary collaboration even when the nurse is absent?
Team nursing model Primary nursing model Total patient care model Case management nursing model |
Primary nursing model
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Which interventions are independent nursing actions (select all that apply)?
IV reinsertion Assessing lung sounds Medication administration First postoperative dressing change Obtaining informed consent from the patient |
IV reinsertion
Assessing lung sounds |
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Telehealth includes using devices to provide which types of care for the patient (select all that apply)?
Administering medications Evaluation of weight loss Video assessment of wounds Monitoring peak flow meter results Real-time blood pressure assessment |
Evaluation of weight loss
Video assessment of wounds Monitoring peak flow meter results Real-time blood pressure assessment |
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Which individual is most likely to experience health care disparities?
A 65-year-old upper class Hispanic male living in the city A 78-year-old Native American male living on a reservation A 50-year-old middle-class white female living in a rural area A 72-year-old African American retired attorney living in a condo |
A 78-year-old Native American male living on a reservation
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The nurse identifies a patient at high risk for health care disparities. What should be included as important nursing interventions to reduce health care disparities (select all that apply)?
Passive listening Relationship building Taking foreign language classes Participating in cross-cultural education Using standardized evidence-based guidelines |
Relationship building
Participating in cross-cultural education Using standardized evidence-based guidelines |
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When obtaining an admission history on a Mexican American older male patient, which cultural value would the nurse recognize as most likely to be important to this patient?
Patriarchal Self-reliance Science-based Harmony with nature |
Patriarchal
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Culturally competent nursing care for a Jewish patient would include which diet?
Kosher Vegetarian Word of wisdom Low carbohydrate |
Kosher
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Which nursing action is most indicative of stereotyping?
The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients. The nurse helps a recent immigrant to explore ways to pay for her newly prescribed antihypertensive medications. The nurse prioritizes the assessment of obesity when providing care for African American and Mexican American women. The nurse arranges for translation services to be provided for a patient who has recently emigrated from Sri Lanka and does not speak English. |
The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients.
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The nurse is performing an assessment of a 78-year-old Chinese American woman who wears a jade bracelet on her left wrist. The nurse asks the patient about the significance of the bracelet and whether it can be removed prior to the patient's scheduled diagnostic procedure. What has the nurse demonstrated?
Diversity Stereotyping Ethnocentrism Cultural competence |
Cultural competence
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The adult children of a male patient who is Hindu have requested a vegetarian diet for their father. What is the nurse's most appropriate response?
Order a vegetarian diet for the patient. Assess the family's rationale for choosing this particular diet. Teach the family about the relationship between protein intake and wound healing. Explore the benefits of a low-meat, high-protein diet with the family and the dietitian. |
Order a vegetarian diet for the patient
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A 72-year-old Nigerian man comes to the United States to visit his adult son. The son tries to encourage his father to have the testing and treatment for a chronic productive cough. The adult son has a positive attitude and believes in the American medical treatment because what has happened to the child while living in the United States?
Acculturation Ethnocentrism Race awareness Cultural imposition |
Acculturation
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The nurse is interested in developing her cultural competence. What roles can she take to do so?
Develop understanding of all ethnic groups. Identify the one culture about which she is interested in being competent. Have extended contact with a cultural group to enhance understanding of its values and beliefs. Understand the specific information about the patient's culture so the understanding can be applied to caring for the patient. |
Have extended contact with a cultural group to enhance understanding of its values and beliefs.
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During an admission history and physical assessment, the patient describes symptoms to the nurse. What should these descriptions be documented as?
Objective data Subjective data Generalized data Comprehensive data |
Subjective
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The nurse would place assessment findings related to vision and hearing under which functional health pattern?
Activity-rest pattern Cognitive-perceptual pattern Self-perception/self-concept pattern Health-perception/health-management pattern |
Cognitive-perceptual pattern
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Which action most clearly demonstrates a nursing focus rather than a medical focus?
The nurse recommends a change to the patient's insulin sliding scale. The nurse interprets the results of the patient's most recent glucose tolerance test. The nurse assesses the benefits of changing the patient to a new oral antihyperglycemic. The nurse assesses the effect that a recent diagnosis of diabetes has on the patient's lifestyle and routines. |
The nurse assesses the effect that a recent diagnosis of diabetes has on the patient's lifestyle and routines.
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A 72-year-old woman has sought care for restless legs syndrome, a problem that has been causing her increasing loss of sleep in recent weeks. The woman states that she attributes the problem to inadequate calcium intake, and she has responded by integrating more dairy products into her diet. Which aspects of symptom investigation does the nurse recognize as present in this situation (select all that apply)?
Quality Timing Severity Radiation Precipitating and palliative |
Timing
Radiation Precipitating and palliative |
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During the nurse's initial health assessment of an older adult patient, the nurse notes that the patient often makes self-deprecating statements, saying that "I'm just a nuisance to my children now" and "It would be easier for everyone if I didn't have to be such a burden to them." The nurse would document a problem in which functional health pattern?
Value-belief pattern Cognitive-perceptual pattern Coping–stress tolerance pattern Self-perception/self-concept pattern |
Self-perception/self-concept pattern
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In which situation would the nurse most likely conduct a comprehensive assessment?
When performing resuscitation on a trauma patient When assessing the progression of a patient's ascites and edema When admitting a patient to a medical unit from the emergency department When assessing a patient who has been receiving rehabilitation following a stroke |
When admitting a patient to a medical unit from the emergency department
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Indicate which data would be classified as objective data (select all that apply).
Earache Dizziness Pitting edema Cyanosis of lips Shortness of breath Hyperactive peristalsis |
Pitting edema
Cyanosis of lips Hyperactive peristalsis |
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Before counting the apical heart rate, which nursing assessment technique should the nurse use to find the correct place to listen to the point of maximal impulse (PMI)?
Inspection Percussion Auscultation Light palpation |
Light palpation
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The patient was admitted via the emergency department (ED) with respiratory distress. What statement best describes the initial assessment of the patient on the medical-surgical unit?
An emergency assessment should be performed to ensure the patient's safety. A focused assessment should be performed to be sure the ED did not miss anything. A focused assessment should be performed to determine if new problems have arisen. A comprehensive assessment should be performed to determine the patient's response to the |
A comprehensive assessment should be performed to determine the patient's response to the respiratory distress and treatment
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Which techniques would be most appropriate to enhance patient learning (select all that apply)?
Obtain frequent feedback. Have a quiet environment. Explain information in great detail. Involve the patient and caregiver in the process. Emphasize relevancy of the information to the patient's lifestyle. |
Obtain frequent feedback.
Have a quiet environment. Involve the patient and caregiver in the process. Emphasize relevancy of the information to the patient's lifestyle. |
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What would be one method of individualizing learning for a patient's unique needs?
Use prepackaged learning materials. Only teach the patient "need-to-know" information. Have the patient arrange topic cards in order of priority. Have the patient watch a video and then read a pamphlet. |
Have the patient arrange topic cards in order of priority.
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Which actions best demonstrate the nurses' awareness of learning styles and the role that they play in patient and caregiver teaching (select all that apply)?
Assess patients' learning styles prior to teaching. Use materials that appeal to a variety of learning styles. Prioritize the learning style with which he or she is most familiar and comfortable. Provide written instructions to younger patients while using visual and audio aids when teaching older patients. Provide visual and audio aids to younger patients while using written instructions when teaching older patients. |
Assess patients' learning styles prior to teaching.
Use materials that appeal to a variety of learning styles. |
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The nurse notes that a male patient regularly asks about the purpose and potential side effects of each oral medication that he has received during his time in the hospital. How should the nurse best interpret the patient's questions?
The patient has an auditory learning style. The patient is identifying his learning needs. The patient is exhibiting a high level of health literacy. The patient is experiencing anxiety related to his diagnosis and treatment. |
The patient is identifying his learning needs.
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A 44-year-old female patient with a long-standing history of type 1 diabetes has brought a number of printouts from websites to her most recent visit with her primary care provider. What direction should the nurse provide to the patient regarding health information on the Internet?
"It is best to make sure that you avoid websites that are not associated with a government agency." "You may have some good information there, but it is best to focus only on the information the doctor provides to you." "There is a great deal of misinformation on the Internet, so it is best to focus on printed material rather than electronic sources." "I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like." |
"I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like."
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The nursing student is assigned to use motivational interviewing to motivate the patient to change dietary eating behaviors. Which statement shows the use of this technique?
"Tell me about the concerns you have about changing your diet." "You have a big weakness for ice cream; we will need to change that." "I feel sorry for you, but you must change your diet if you plan to feel better." "I would not want to change my diet, but I would sure do it instead of getting sicker." |
"Tell me about the concerns you have about changing your diet."
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The patient says she prefers to watch how things are done rather than to read the information or instructions to learn about how to take care of herself. Which teaching strategy would be best for this patient?
Watch a DVD. Read the pamphlet. Talk about it with the nurse. Use the Internet to read about it. |
Watch a DVD.
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Which teaching strategy would be best to offer to a 20-year-old patient?
Lecture or books Websites or podcasts Television or pamphlets Role play or support group |
Websites or podcasts
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Which question elicits additional information to evaluate the patient's understanding?
"Can you show me how to change your dressing?" "Do you understand how to change your dressing?" "Do you think you can change your dressing at home?" "What will you do if the dressing has excess drainage?" |
"What will you do if the dressing has excess drainage?"
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Based on adult learning principles, which situation indicates that the patient is ready to learn about taking enoxaparin (Lovenox) injections at home?
The patient is requesting pain medication. The patient is too tired to stay awake to watch the teaching DVD. The patient wants to practice before actually injecting himself with the needle. The patient is nervous and says he cannot do it when he picks up the bottle of medication. |
The patient wants to practice before actually injecting himself with the needle.
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What is most appropriate for the nurse to do when interviewing an older patient?
Ensure all assistive devices are in place. Interview the patient and caregiver together. Perform the interview before administering analgesics. Move on to the next question if the patient does not respond quickly. |
Ensure all assistive devices are in place.
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Which assessment findings would alert the nurse to possible elder mistreatment (select all that apply)?
Agitation Depression Weight gain Weight loss Hypernatremia |
agitation
depression weight loss |
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A 67-year-old woman who has a long-standing diagnosis of incontinence is in the habit of arriving 20 minutes early for church in order to ensure that she gets a seat near the end of a row and close to the exit so that she has ready access to the restroom. Which tasks of the chronically ill is the woman demonstrating (select all that apply)?
Controlling symptoms Preventing social isolation Preventing and managing a crisis Denying the reality of the problem Adjusting to changes in the course of the disease |
Preventing and managing a crisis
Controlling symptoms |
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A 70-year-old man has just been diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient's wife in the teaching around the management of the disease?
As soon as possible When the patient requests assistance from his spouse and family When the patient becomes unable to manage his symptoms independently After the patient has had the opportunity to adjust to his treatment regimen |
As soon as possible
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A nurse who is providing care for an 81-year-old female patient recognizes the need to maximize the patient's mobility during her recovery from surgery. What accurately describes the best rationale for the nurse's actions?
Continued activity prevents deconditioning. Pharmacokinetics are improved by patient mobility. Lack of stimulation contributes to the development of cognitive deficits in older adults. Regularly scheduled physical rehabilitation provides an important sense of purpose for older patients. |
Continued activity prevents deconditioning.
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Which criterion must a 65-year-old person meet in order to qualify for Medicare funding?
Being entitled to Social Security benefits A documented absence of family caregivers A validated need for long-term residential care A history of failed responses to standard medical treatments |
Being entitled to Social Security benefits
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A male patient has a history of hypertension and type 1 diabetes mellitus. Because of these chronic illnesses, the patient exercises and eats the healthy diet that his wife prepares for him. Which factors will most likely have a positive impact on his biologic aging (select all that apply)?
Exercise Diabetes Social support Good nutrition Coping resources |
Social support
Good nutrition Coping resources exercise |
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A 60-year-old female patient has had increased evidence of dementia and physical deterioration. What would be the best assistance to recommend to her caregiver husband who is exhausted?
Long-term care Adult day care Home health care Homemaker services |
Adult day care
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What should be included when planning care for an older adult?
Patient priorities should be the only focus of care. Additional time related to declining energy reserves Reduction of disease and problems should be the focus. Tobacco cessation will help the patient cope with other illnesses. |
Additional time related to declining energy reserves
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Aging primarily affects the _________of drugs.
excretion absorption metabolism distribution |
metabolism
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A nurse is caring for an adult who sustained a severe traumatic brain injury following a motor vehicle accident. Once the patient recovers from the acute aspects of this injury and is no longer ventilator-dependent, discharge planning would include that this patient will be transferred to what type of practice setting?
Assisted living Acute rehabilitation Long-term acute care Skilled nursing facility |
Acute rehabilitation
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The nurse is preparing to teach the patient about maintaining his health. Which whole medical system would best aid the nurse in guiding the patient?
Naturopathy Homeopathy Holistic nursing Traditional Chinese medicine |
Naturopathy
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The patient describes methods he has been using for affordable health care. Which ones are complementary and alternative therapies (CATs) (select all that apply)?
Garlic Prayer Acupuncture Healing Touch Chiropractic therapy |
Garlic
Acupuncture Healing Touch Chiropractic therapy |
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Which concepts are part of the focus of the integrative model of health care (select all that apply)?
Fix the ailing body part. Health is a personal responsibility. Diseases must be treated for healing. Use natural, less invasive modalities. Join the mind-body-spirit for healing. Health care focuses on the physical body. |
Health is a personal responsibility.
Use natural, less invasive modalities. Join the mind-body-spirit for healing. |
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The nurse is teaching the patient about the use of herbs. What key concept needs to be included when teaching about the use of herbs?
There may be an increased risk of bleeding. Take as much as needed to improve symptoms. Report any side effects to the clerk at the health food store. Be aware of the risks such as drug reactions when taken in combination with other drugs. |
Be aware of the risks such as drug reactions when taken in combination with other drugs.
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A nurse is counseling a patient about dietary supplements normally used for the prevention and treatment of cardiovascular disease. Which supplement has strong scientific evidence for its use?
Melatonin Green tea Glucosamine Omega-3 fatty acids |
Omega 3
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The nurse responds to a patient's question regarding the safety and efficacy of glucosamine for the treatment of osteoarthritis based on what knowledge?
All dietary supplements are controlled by the FDA and thus are deemed safe and effective. There is weak scientific evidence for the use of this supplement in the treatment of osteoarthritis. There is good scientific evidence for the use of this supplement in the treatment of osteoarthritis. There is unclear scientific evidence for the use of this supplement in the treatment of osteoarthritis. |
There is good scientific evidence for the use of this supplement in the treatment of osteoarthritis.
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Which herbal product is assumed safe for short-term patient use for decreasing the duration of upper respiratory tract infections?
Ginseng Echinacea Ginkgo biloba Cranberry juice |
Echinacea
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On the advice of a website that was recommended by a friend, a patient with a diagnosis of osteoarthritis has stopped taking her regular nonsteroidal antiinflammatory drug (NSAID) and is planning to begin a naturopathic regimen that is based on herbal supplements. How should the nurse best respond to this patient?
Discourage the patient from using alternative therapies. Encourage the patient in her efforts to promote self-efficacy. Recommend that the patient review her plan with her primary care provider. Recommend that the patient continue using her regular NSAID until the new regimen has had time to take effect. |
Recommend that the patient review her plan with her primary care provider.
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The daughters of a 78-year-old nonresponsive patient who had an ischemic stroke 2 weeks ago have asked the nurse if they can bring a Healing Touch (HT) practitioner to the bedside. How should the nurse best respond?
Review the literature on HT prior to granting permission. Consult with the health care team and facilitate the practitioner's visit. Encourage the family to defer their decision until physiotherapy has been shown to be ineffective. Dialogue with the family members about whether they would prefer to change to a complementary and alternative plan of care.The daughters of a 78-year-old nonresponsive patient who had an ischemic stroke 2 weeks ago have asked the nurse if they can bring a Healing Touch (HT) practitioner to the bedside. How should the nurse best respond? Review the literature on HT prior to granting permission. Consult with the health care team and facilitate the practitioner's visit. Encourage the family to defer their decision until physiothera |
Consult with the health care team and facilitate the practitioner's visit.
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The daughters of a 78-year-old nonresponsive patient who had an ischemic stroke 2 weeks ago have asked the nurse if they can bring a Healing Touch (HT) practitioner to the bedside. How should the nurse best respond?
Review the literature on HT prior to granting permission. Consult with the health care team and facilitate the practitioner's visit. Encourage the family to defer their decision until physiotherapy has been shown to be ineffective. Dialogue with the family members about whether they would prefer to change to a complementary and alternative plan of care. |
Consult with the health care team and facilitate the practitioner's visit.
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Which scenario most clearly warrants further assessment and possible intervention?
The family of a patient with Alzheimer's is using valerian in order to help with her sleep. An obese male patient takes garlic supplements in an effort to reduce his cholesterol levels. A depressed patient supplements her serotonin-reuptake inhibitor (SSRI) with St. John's wort. A male patient with diabetes is taking echinacea to treat his upper respiratory infection. |
A depressed patient supplements her serotonin-reuptake inhibitor (SSRI) with St. John's wort.
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Which statement shows that the nurse understands her role related to complementary and alternative therapies (CAT) and patient care?
"Why would you take aloe for constipation?" "What types of herbs, vitamins, or supplements do you take?" "You can continue taking the coenzyme Q10 while you take the metoprolol (Lopressor) if you want to." "I don't need to know about the herbs or supplements you use because they are natural and not drugs." |
What types of herbs, vitamins, or supplements do you take?"
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The nurse in the surgeon's office is providing preoperative teaching for the patient before back surgery. What teaching must be included for the patient who is currently using herbal therapy?
You may continue your massage therapy after your surgery. Stop taking any herbal products 2 to 3 weeks before surgery. Only take herbal products from companies with a good reputation. Moisture, sunlight, and heat may alter the components of herbal treatments. |
Stop taking any herbal products 2 to 3 weeks before surgery.
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Before teaching stress management techniques, what is important for the nurse to do first?
Personally become familiar with them. Obtain certification in stress management. Obtain permission from the health care provider. Recognize the potential harmful effects of these techniques. |
Personally become familiar with them.
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What factors affecting a person's response should the nurse be aware of when planning care for a patient experiencing physiologic or emotional/psychologic stressors?
Time of day Cultural and ethnic influences Loss of appetite and weight loss Inability to answer the admission questions |
Cultural and ethnic influences
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A student is experiencing stress because he does not feel prepared for his oral examination in the morning. Which hormone is likely having the most significant effect on the student's current physiologic state?
Insulin Cortisol Glucagon Antidiuretic hormone (ADH) |
Cortisol
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The patient was told today that he has prostate cancer with bone metastasis. Because of the bone metastasis, the patient has been advised not to shovel snow or work in the yard to avoid breaking bones. Physical activity is his usual coping strategy. He has decided to get the house ready to sell so he and his wife are prepared for the future. What should the nurse suggest for him to assist in emotion-focused coping with his diagnosis?
Watch funny movies to feel better. Paint the inside of the house so it is ready to sell. Go through old papers and organize them before he dies. Write and share his memories with his family and friends. |
Write and share his memories with his family and friends
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While teaching a stress management class for caregivers of patients with Alzheimer's disease, you have led the caregivers through a stress-reduction exercise by asking them to envision places and experiences that are calming. Which technique have you utilized?
Centering Meditation Guided imagery Relaxation breathing |
Guided imagery
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A 40-year-old male patient is alarmed at his recent diagnosis of type 2 diabetes. Which of the man's following actions best indicates a problem-focused coping strategy?
Resolving to begin exercising three times weekly Integrating meditation and guided imagery into his routines Learning how to perform relaxation breathing effectively and regularly Gathering printed literature and online information regarding his new diagnosis |
Resolving to begin exercising three times weekly
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The patient came to the clinic seeking help for headaches and insomnia. What other manifestation could be present if stress is the cause of the patient's problems?
Weight gain Hypoventilation Increased energy Musculoskeletal pain |
Musculoskeletal pain
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Which hormones are known to inhibit the immune system when a person is stressed (select all that apply)?
Cortisol Glucagon Aldosterone Catecholamines Growth hormone |
Cortisol
Catecholamines |
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Which individual most clearly exhibits the signs and symptoms of primary insomnia?
A man whose increased sleep latency is not clearly attributable to any particular cause A woman who is in the habit of having a cappuccino in the late evening while she watches TV A man whose corticosteroid therapy causes him to feel "edgy" and unable to fall asleep at night A woman who has experienced frequent nighttime awakenings since the recent death of her husband |
A man whose increased sleep latency is not clearly attributable to any particular cause
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A college student has sought care prompted by his complaints of insomnia over the past several months. What should his health care provider initially recommend?
Melatonin Benzodiazepines Sleep hygiene practices Over-the-counter sleep aids |
Sleep hygiene practices
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Which assessment question is most appropriate when the nurse is assessing a patient who is receiving care for suspected obstructive sleep apnea (OSA)?
"Do you smoke?" "Do you tend to awaken early in the morning?" "Are you under a lot of stress at work or at home right now?" "Do you have a history of chronic obstructive pulmonary disease?" |
Do you smoke?"
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An obese male patient is scheduled to begin treatment with continuous positive airway pressure (CPAP). How will this treatment method alleviate obstructive sleep apnea (OSA)?
Calming the patient Preventing airway collapse Increasing the efficiency of gas exchange across alveolar walls Requiring the patient to breathe through his nose rather than his mouth |
Preventing airway collapse
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What principle should guide nursing practice when providing care for older patients?
Drug therapy should be used conservatively. Older adults require less sleep than younger adults. Cognitive-behavioral interventions are less effective than among younger adults. Patient teaching should focus on older adults accepting age-related changes in their sleep cycles. |
Drug therapy should be used conservatively.
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The nurse usually works day shift but will be working night shift to help a friend. What can the nurse do to help herself sleep during the day?
Make the bedroom warmer. Use room-darkening window shades. Drink warm Earl Grey tea at the end of her shift. Go to the gym to work out before going home to sleep. |
Use room-darkening window shades.
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Which studies are used to diagnose insomnia?
EEG Self-report Actigraphy Polysomnography |
Self-report
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The patient is in the ICU and becoming more irritable as the days go by. The nurse determines the patient is not getting enough sleep. What actions will best help facilitate the patient's sleeping?
Give the patient a back rub. Keep the lights on during the day. Talk to the patient when he wakes up at night. Do the vital signs and treatments at the same time. |
Do the vital signs and treatments at the same time.
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The patient will schedule a test to see if he has mild sleep apnea. What should the nurse teach the patient to do until the test can be completed?
Take sleep medications. Use his wife's CPAP mask. Sleep in a side-lying position. Do not use pillows when sleeping. |
Sleep in a side-lying position.
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A patient was just diagnosed with narcolepsy and wants to know what he can do to get rid of it. What is the best response the nurse can give this patient?
"If you take your medicine and naps, you will be cured." "Patient support groups may be able to help you feel better." "Drug therapy and behavioral strategies will be used to help treat it." "Safety precautions must only be when you are driving an automobile." |
"Drug therapy and behavioral strategies will be used to help treat it."
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Insufficient sleep is associated with changes in bodily function and health problems. Which disease/disorder description is related to disturbed sleep?
Insufficient sleep is linked to a decreased risk for type 2 diabetes mellitus. Inadequate sleep in people with hypertension leads to future decreases in BP. Short sleep duration may result in metabolic changes that are linked to obesity. Radiation for cancer treatment is associated with fragmented sleep and fatigue. |
Short sleep duration may result in metabolic changes that are linked to obesity.
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Before administering celecoxib (Celebrex), the nurse will assess the patient's medical record for which medication that would increase the risk of adverse effects?
Aspirin Scopolamine Theophylline Acetaminophen |
Aspirin
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After administering acetaminophen and oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room?
Leave the overbed light on at low setting. Ensure that the upper two side rails are raised. Offer to turn on the television to provide distraction. Ensure that documentation of intake and output is accurate. |
Ensure that the upper two side rails are raised.
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Which assessment is of highest priority for the nurse to complete before administration of morphine?
Pain rating Blood pressure Respiratory rate Level of consciousness |
Respiratory rate
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Which effect should the nurse instruct a patient receiving NSAIDs to report?
Blurred vision Nasal stuffiness Urinary retention Black or tarry stools |
Black or tarry stools
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Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent?
Give the medication on an empty stomach. Count the number of doses on hand before administration. Give the medication with a glass of juice or other cold beverage. Assess the patient for allergies to aspirin before administration. |
Count the number of doses on hand before administration.
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To reduce the risk of adverse effects, what should the nurse do when caring for a patient receiving morphine sulfate via patient-controlled analgesia (PCA)?
Instruct the patient not to push the button too frequently. Teach the caregiver not to push the button for the patient. Ask the patient to do deep breathing exercises every hour. Administer medications to prevent the occurrence of diarrhea. |
Teach the caregiver not to push the button for the patient.
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The nurse should question an order written for Percocet for a patient exhibiting which clinical manifestation? Severe jaundice Oral candidiasis Increased urine output Elevated blood glucose |
Severe jaundice
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A patient with osteoarthritis has been taking ibuprofen (Advil) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge?
Another NSAID may be indicated because of individual variations in response to drug therapy. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching. |
Another NSAID may be indicated because of individual variations in response to drug therapy.
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When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter?
16 breaths/min 14 breaths/min 12 breaths/min 10 breaths/min |
12
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Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA?
Diarrhea Urinary incontinence Nausea and vomiting Increased blood pressure |
N & V
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A postoperative patient has an order to receive morphine sulfate 4 mg IM every 3 to 4 hours prn for pain. On hand are prefilled syringes labeled morphine sulfate 10 mg/mL. How many milliliters should the nurse administer?
0.4 mL 0.55 mL 0.6 mL 0.75 mL |
0.4ml
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A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate?
"PCA will never be effective unless a loading dose is given first." "The IV push dose will enhance the effects of the PCA for the next 8 hours." "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim." |
The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA."
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The nurse is caring for a patient who is receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication?
Pain rating 3/10, awake and alert, respirations 24 Pain rating 2/10, awake and alert, respirations 18 Pain rating 2/10, drowsy but arousable, respirations 18 Pain rating 1/10, drowsy but arousable, respirations 16 |
Pain rating 2/10, awake and alert, respirations 18
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The nurse should teach a patient to avoid which medication while taking ibuprofen?
Aspirin Furosemide (Lasix) Nitroglycerin (Nitro-Bid) Morphine sulfate (generic) |
Aspirin
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A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication?
Diarrhea Agitation Constipation Urinary incontinence |
Constipation
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The patient is receiving fentanyl (Duragesic) patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential adverse effect of this medication?
Hypertension Pupillary dilation Urinary incontinence Decreased respiratory rate |
decreased RR
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The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply)?
Ataxia Itching Nausea Urinary retention Gastrointestinal bleeding |
Itching
Nausea Urinary retention |
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The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms?
Atropine sulfate Protamine sulfate Naloxone (Narcan) Neostigmine bromide (Prostigmin) |
Narcan
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The nurse is performing nonpharmacologic comfort measures. In addition to the comfort measures seen in the video, what other nonpharmacologic measures could the nurse use? (Select all that apply.)
Play music. Give melatonin. Perform massage. Darken the room. Provide distractions. Administer heat or cold therapy. |
Perform massage.
Provide distractions. Administer heat or cold therapy. |
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The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply)?
NSAIDs Fentanyl Antiseizure drugs β-adrenergic agonists Tricyclic antidepressants |
Antiseizure drugs
Tricyclic antidepressants |
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The patient is a known abuser of narcotics and just had surgery. The nurse is frustrated by drug addiction and worried about the high dose of narcotic analgesic prescribed for this patient. What is the best action for the nurse to take?
Remember that pain can be observed in patients. Relieve this patient's pain to avoid adverse consequences. Be sure the patient is really in pain before giving the analgesic. This patient has the right to appropriate assessment and management of pain. |
This patient has the right to appropriate assessment and management of pain.
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During admission of a patient diagnosed with metastatic lung cancer, what should the nurse assess for as a key indicator of clinical depression related to terminal illness?
Frustration with pain Anorexia and nausea Feelings of hopelessness Inability to carry out activities of daily living |
Feelings of hopelessness
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A patient with terminal cancer tells the nurse, "I know I am going to die pretty soon, perhaps in the next month." What is the most appropriate response by the nurse?
"What are your feelings about being so sick and thinking you may die soon?" "None of us know when we are going to die. Is this a particularly difficult day?" "Would you like for me to call your spiritual advisor so you can talk about your feelings?" "Perhaps you are depressed about your illness. I will speak to the doctor about getting some medications for you." |
What are your feelings about being so sick and thinking you may die soon?"
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The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of ___________.
3 months or less to live 6 months or less to live 12 months or less to live 18 months or less to live |
6 months or less to live
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A patient has been receiving palliative care for the past several weeks in light of her worsening condition following a series of strokes. The caregiver has rung the call bell, stating that the patient now "stops breathing for a while, then breathes fast and hard, and then stops again." What should the nurse recognize that the patient is experiencing?
Apnea Bradypnea Death rattle Cheyne-Stokes respirations |
Cheyne-Stokes respirations
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Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient (select all that apply)?
Strong spiritual beliefs Medical diagnosis of the patient Advanced age of the patient Acceptance of the expected death of the patient Adequate time for the caregiver to prepare for the death |
Strong spiritual beliefs
Acceptance of the expected death of the patient Adequate time for the caregiver to prepare for the death |
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A man died at the age of 71 following a myocardial infarction that he experienced while performing yard work. What would indicate that his wife is experiencing prolonged grief disorder?
Initially she denied that he died. Talking about her husband extensively in year following his death Stating that she expects him home soon on the anniversary of his death Crying uncontrollably and unpredictably in the weeks following her husband's death |
Stating that she expects him home soon on the anniversary of his death
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How should the nurse provide appropriate cultural and spiritual care for the patient and family to best be able to help them when nearing the end of the patient's life?
Assess the individual patient's wishes. Call a pastor or priest for the family to help them cope. Assess the beliefs and preferences of the patient and family. Do not insult African Americans by suggesting hospice care. |
Assess the beliefs and preferences of the patient and family.
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When going to the hospital, which forms should patients be taught to bring with them in case end-of-life care becomes an ethical or legal issue?
Euthanasia Organ donor card Advance directives Do not resuscitate (DNR) |
Do not resuscitate (DNR)
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The dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will best meet this patient's needs?
Encourage more physical activity. Assess for pain, constipation, and urinary retention. Assess for spiritual distress and restrain in varying positions. Assess for quality, intensity, location, and contributing factors of discomfort. |
Assess for pain, constipation, and urinary retention.
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When the nurse assesses the patient, what manifestation indicates to the nurse that the patient is very near death?
The patient responds to noises. The patient's skin is mottled and waxlike. The heart rate and blood pressure increase. The patient is reviewing his life with his family. Incorrect |
The patient's skin is mottled and waxlike.
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The nurse is caring for a patient admitted to the hospital with pneumonia who has a history of misuse of alprazolam (Xanax). Which clinical manifestations could be attributed to withdrawal from this medication (select all that apply)?
Anxiety Tremors Seizures Delirium Drowsiness |
seizures
delirium |
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A patient arrives to the emergency department with a reported overdose of diazepam (Valium). Which medication would the nurse prepare to administer as an antidote?
Protamine sulfate Naloxone (Narcan) Flumazenil (Romazicon) Phytonadione (AquaMephyton) |
Flumazenil (Romazicon)
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A patient is receiving chlordiazepoxide (Librium) to prevent the occurrence of delirium tremens. Which clinical manifestation would indicate an overdose of this medication?
Bradycardia Hyperreflexia Warm, flushed skin Shallow respirations |
Shallow respirations
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When caring for a patient with acute intoxication and a history of chronic alcoholism, the nurse will anticipate administering which drug?
Morphine sulfate Naloxone (Narcan) Flumazenil (Romazicon) IV thiamine and glucose |
IV thiamine and glucose
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When admitting a patient to the emergency department who complains of chest pain, which assessment finding would alert the nurse to possible cocaine abuse?
Insomnia Bradycardia Hypothermia Constricted pupils |
Insomnia
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The nurse is providing care for a patient who has been admitted with alcohol withdrawal delirium. Which intervention should be the first priority for the nurse?
Applying physical restraints Administering benzodiazepines Questioning the patient about his last alcohol intake Providing information on community resources for alcohol treatment |
Administering benzodiazepines
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A patient admitted to the hospital early in the morning for elective surgery asks the nurse if he can go outdoors to have one last cigarette before surgery. What is the nurse's most appropriate response to the patient's request?
Tell the patient that smoking is not allowed anywhere on hospital property. Notify the physician that the patient may need an over-the-counter nicotine replacement agent. Inform him that this would be an ideal time for him to quit smoking because he won't want to smoke right after surgery. Contact the anesthesia care provider to ensure that the patient's smoking history is noted as a risk factor for surgery. |
Notify the physician that the patient may need an over-the-counter nicotine replacement agent.
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The patient is describing his use of an illicit drug as needing a larger dose to get the same effect. How should the nurse document this patient's usage?
Tolerance Addiction Substance abuse Substance dependence |
tolerance
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The patient tells the nurse that he has used cannabis regularly for the last 20 years. What should the nurse expect to find in the history and physical assessment (select all that apply)?
Gastric ulcers Violent behavior Productive cough Memory impairment Crackles in the lungs Coronary artery disease |
Productive cough
Memory impairment Crackles in the lungs |
