Foundations Nclex Review Questions

Front 1

The student interested in attending an accredited school for practical nursing knows than an accredited program:

Back 1

1. voluntarily seeks a review by a given organization to determine whether the program meets that organization's preestablished criteria.
2. is one that meets the minimal standards set by the respective state agencies responsible for overseeing educational programs.
3. is necessary before the graduate is eligible to take the NCLEX-PN
4. is a federally funded health care program that educates practical nurse students

Hint 1

is necessary before the graduate is eligible to take the NCLEX-PN

Front 2

The acute awareness by the health care consumer of preventive medicine has resulted in an increase in:

Back 2

1. anxiety over diagnostic workups such as colonoscopies or gynecologic examinations.
2. the number of admissions for inpatient services.
3. the length of a hospitalization stay
4. knowledge and services to promote health and prevent illness (wellness-illness continuum)

Hint 2

knowledge and services to promote health and prevent illness (wellness-illness continuum)

Front 3

The factor that best advanced the practice of nursing in the first century was the:

Back 3

1. growth of cities
2. better education of nurses
3. teachings of Christianity
4. improved conditions for women

Hint 3

teachings of Christianity

Front 4

Nursing education programs may seek voluntary accreditation by the appropriate council of the:

Back 4

1. American Nurses Association
2. International Council of Nurses
3. Congress for Nursing Practice
4. National League for Nursing

Hint 4

National League for Nursing

Front 5

When developing a definition of "health," a person should consider that health is:

Back 5

1. a condition of physical, mental, and social well-being and absence of disease
2. the ability to pursue ADLs
3. a function of the physiologic state
4. a static condition; the absence of pathology

Hint 5

a condition of physical, mental, and social well-being and absence of disease

Front 6

Comprehensive or total pt care that considers the physical, emotional, social, economic, and spiritual needs of the person, as well as the person's response to the illness and the impact of the illness on the person's ability to meet self-care needs is a philosophy referred to as:

Back 6

1. the wellness-illness continuum
2. the Pt Care Partnership
3. holistic nursing
4. the health care delivery system

Hint 6

holistic nursing

Front 7

The student nurse reviewing the history of nursing knows that the "Lady with the Lamp" is:

Back 7

1. Clara Barton
2. Florence Nightingale
3. Phoebe
4. Lavinia Dock

Hint 7

Florence Nightingale

Front 8

The American Society of Superintendents of Training Schools of Nursing was established in 1894. The major goal of this organization was:

Back 8

1. to promote development of new schools of nursing
2. to train nursing leaders
3. to set educational standards for nurses
4. to develop standards for licensure

Hint 8

to set educational standards for nurses

Front 9

The ancient Hebrews, according to the Talmud and the Old Testament, documented several health and disease practices. They are also attributed with:

Back 9

1. the first practice of public health and home health
2. the first school of nursing in Europe
3. the first understanding of the wellness-illness continuum
4. the first nursing organization

Hint 9

the first practice of public health and home health

Front 10

The student nurse who is studying the history of health care recognizes that Hippocrates is credited with the development of:

Back 10

1. the first text on health care
2. the first ethical guide for medical conduct
3. the first medical society
4. the first nursing care guide

Hint 10

the first ethical guide for medical conduct

Front 11

Care delivered by RNs and LPNs is legally defined as their scope of practice, which is determined by:

Back 11

1. the nursing process
2. the nurse in charge
3. the Hippocratic Oath
4. the nurse practice act

Hint 11

the nurse practice act

Front 12

The nursing student knows that the first nursing theorist was:

Back 12

1. Phoebe
2. Clara Barton
3. Florence Nightingale
4. Sister Calista Roy

Hint 12

Florence Nightingale

Front 13

The most commonly used model that assists in the understanding of the pt's place on the wellness-illness continuum is:

Back 13

1. Abraham Maslow
2. Dorothea Dix
3. Clara Barton
4. Theodore Fliedner

Hint 13

Abraham Maslow

Front 14

The first nurse to train in America was:

Back 14

1. Lavinia Dock
2. Linda Richards
3. Clara Barton
4. Mary Breckenridge

Hint 14

Linda Richards

Front 15

The first school dedicated to the training of the practical nurse in the United States was:

Back 15

1. the Ballard School
2. the YWCA
3. the Thompson Practical Nursing School
4. the Shepard-Gill School

Hint 15

the Ballard School

Front 16

Health is:

Back 16

1. the absence of illness
2. a state of complete physical, mental and social well-being
3. a condition between disease and good health
4. the opposite of disease

Hint 16

a state of complete physical, mental, and social well-being

Front 17

Men in nursing:

Back 17

1. are not permitted to serve in the military
2. became prominent during the Civil War
3. are becoming fewer and fewer
4. are regaining their historical position in the profession as nurses

Hint 17

are regaining their historical position in the profession as nurses

Front 18

The newly licensed practical nurse (LPN) carefully reads the nurse practice act (NPA) of the state in which she will practice. The primary purpose of the NPA is to:

Back 18

1. determine the quality of nursing care
2. enforce the standards of nursing practice
3. define the scope of nursing practice
4. set the nurse's educational requirements

Hint 18

define the scope of nursing practice

Front 19

The nurse working in a nursing home knows that one of his duties is to be an advocate for his pts. A primary duty of an advocate is to:

Back 19

1. complete all nursing responsibilities on time
2. maintain the pt's right to privacy
3. safeguard the well-being of every pt
4. act as the pt's legal representative

Hint 19

maintain the pt's right to privacy

Front 20

The health care provider's order read "assist the pt with walking." The nurse caring for the older adult pt let her walk by herself and the pt fell, fracturing her humerus. The nurse could:

Back 20

1. be found guilty of malpractice
2. only be guilty of misconduct
3. be charged with technical battery
4. not be found liable for any harm

Hint 20

be found guilty of malpractice

Front 21

The pt refused to take the medication his doctor ordered for relief of pain. The LPN knows this is a pt right established by:

Back 21

1. the principle of beneficence
2. the doctrine of negligence
3. specific nurse practice acts
4. the Pt Self-Determination Act

Hint 21

the pt self-determination act

Front 22

The LPN/LVN knows that that one of the best defenses against a lawsuit is for a nurse to:

Back 22

1. work only in a large hospital or nursing home
2. provide for every pt's needs as quickly as possible
3. promote a positive nurse-pt relationship
4. carry individual professional liability insurance

Hint 22

promote a positive nurse-pt relationship

Front 23

The nurse believes that all pts should be treated as individual. The ethical principle that this belief reflects is:

Back 23

1. autonomy
2. beneficence
3. nonmaleficence
4. respect for people

Hint 23

respect for people

Front 24

LPN/LVNs have a code of professional and personal ethics to follow. The purpose of a code of ethics is to:

Back 24

1. establish penalties for any unethical behavior
2. promote trustworthy, accountable LPN/LVNs
3. make certain that all nurses are competent and always honest
4. give the nurse guidelines for ethical decision making

Hint 24

promote trustworthy, accountable LPN/LVNs

Front 25

The pt admitted for surgery has a lump in her breast. The pt's daughter asks the LVN if her mother should have the surgery. Which issue must the LVN consider before answering

Back 25

1. confidentiality and invasion of privacy
2. informed consent, beneficence, and respect
3. respect for people and personal autonomy
4. nonmaleficence, justice, and liability

Hint 25

confidentiality and invasion of privacy

Front 26

The nurse's first job as an LPN is on a unit that cares for terminally ill children. Before helping families deal with their children's illnesses, the nurse will need to:

Back 26

1. study the nurse practice act to find rules relating to the medical care of terminally ill children
2. spend time performing value clarification to aid in identifying her feelings about this new role
3. evaluate her own personal mores and customs that may affect the practice of nursing in general
4. review the state and federal laws the prescribe how a child may be treated when near death

Hint 26

spend time performing value clarification to aid in identifying her feelings about this new role

Front 27

The LPN knows that the purpose of an advance directive is to:

Back 27

1. help every person exercise the right to die with dignity
2. encourage a person to determine how he or she will die
3. allow a pt to exercise the right of autonomy
4. provide a means to prevent medical maltreatment

Hint 27

allow a pt to exercise the right of autonomy

Front 28

The nurse knows that all pts have the right to nursing interventions regardless of their race, religion, or sex. The ethical prinicple that best describes this concept is:

Back 28

1. nonmaleficence
2. justice
3. autonomy
4. beneficence

Hint 28

justice

Front 29

An alert adult pt has refused an intramuscular injection. The nurse waits until the pt is asleep and gives the injection anyway. The nurse should be charged with:

Back 29

1. civil battery
2. malicious homicide
3. criminal negligence
4. invasion of privacy

Hint 29

civil battery

Front 30

The nurse is licensed to practice nursing in NY. She just recieved a license by endorsement from Ohio. The nurse knows that when she works in Ohio, she must follow the:

Back 30

1. Nurse Practice Act of the US
2. Nurse Practice Act of NY
3. Universal Nurse Practice Act
4. Nurse Practice Act of Ohio

Hint 30

Nurse Practice Act of Ohio

Front 31

The nurse loves photography and brings his camera to work at the nursing home. He takes a picture of one of his co-workers walking a pt. The nurse has just:

Back 31

1. violated the pt's right to privacy
2. failed to get proper medical clearance
3. performed an act of nursing malpractice
4. legally obtained a realistic picture

Hint 31

violated the pt's right to privacy

Front 32

The nurse gets a report, puts his pt assignment notebook in his pocket, and goes on break. His notebook has very specific information about his pts and is missing from his pocket when he returns to the unit. The book is found later on the floor in the cafeteria by a visitor and is returned to the information desk. The nurse:

Back 32

1. may have breached the Patient Self-Determination Act
2. is guilty of criminal misconduct
3. could be fired for malpractice
4. has violated HIPAA

Hint 32

has violated HIPAA

Front 33

The newly licensed nurse starting her first job is assigned to catheterize a male pt but has never done this procedure before. Her best first action is to:

Back 33

1. quickly call her supervisor and disqualify herself from performing the procedure
2. find and read the procedure for male catheterization in the procedure book on her unit and ask another experienced nurse to supervise her during the procedure
3. immediately advise the charge nurse that someone else will need to take over this pt
4. promptly notify the staff development office that an instructor needs to do this procedure

Hint 33

find and read the procedure for male catheterization in the procedure book on her unit and ask another experienced nurse to supervise her during the procedure

Front 34

The pt is fearful concerning upcoming surgery. Which statement by the nurse would be most therapeutic?

Back 34

1. "Sometimes anxiety is not easy to deal with. Can you tell me what is bothering you the most?"
2. "Don't worry. Everyone has some anxiety about having surgery."
3. "Just try to think about the positive results from the surgery. You'll recover quickly."
4. "I had surgery once and it still scares me to think about it, so I know how you feel."

Hint 34

"Sometimes anxiety is not easy to deal with. Can you tell me what is bothering you the most?"

Front 35

During an admission interview, the pt refers several times to "all the problems I had last time." The most appropriate communication technique for the nurse to use in this situation is:

Back 35

1. reflection
2. paraphrasing
3. minimal encouragement
4. focusing

Hint 35

focusing

Front 36

The pt states, "I'm so nervous about being hospitalized." Which statement would be the nurse's best response to get the pt to elaborate?

Back 36

1. "It's normal to be nervous, but we'll take good care of you."
2. "You're feeling especially nervous?"
3. "How many times have you been hospitalized?"
4. "There will be nurses here all the time to check on you."

Hint 36

"You're feeling especially nervous?"

Front 37

The nurse is talking with the pt about her husband's death 2 years ago. Tears form in the pt's eyes, and she stops talking. A therapeutic response by the nurse would be to:

Back 37

1. change the subject to something less difficult for the pt
2. remain silent and hold the pt's hand
3. leave the room to provide privacy
4. pretend no to notice the tears and continue the conversation

Hint 37

remain silent and hold the pt's hand

Front 38

Which of the following is an example of clarification?

Back 38

1. "You will take your medicine now, won't you?"
2. "Does this headache have anything in common with your previous headaches?"
3. "In other words, you feel that your stomachaches are associated with stress at work?"
4. "What do you mean by that?"

Hint 38

"In other words, you feel that your stomachaches are associated with stress at work?"

Front 39

The newly admitted Vietnamese pt speaks almost no English. The nurse needs to obtain a urine specimen for culture and sensitivity from him. An interpreter is not readily available. The best approach to obtaining the specimen would be to:

Back 39

1. speak very slowly and distinctly
2. show the pt the equipment and illustrations of the process
3. obtain a physician's order to catheterize the pt to collect the specimen
4. delay the collection of the specimen until an interpreter can be found

Hint 39

Show the pt the equipment and illustrations of the process

Front 40

Abdominal surgery has revealed that the pt, a young mother, has advanced metastatic colon cancer. While the nurse is changing her dressing, the pt begins to cry and states, "If I had just gone to the doctor sooner, my kids wouldn't have to grow up without a mother." Which response by the nurse would be most therapeutic?

Back 40

1. "It's natural to blame yourself in situations like this."
2. "Is their father available to care for the children?"
3. "Don't give up. The chemotherapy and radiation might be very effective."
4. "You feel that if you had been diagnosed earlier, this situation might be different."

Hint 40

"You feel that if you had been diagnosed earlier, this situation might be different"

Front 41

During his admission interview, an older pt states, "I can't hear you very well." After determining that the pt does not have a hearing aid, the nurse should:

Back 41

1. speak in a higher-pitched voice
2. speak loudly into his "good" ear
3. exaggerate lip movement while speaking
4. face the pt and speak slowly and distinctly

Hint 41

face the pt and speak slowly and distinctly

Front 42

Which statement by the student nurse is an example of assertive communication

Back 42

1. "It's time for your bath now. Would you prefer to use the shower chair or do you think you are strong enough to stand during your shower today?"
2. "I'd like you to take your shower now, but if you'd rather do it later, I guess that would be okay."
3. "It would be best if you took your bath now, but since you want to wait until tonight, I'll ask my instructor if that would be okay."
4. "I'm sure you'll feel better after you have your bath. will you please take it now?"

Hint 42

"It's time for your bath now. Would you prefer to use the shower chair or do you think you are strong enough to stand during your shower today?"

Front 43

The pt has a long history of smoking and has just been diagnosed with lung cancer. He states to the nurse, "There's no point in trying to stop smoking now. I might as well enjoy the time I have left." The best response by the nurse would be:

Back 43

1. "You're probably right. It won't do much good to stop smoking now."
2. "You feel that there is no reason to stop smoking now?"
3. "It's never to late to stop smoking."
4. "I know it's hard, but if you stop smoking now, your condition might improve."

Hint 43

"You feel that there is no reason to stop smoking now?"

Front 44

The pt tells the nurse that he is frightened about having cancer. Which response by the nurse would be most effective in getting the pt to ventilate his concerns?

Back 44

1. "Fear is a common reaction to having cancer."
2. "Tell me more about being frightened by having cancer."
3. "Have you told your wife you are afraid?"
4. "Would you like me to call the chaplain to visit with you?"

Hint 44

"Tell me more about being frightened by having cancer."

Front 45

The nurse is admitting a pt with long standing type 1 diabetes. Which communication technique would be most efficient in ascertaining the number of units of insulin the pt usually takes?

Back 45

1. Closed question
2. Reflection
3. Minimal encouragement
4. Paraphrasing

Hint 45

Closed question

Front 46

The pt is being seen in the clinic for a follow-up visit after fracturing her ankle. The nurse notes that she is not using her crutches correctly. Which statement by the nurse would be the most appropriate?

Back 46

1. "You are not using your crutches correctly."
2. "Let me show you some ways to make crutch walking easier for you."
3. "Who taught you to use crutches like that?"
4. "Do your crutches seem to fit you properly?"

Hint 46

"Let me show you some ways to make crutch walking easier for you."

Front 47

Which method would be most appropriate for communicating with an alert pt on a ventilator with an endotracheal tube in place?

Back 47

1. Open-ended questions
2. Communication board
3. Reflection
4. Restatement

Hint 47

Communication board

Front 48

The pt is in a coma following a motor vehicle accident. Which statement regarding communication with the pt is most appropriate?

Back 48

1. Speak to the pt as if he can hear what is being said.
2. Avoid verbal stimulation because of its potential to trigger excitability
3. Encourage family members to limit visitation to no more than 5 minutes per hour
4. Turn on the television to stimulate the pt

Hint 48

Speak to the pt as if he can hear what is being said

Front 49

Which statement is true?

Back 49

1. Use of therapeutic communication techniques will guarantee that a therapeutic interaction takes place
2. Some form of communication takes place each time there is an interaction between individuals
3. The intended receiver is always the person receiving the communication
4. Verbal communication is more effective than nonverbal communication

Hint 49

Some form of communication takes place each time there is an interaction between individuals

Front 50

Which communication technique is always considered appropriate?

Back 50

1. Active listening
2. Silence
3. Touch
4. Eye contact

Hint 50

Active listening

Front 51

The nurse is providing discharge instructions to a pt. Which action would provide the most accurate assessment of understanding by the pt?

Back 51

1. Asking the pt if he understands the instructions
2. Repeating the instructions a second time
3. Providing the pt with written instructions
4. Asking the pt to repeat the instructions

Hint 51

Asking the pt to repeat the instructions

Front 52

Which nurse-pt interaction usually occurs in the "personal zone" of space surrounding the pt?

Back 52

1. uretheral catheterization
2. complete bed bath
3. discharge instructions
4. enema administration

Hint 52

discharge instructions

Front 53

Which approach would be most appropriate for effective communication with a pt with cognitive impairment?

Back 53

1. Repeating a phrase until the pt indicates understanding
2. Asking friends and family to step out of the room to decrease distraction
3. Using simple sentences and avoiding detailed explanations
4. Directing communication to significant others rather than the pt

Hint 53

Using simple sentences and avoiding detailed explanations

Front 54

A 44yo pt is undergoing antibiotic therapy for pneumonia. His rectal temperature reading is 101.4F. His oral temperature would be considered to be:

Back 54

1. 101.6F (38.7C)
2. 100.6F (38.1C)
3. 99.6F (37.5C)
4. 97.6F (36.4C)

Hint 54

100.6F (38.1C)

Front 55

A 30yo pt develops a postpartum temperature that is elevated in the evening but returns to a normal reading in the morning. This has occurred for several days. This pattern of fever would be classified as:

Back 55

1. constant
2. intermittent
3. remittent
4. crisis

Hint 55

intermittent

Front 56

A 66yo pt has a 10 year hx of coronary artery disease. He is presently recovering from a myocardial infarction. For the most accurate assessment of pulse rate, the nurse obtains a(n):

Back 56

1. carotid pulse
2. radial pulse
3. apical pulse
4. brachial pulse

Hint 56

apical pulse

Front 57

A 16yo pt is admitted to the emergency department with an exacerbation of asthma. Her respirations are 40/min. After tx, her rate returns to normal limits. Normal limits for the pt's respirations would be:

Back 57

1. 30 to 60
2. 12 to 20
3. 8 to 12
4. 24 to 30

Hint 57

12 to 20

Front 58

During a routine physical, a 48yo woman's blood pressure is noted at 180/90 mm Hg. She fears she is hypertensive. The nurse explains that the dx of hypertension is made when there is a sustained elevated bp of over:

Back 58

1. 160/100
2. 140/90
3. 130/70
4. 120/80

Hint 58

120/80

Front 59

A 65yo man has a hx of emphysema resulting from 30 years of cigarette smoking. He frequently complains of dyspnea. Dyspnea is defined as:

Back 59

1. pallor
2. absence of retractions
3. cyanosis
4. difficulty breathing

Hint 59

difficulty breathing

Front 60

A 52yo woman c/o palpitations resulting from anxiety over her impending surgery. Her pulse rate is found to be 110/min. One possible description of her heart rate is:

Back 60

1. bradycardia
2. tachycardia
3. tachypnea
4. hypertension

Hint 60

tachycardia

Front 61

The nurse obtains a supine BP reading of 130/64 mm Hg. One hour later, the nurse obtains a supine BP reading of 134/62 mm Hg and a sitting BP reading of 95/62 mm Hg. The nurse's immediate action is to:

Back 61

1. assist the pt to return to a supine position
2. obtain a bp reading in the other arm
3. report the findings to the nurse in charge
4. question the pt about syncope

Hint 61

question the pt about syncope

Front 62

The nurse is assessing a pt's BP for the first time as part of the pt's postoperative assessment. After reaching the cuff's level of maximum inflation, the nurse:

Back 62

1. deflates the cuff slowly and waits 15 to 20 seconds before reinflating
2. deflates the cuff rapidly and waits 15 to 30 seconds before reinflating
3. deflates the cuff slowly and waits 1 minute before reinflating
4. deflates the cuff rapidly and waits 1 minute before reinflating

Hint 62

deflates the cuff rapidly and waits 15 to 30 seconds before reinflating

Front 63

The nurse has been assigned several pts. Which one of the following pts is more likely to have a higher than normal temperature?

Back 63

1. a depressed, apathetic pt
2. a pt assessed with hemorrhage
3. a pt who is recovering from surgery
4. a pt experiencing strong emotions

Hint 63

a pt experiencing strong emotions

Front 64

A 16yo pt is admitted after a motorcycle accident. The nurse is assessing his pulse pressure. His BP reading is 140/102mm Hg. Which is the correct pulse pressure?

Back 64

1. 40
2. 88
3. 140
4. 102

Hint 64

88

Front 65

The nurse is preparing to assess a 2 day old infant's pulse rate. Which site should be used?

Back 65

1. scalp artery
2. femoral artery
3. apical site
4. radial site

Hint 65

apical site

Front 66

Nurses often assess for the apical and radial pulses. Which statement is correct concerning the apical and radial pulse measurements?

Back 66

1. The apical pulse should be taken for 1 full minute and then the radial pulse for 1 full minute
2. The apical and radial pulse rates are lower when the temperature is elevated
3. The apical and radial pulses are taken at the same time for 30 seconds
4. The apical and radial pulses are taken at the same time for 60 seconds

Hint 66

the apical and radial pulses are taken at the same time for 60 seconds

Front 67

The physician ordered and orthostatic BP measurement. Which statement is correct concerning the orthostatic method of assessing BP?

Back 67

1. the measurement is taken in the supine position, then sitting up, and then when the pt is standing
2. the measurement is taken first with the pt sitting up, then with the pt lying down
3. the nurse waits 5 minutes before assessing the BP in the sitting position after assessing the BP in the supine position
4. the nurse has the pt lie down for at least 10 minutes before performing the procedure

Hint 67

the measurement is taken in the supine position, then sitting up, and then when the pt is standing

Front 68

The pt's oral temperature is 37C. The nurse reports that the pt is:

Back 68

1. febrile
2. afebrile
3. hypotensive
4. hypertensive

Hint 68

afebrile

Front 69

The nurse recalls that an important factor in the measurement of VS is that:

Back 69

1. ranges of normal for VS are very narrow and apply to all pts
2. the most significant aspect of measuring VS is their documentation
3. environmental factors have an insignificant effect on the pt's VS
4. all measuring equipment is chosen on the basis of the pt's conditions and characteristics

Hint 69

all measuring equipment is chosen on the basis of the pt's conditions and characteristics

Front 70

The pt has been hospitalized after a severe head injury. The nurse recognizes that the pt's difficulty in maintaining a normal body temperature when there is no infection present is possibly the result of:

Back 70

1. choosing the wrong time of day to obtain VS
2. errors by the nurse in measuring temperature
3. increased vasodilation of the superficial vessels contributing to excess heat losses
4. the pt's head injury causing interference with the function of the hypothalamus

Hint 70

the pt's head injury causing interference with the function of the hypothalamus

Front 71

A pulse deficit provides information about the heart's ability to adequately perfuse the body. A pulse deficit is:

Back 71

1. the difference between the radial and the apical pulse rates
2. the digital pressure felt when taking radial and ulnar pulses
3. the amount of pressure felt when taking radial and ulnar pulses
4. the difference between the systolic and the diastolic blood pressure readings

Hint 71

the difference between the radial and the apical pulse rates

Front 72

The nurse finds that the pt's oral temperature is 98.8F (37.1C). The next nursing action is to:

Back 72

1. administer an antiemetic drug
2. offer the pt an additional blanket
3. report that the pt is normal
4. compare this with the pt's baseline

Hint 72

compare this with the pt's baseline

Front 73

To measure the pt's radial pulse rate, the nurse:

Back 73

1. palpates a superficial artery at the medial side of the wrist
2. places the binaurals directly and firmly into the ears
3. compresses the bell of the stethoscope firmly over the heart
4. locates the pulsation on the anterior part of the wrist

Hint 73

palpates a superficial artery at the medial side of the wrist

Front 74

The assistive personnel report to you that the pt is feeling "funny." The nurse's first action would be to:

Back 74

1. notify the physician
2. obtain the pt's VS yourself
3. delegate the assistant to retake the VS
4. tell the assistant to keep assessing the pt and report any further complaints

Hint 74

obtain the pt's VS yourself

Front 75

The nurse is taking VS measurements and notes that the pt has a strong radial pulse that diminishes in intensity and that there are interruptions in rhythm about every 4-6 beats. The immediate action is to:

Back 75

1. report the findings to a physician
2. measure a 60 second apical pulse
3. connect the pt to a cardiac monitor
4. obtain a 60 second apical-radial pulse

Hint 75

measure a 60 second apical pulse

Front 76

When documenting a pt's blood pressure, the systolic pressure is recorded as the point at which the:

Back 76

1. first Korotkoff sound appears
2. second Korotkoff sound appears
3. fourth Korotkoff sound appears
4.fifth Korotkoff sound appears

Hint 76

first Korotkoff sound appears

Front 77

Which method of measuring temperature reveals core temperature?

Back 77

1. skin
2. temporal
3. oral
4. axillary

Hint 77

oral

Front 78

The nurse is providing discharge teaching to a pt who has recently been diagnosed with a cardiac condition. In teaching this pt how to assess the radial pulse, the nurse will instruct him to palpate the:

Back 78

1. radial artery
2. carotid artery
3. brachial artery
4. femoral artery

Hint 78

carotid artery

Front 79

When teaching the pt about monitoring his own pulse, the nurse informs the pt that the pulse may be elevated by:

Back 79

1. taking beta blockers
2. fever
3. sleeping
4. standing up to quickly

Hint 79

fever

Front 80

The nurse measures the BP of an adult pt being seen in the clinic for complaints of an earache. The pt's BP is 162/94 mm Hg, and asks if he has hypertension. The nurse knows that the physician will diagnose hypertension when the pt:

Back 80

1. has a BP above normal range on the next clinic visit
2. monitors his BP at home and finds two more elevated readings
3. has a BP above normal range on two subsequent clinic visits
4. complains of a constant headache

Hint 80

has a BP above normal range on two subsequent clinic visits

Front 81

The nurse begins to measure the BP of an adult. The pt says that his doctor has instructed him to always use a large cuff. The nurse knows that the reason for this is that:

Back 81

1. a blood pressure cuff that is too small will give inaccurately high readings
2. a blood pressure cuff that is too small will likely injure the brachial artery
3. large cuffs are typically more accurate on adults than normal-size cuffs
4. normal-size cuffs should be used for pediatric pts

Hint 81

a blood pressure cuff that is too small will give inaccurately high readings

Front 82

The nurse notices the nursing assistant talking with pts as he uses an electronic cuff to measure their blood pressure. The nurse instructs the nursing assistant to avoid talking with pts while using an electronic cuff because while talking the bp may elevate as much as:

Back 82

1. 5% to 35%
2. 10% to 40%
3. 20% to 50%
4. 30% to 60%

Hint 82

10% to 40%

Front 83

The nurse is developing a care plan for a pt taking a diuretic to treat fluid retention. The nurse knows that weighing the pt on a daily basis will assist in monitoring the effectiveness of the medication since a weight loss of 1kg indicates a fluid loss of:

Back 83

1. 1L
2. 10L
3. 100L
4. 1000L

Hint 83

1L

Front 84

The nurse has just gotten the pt in the chair after his bath. If using the mnemonic ABC, in and out, PS, what does the "P" indicate?

Back 84

1. purulent
2. pus
3. pain
4. pallor

Hint 84

pain

Front 85

A 22yo pt has been admitted with acute bronchitis. When performing a lung assessment, the nurse is able to auscultate the lower lobes by listening to what location on the body?

Back 85

1. posteriorly
2. anteriorly
3. laterally
4. superiorly

Hint 85

posteriorly

Front 86

A 90yo pt is having difficulty answering the nurse's questions while completing the pt hx. What will the nurse keep in mind about caring for older adults?

Back 86

1. all older adults age at the same rate
2. it is best to write down all of the questions and have the pt's family complete the information
3. sit down at eye level with the pt and allow a longer period to answer each question
4. talk more loudly and raise the pitch of the voice

Hint 86

sit down at eye level with the pt and allow a longer period to answer each question

Front 87

The pt has heart failure. When assessing her lower extremities, the nurse notices that a deep indentation remains for 30 seconds when the skin over the medial malleolus is pressed. The nurse documents this finding as:

Back 87

1. nonpitting edema
2. 2+ pedal pulses
3. 3+ pitting edema
4. 2+ pitting edema

Hint 87

3+ pitting edema

Front 88

The nurse answers the pt's call light just after lunch. The pt complains of severe abdominal pain. What type of assessment should the nurse perform?

Back 88

1. head-to-toe assessment
2. focused assessment
3. system-by-system assessment
4. complete assessment

Hint 88

focused assessment

Front 89

A 72yo man is admitted for chest pain. How would the nurse document the information the pt gives about his symptoms?

Back 89

1. Use the pt's own words in quotation marks
2. Briefly summarize what the pt says.
3. Interpret the pt;s comment using medical terminology
4. Use the information for the chief complaint from the admission sheet

Hint 89

use the pt's own words in quotation marks

Front 90

During the review of systems, the nurse questions the 88yo pt about her gastrointestinal system. The nurse will ask about what symptom?

Back 90

1. wheezing
2. pyrosis (heartburn)
3. polyuria
4. dyspnea

Hint 90

pyrosis (heartburn)

Front 91

The nurse has been assigned to care for a 62yo man. After introducing herself to the pt and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking VS?

Back 91

1. assess for LOC and orientation
2. assess the skin
3. listen to lung sounds
4. check for pitting edema

Hint 91

assess for LOC and orientation

Front 92

A 56yo woman has been admitted for dehydration after a prolonged period of diarrhea. Which finding do you expect to observe in this pt?

Back 92

1. skin warm, moist, pink with good skin turgor
2. skin hot, dry, pale with decreased skin turgor
3. skin cool, dry, pink with increased skin turgor
4. skin cool, moist, pale with decreased skin turgor

Hint 92

skin hot, dry, pale, with decreased skin turgor

Front 93

The nurse is performing an initial nursing assessment on an 82yo woman. When palpating her carotid arteries a vibration is felt along the artery. This vibration is called a(n):

Back 93

1. palpation
2. thrill
3. bruit
4. aneurysm

Hint 93

thrill

Front 94

Which position is not used to assess the female genitalia?

Back 94

1. high fowler's
2. dorsal recumbent
3. lithotomy
4. sims'

Hint 94

high fowler's

Front 95

Which risk factor for cardiovascular disease can be modified?

Back 95

1. age
2. race
3. diet
4. family history

Hint 95

diet

Front 96

An 82yo pt is admitted with respiratory difficulty. His respiratory rate is 36 breaths per minute, and he appears anxious. His chest x-ray film reveals right lower lobe pneumonia. The pt's respiratory rate of 36bpm is termed:

Back 96

1. sonorous
2. bradypnea
3. tachypnea
4. apnea

Hint 96

tachypnea

Front 97

The nurse auscultating breath sounds on a pt who has lower lobe pneumonia detects adventitious breath sounds, which are a loud, bubbly noise heard during inspiration. These are called:

Back 97

1. coarse crackles
2. sonorous wheezes
3. pleural friction rub
4. sibilant wheezes

Hint 97

coarse crackles

Front 98

The nurse assesses a 72yo pt who complains of a severe headache and vertigo. These data would be classified as:

Back 98

1. objective data
2. subjective data

Hint 98

subjective data

Front 99

Which would be included in an assessment of the peripheral vascular system? (Select all that apply)

Back 99

1. Assess the pulse rate by counting the pulsations for 60 seconds
2. peripheral pulses that can be assessed include brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial
3. in a person with good cardiac function and distal perfusion, capillary refill should take less than 6 seconds
4. the strength of the pulse can be measured by using the following scale: 0, 1+, 2+, 3+, and 4+

Hint 99

Assess the pulse rate by counting the pulsations for 60 seconds.
Peripheral pulses that can be assessed include brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial.
The strength of the pulse can be measured by using the following scale: 0, 1+, 2+, 3+, and 4+

Front 100

The normal rate of bowel sounds is _______ per minute

Back 100

1. 2 to 18
2. 22 to 44
3. 4 to 32
4. 38 to 52

Hint 100

4 to 32

Front 101

The main reason that auscultation precedes palpation of the abdomen is to:

Back 101

1. prevent distortion of vascular sounds
2. prevent distortion of bowel sounds
3. determine any areas of tenderness or pain
4. allow the pt to relax and be comfortable

Hint 101

prevent distortion of bowel sounds

Front 102

Which is a medical diagnosis?

Back 102

1. acute pain
2. pneumonia
3. activity tolerance
4. ineffective airway tolerance

Hint 102

pneumonia

Front 103

Which nurse is demonstrating critical thinking?

Back 103

1. The nurse who follows a physician's order without question
2. The nurse who admits a seriously ill pt to a room far from the nurses' station
3. The nurse who checks the accuracy of an intravenous pump used to deliver medications
4. The nurse who administers medications using the five "rights" of medication administration (right drug, right dose, right route, right time, and right pt)

Hint 103

the nurse who checks the accuracy of an intravenous pump used to deliver medications

Front 104

The student who plans to use Nursing Interventions Classification material will benefit from a list of:

Back 104

1. nursing interventions
2. nursing activities
3. nursing outcomes
4. nursing indicators

Hint 104

nursing activities

Front 105

A pt is admitted to a large teaching hospital with coronary artery disease and has a bypass graft performed to increase blood supply to his heart muscle. His wound continues to drain and, when he is discharged, home health nurses will visit to continue to care for him. The person responsible for coordinating the pt's discharge plans is probably the:

Back 105

1. RN team leader
2. social worker
3. case manager
4. physician

Hint 105

case manager

Front 106

Which diagnosis includes all appropriate components of an actual nursing diagnosis?

Back 106

1. impaired gas exchange
2. potential complication: gastric bleeding related to gastric ulcer
3. fear related to separation from support system manifested by statements of being scared, pallor, and increased respirations
4. risk for falls related to confusion manifested by calling nurse by name of aunt

Hint 106

fear related to separation from support system manifested by statements of being scared, pallor, and increased respirations

Front 107

"Constipation related to the effects of analgesic medications on the bowel manifested by statements of straining to have a bowel movement and no bowel movement in 5 days" is an example of:

Back 107

1. an actual nursing diagnosis
2. a risk nursing diagnosis
3. a wellness nursing diagnosis
4. a medical nursing diagnosis

Hint 107

an actual nursing diagnosis

Front 108

Based on Maslow's hierarchy of needs, which nursing diagnosis label has the highest priority?

Back 108

1. risk for aspiration
2. deficient fluid volume
3. acute pain
4. stress urinary incontinence

Hint 108

risk for aspiration

Front 109

Which pt outcome statement meets the necessary criteria?

Back 109

1. the pt will identify the types of foods to include in a high-fiber diet
2. the nurse will teach the pt about constipation prevention
3. the nurse will increase total fluids during hospitalization
4. the pt will have a soft, formed bowel movement on the third day after nursing interventions

Hint 109

the pt will have a soft, formed bowel movement on the third day after nursing interventions

Front 110

The pt is admitted to the hospital with an upper respiratory infection. The nurse writes the following nursing diagnosis: Risk for deficient fluid volume related to refusal to drink fluids secondary to a sore throat. Which is the best outcome statement for the pt?

Back 110

1. the nurse will offer 2000mL of fluids per day during hospitalization
2. the pt will experience a less sore throat in 8 hours
3. the pt will maintain adequate hydration as evidenced by moist mucous membranes; elastic skin turgor; and voiding of clear dilute urine
4. the nurse will maintain an intravenous infusion of fluids for the ordered length of time

Hint 110

the pt will maintain adequate hydration as evidenced by moist mucous membranes; elastic skin turgor; and voiding of clear dilute urine

Front 111

A woman who has had four children comes to the clinic. She tells the nurse that when she laughs or coughs she "wets her underwear." The nurse discusses with the pt exercises that are helpful to reduce this stress incontinence. The nurse teaches the pt to perform Kegel exercises 25 times a day with FOUR TO SIX REPETITIONS each time. The capitalized words indicate:

Back 111

1. the nursing process
2. a nursing diagnosis
3. an outcome statement
4. a nursing order

Hint 111

a nursing order

Front 112

A 14yo pt is admitted to the emergency department with a possible medical diagnosis of acute appendicitis. The nurse begins to perform an assessment by interviewing:

Back 112

1. the pt's parents
2. the pt
3. the physician
4. the admissions nurse

Hint 112

the physician

Front 113

A pt who describes his illness is providing:

Back 113

1. subjective data
2. objective data
3. overt data
4. signs of his illness

Hint 113

subjective data

Front 114

Defining characteristics:

Back 114

1. are descriptions of the problem
2. tell how the nursing diagnosis is manifested
3. give a name to the cluster of signs and symptoms
4. list factors that contribute to the problem

Hint 114

tell how the nursing diagnosis is manifested

Front 115

The main purpose of cue clustering is to:

Back 115

1. organize the data
2. assist in the formation of a nursing diagnosis
3. select appropriate nursing interventions
3. validate the completeness of the assessment

Hint 115

assist in the formation of a nursing diagnosis

Front 116

Which nursing diagnostic label would be ranked first in priority?

Back 116

1. risk for ineffective airway clearance
2. colonic constipation
3. alteration in nutrition: less than body requirements
4. total urinary incontinence

Hint 116

risk for ineffective airway clearance

Front 117

The phrases used to connect the parts of a nursing diagnosis are:

Back 117

1. "related to" and "due to"
2. "due to" and "manifested by"
3. "related to" and "manifested by"
4. "due to" and "as evidenced by"

Hint 117

"due to" and "as evidenced by"

Front 118

During the last phase of the nursing process, the nurse:

Back 118

1. gathers data to use in planning care
2. selects nursing interventions to achieve the desired outcomes
3. compares the desired outcome with the actual outcome
4. prioritizes nursing interventions

Hint 118

compares the desired outcome with the actual outcome

Front 119

A nursing diagnosis expresses:

Back 119

1. the pt's needs according to Maslow's hierarchy
2. the pt's disease process
3. the required nursing intervention
4. a conclusion about the pt's response to an illness

Hint 119

the pt's needs according to Maslow's hierarchy

Front 120

The pt is experiencing severe respiratory distress that is related to his chronic obstructive pulmonary disease. Which source of information would the nurse use when performing a nursing history?

Back 120

1. the pt
2. the pt and his wife
3. the physician
4. the medical record

Hint 120

the pt and his wife

Front 121

The LPN/LVN has finished bathing a pt. The pt states that he is sick to his stomach and has refused his breakfast. What additional clinical evidence would support the nursing diagnosis of nausea?

Back 121

1. unwillingness to ambulate
2. increased swallowing of saliva
3. statements describing acid reflux
4. decreased awareness of his environment

Hint 121

increased swallowing of saliva

Front 122

Which choice constitutes objective data?

Back 122

1. "When I walk to the mailbox, I get very short of breath."
2. "My legs ache when I climb stairs."
3. 7-inch transverse abdominal incision
4. Statements of pain

Hint 122

7-inch transverse abdominal incision

Front 123

A newborn has the nursing diagnosis of risk for ineffective thermoregulation. What is the most accurate outcome for this diagnosis?

Back 123

1. parents state that they will keep the infant's room warm
2. parents state that they will wrap their infant in two blankets
3. parents state that they will keep their infant's temperature between 97.5F and 98.6F.
4. Parents state that they will be sure that their infant wears something on her head at home

Hint 123

Parents state that they will keep their infant's temperature between 97.5F and 98.6F

Front 124

The nurse notes skin breakdown on a pt's coccyx during a bath. This data will be used to write a nursing diagnosis statement as:

Back 124

1. the nursing diagnosis
2. the etiologic or related factor
3. the defining characteristic
4. not necessary for writing the statement

Hint 124

the defining characteristic

Front 125

Which example includes all appropriate components of a risk for nursing diagnosis?

Back 125

1. risk for activity tolerance
2. risk for aspiration related to difficulty swallowing
3. potential complication: hemorrhage
4. risk for ineffective airway clearance manifested by wheezing

Hint 125

risk for aspiration related to difficulty swallowing

Front 126

When documenting care and observations in a pt record:

Back 126

1. use of approved medical terms and abbreviations is permitted
2. use of any locally used abbreviations is permitted
3. to prevent errors, no abbreviations are permitted to be used
4. a nurse does not worry about the use of abbreviations

Hint 126

use of approved medical terms and abbreviations is permitted

Front 127

Patient health care records are:

Back 127

1. confidential information and cannot be take to court
2. owned by the pt, who has a right to see the data
3. not used by anyone lese but the direct care providers
4. concise, legal records of all care given and responses

Hint 127

concise, legal records of all care given and responses

Front 128

When the POMR method is used for documentation:

Back 128

1. the problem list has only active and resolved problems
2. only the physician charts on the progress notes
3. the charting format is SOAPE or SOAPIER
4. focus or the DARE charting format is never used

Hint 128

the charting format is SOAPE or SOAPIER

Front 129

The nurse is using the SOAPE method to chart. In this method the S stands for:

Back 129

1. signs and symptoms that the nurse assesses
2. subjective information the pt states or feels
3. subjective information the nurse measures
4. solutions to problems the nurse identifies

Hint 129

subjective information the pt states or feels

Front 130

When charting, the nurse should:

Back 130

1. chart as soon and as often as necessary
2. remember to chart only basic care information
3. leave blank lines for others if asked
4. chart facts using judgmental terms if needed

Hint 130

chart as soon and as often as necessary

Front 131

Understanding that health care personnel must respect the confidentiality of pt's records, the nurse:

Back 131

1. has an ethical prerogative to look at a friend's chart to see the dx
2. knows that only the Pt's Bill of Rights advocates confidentiality
3. reads charts only for a professional reason
4. shares information from a chart to protect a friend

Hint 131

reads charts only for a professional reason

Front 132

The use of computers in the hospital by nurses:

Back 132

1. can save on charting time once nurses are comfortable using computers
2. is not considered important or efficient
3. can be done only on a shared terminal at the desk
4. lacks security measures to protect confidentiality

Hint 132

can save on charting time once nurses are comfortable using computers

Front 133

When completing an incident report, the nurse is aware that it is necessary to:

Back 133

1. document in the chart that the incident report has been filed
2. have all parties involved sign the report
3. ask the supervising nurse to complete the incident report
4. document facts regarding the incident

Hint 133

document facts regarding the incident

Front 134

Which statement is correct about formats for documentation?

Back 134

1. focus charting is a goal-oriented system
2. clinical pathways are the most commonly used format now
3. charting by exception documents those conditions, interventions, or outcomes outside the norm
4. standardized care plans are not cost effective

Hint 134

charting by exception documents those conditions, interventions, or outcomes outside the norm

Front 135

Which statement is a recommended guideline for charting?

Back 135

1. pull a chart by the room number on the label
2. include content that suggests a risk situation
3. skip lines between charting entries
4. have the pt's name and identification number on every sheet

Hint 135

have the pt's name and identification number on every sheet

Front 136

The 24-hour pt care record-keeping system is useful in:

Back 136

1. shortening the pt's hospital stay
2. keeping a more detailed account
3. ensuring the pt's privacy
4. consolidating the nursing record

Hint 136

consolidating the nursing record

Front 137

Acuity charting requires:

Back 137

1. staff to document their interventions
2. detailed assessment information
3. a pt's successful recovery from surgery
4. a discharge summary

Hint 137

staff to document their interventions

Front 138

Which statement is a safe principle of computerized charting?

Back 138

1. a computer terminal may be left unattended during lunchtime
2. each unit or dept has its own password
3. there is no room for mistakes in computerized charting
4. do not leave pt information displayed on the monitor

Hint 138

do not leave pt information displayed on the monitor

Front 139

Which accreditation agency specifies guidelines for documentation?

Back 139

1. The Joint Commission (JTC)
2. American Nurses Association
3. National League of Nursing
4. American Academy of Colleges f Nursing

Hint 139

The Joint Commission (JTC)

Front 140

The primary purpose of Title II of HIPAA is to:

Back 140

1. ensure proper documentation in pt's medical records
2. maintain privacy and confidentiality of pt's health information
3. regulate the availability and range of group insurance plans
4. limit restrictions on insurance coverage based on preexisting conditions

Hint 140

maintain privacy and confidentiality of pt's health information

Front 141

Which statement is correct about abbreviations?

Back 141

1. every facility should have an approved abbreviations list
2. creating abbreviations saves time for the reader
3. abbreviating drug names and dosages helps reduce medication errors
4. whiting out questionable abbreviations could make a jury think you are hiding something

Hint 141

every facility should have an approved abbreviations list

Front 142

When comparing documentation for acute care in hospitals with documentation for long-term care, major differences are related to:

Back 142

1. the goal of the highest quality care at the lowest cost
2. using a multidisciplinary approach for assessment and planning
3. the prospective payment system determining the standards for reimbursement
4. increasing numbers of older adults and disabled people in the US requiring long-term care

Hint 142

the prospective payment system determining the standards for reimbursement

Front 143

The nurse documents in the pt record, "0830 pt appears to be in severe pain and refuses to ambulate. BP and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief. J. Doe RN." The most significant statement about the documentation would be that it is:

Back 143

1. inadequate because the pain is not described on a scale of 1 to 10
2. good because it shows immediate responsiveness to the problem
3. acceptable because it includes assessment, intervention, and evaluation
4. unacceptable because it is vague subjective data without supportive data

Hint 143

unacceptable because it is vague subjective data without supportive data

Front 144

The best description of narrative documentation is that it:

Back 144

1. organizes data by problem or dx
2. describes occurrences in chronological order
3. includes objective data, subjective data, assessment, and plan
4. originated from the medical model

Hint 144

describes occurrences in chronological order

Front 145

In most states, pts can gain access to their medical records by:

Back 145

1. asking the nursing staff to allow them to view each entry in the record
2. submitting a written request to the facility to view the record
3. requesting the state board of health to allow access to the record
4. asking the staff for copies of their records

Hint 145

submitting a written request to the facility to view the record

Front 146

Standards and policies regarding documentation in long-term care facilities is guided by:

Back 146

1. MDS
2. CBE
3. DARE
4. POMR

Hint 146

MDS

Front 147

The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:

Back 147

1. thorough documentation by the nurse
2. submission of appropriate physician progress notes
3. clinical (critical) pathways
4. diagnosis-related groups (DRGs)

Hint 147

diagnosis-related groups (DRGs)

Front 148

The nurse works in a community with many Mexican-American families. The best way for her to learn about their culture would be to:

Back 148

1. eat at Mexican-American restaurants in the area
2. schedule a home visit with a Mexican-American family
3. conduct a library study or internet search of information on the culture
4. observe cultural behaviors in a movie theater in the area

Hint 148

conduct a library study or internet search of information on the culture

Front 149

The pt is admitted to the hospital complaining of diffuse symptoms such as nausea, vomiting, weight loss, headaches, insomnia, and chest pain, which she describes by saying, "My heart aches." Which intervention would be appropriate for this pt, whose cultural beliefs may differ from the nurse's beliefs about physical illness?

Back 149

1. adhere to the philosophy, "I treat all my pts the same."
2. Encourage the pt to describe her symptoms using only English
3. contact an adviser who is familiar with the cultural beliefs of the pt
4. allow the pt to continue taking herbal preparations while she is hospitalized

Hint 149

contact an adviser who is familiar with the cultural beliefs of the pt

Front 150

A Muslim pt visiting the physician's office was told she will have to remove her clothes and put on an examination gown. The pt became upset and refused to do so. The nurse allows the pt to remain in her street clothes because she knows:

Back 150

1. the pt is embarrassed
2. as a Muslim, the pt must keep as much of her body covered as possible
3. the pt is being uncooperative
4. the pt cannot disrobe in front of another female

Hint 150

as a Muslim, the pt must keep as much of her body covered as possible

Front 151

The pt explains to the nurse that he became ill because the natural balance in his body was upset when he moved int a new apt. He has been taking herbs and rearranging objects to change the environment. The nurse notes that the pt's health belief system is most likely:

Back 151

1. biomedical
2. folk
3. holistic
4. a combination of all 3

Hint 151

folk

Front 152

When the pt, a native of Mexico, comes to the clinic, she asks the nurse to allow her 10 yo daughter to remain with her in the examining room. The nurse should:

Back 152

1. ask the child to leave to maintain privacy for the pt
2. explain to the pt that children are not allowed to stay in the examining room because of infection
3. consider that the child may be there to serve as an interpreter for her mother
4. ignore the child

Hint 152

consider that the child may be there to serve as an interpreter

Front 153

The student nurse tells her instructor that she does not understand why a Chinese-American family is not grieving for their dying father. The instructor's response is based on knowing that the student nurse is:

Back 153

1. subculture oriented
2. stereotyping
3. ethnocentric
4. culturally racist

Hint 153

ethnocentric

Front 154

The male nurse is assigned to care for a female Muslim pt. When the nurse enters the room to being her care, the pt and her husband become upset. Her husband tells the nurse that he cannot care for his wife. This is probably because:

Back 154

1. the couple are prejudiced towards the nurse's race
2. the pt is a Muslim, so only women should be assigned to care for her
3. the nurse is not Muslim and therefore cannot care for the pt
4. the couple do not speak English

Hint 154

the pt is a Muslim, so only women should be assigned to care for her

Front 155

A 25yo white nurse who was born and raised in the Midwest is typical of most native born Americans because she believes that illness is generally caused by:

Back 155

1. fate and God's will
2. socioeconomic class
3. getting what you deserve
4. physiologic changes

Hint 155

physiologic changes

Front 156

The nurse is planning to do a cultural assessment of a Chinese-American pt. It would be best if the nurse:

Back 156

1. sits facing the pt
2. touches the pt frequently to convey concern
3. positions the chair so that the nurse sits at a right angle to the pt
4. maintains good eye contact while asking questions

Hint 156

touches the pt frequently to convey concern

Front 157

A female nurse who is black is assigned to care for a new 86yo resident in a nursing home. When she enters his room, he makes several racially offensive remarks. What would be an appropriate response?

Back 157

1. refuse to give care to the pt
2. understand that he is possibly less tolerant of other races because of his own cultural experience or he perhaps has disturbed cognitive functions
3. become angry and retaliate by making racial statements directed at the pt
4. tell her supervisor that she will not take care of any other white pts

Hint 157

understand that he is possibly less tolerant of other races because of his own cultural experiences or he perhaps has disturbed cognitive functions

Front 158

The nurse is assigned to care for a Muslim pt. When the nurse enters the room, he realizes that the pt is praying. The nurse should:

Back 158

1. stay in the room and wait until the pt is finished with his prayers
2. quietly leave the room and give the pt privacy to pray
3. interrupt the pt and tell him it is time for his care to be given
4. tell the pt that he cannot pray while he is in the hospital

Hint 158

quietly leave the room and give the pt privacy to pray

Front 159

A Mexican-American is pregnant with her second child. When the nurse is reviewing her diet, the pt states that she never drinks milk. The nurse knows that a cultural reason for this may be:

Back 159

1. the pt does not like the taste of milk
2. milk is forbidden in her cultural diet
3. lactose intolerance occurs often among Mexican-Americans
4. the pt cannot afford to buy milk

Hint 159

lactose intolerance occurs often among Mexican-Americans

Front 160

A 72yo black woman from Mississippi has been diagnosed with type 2 diabetes and hypertension. The student nurse tells the pt that her vegetables should be steamed and served plain. The pt responds, "But honey, I always cook my green beans with ham and salt and pepper. How can I eat them plain?" A culturally sensitive response might be:

Back 160

1. "I'm sorry, but you will just have to change your method of cooking."
2. "I guess you will just have to give up eating green beans."
3. "You must follow the physician's order if you want to get better."
4. "Why don't you try cooking the beans with half as much ham and do not add salt?"

Hint 160

"You must follow the physician's order if you want to get better."

Front 161

When caring for a pt who speaks a foreign language, it would be incorrect of the nurse to use impaired verbal communication as a nursing dx because:

Back 161

1. an inability to understand each other is the problem, not impaired verbal communication
2. the pt is using a different health belief system that interferes with communication
3. the pt is perhaps following acceptable communication guidelines within his or her culture
4. the pt has deficient knowledge, not impaired verbal communication

Hint 161

an inability to understand each other is the problem, not impaired verbal communication

Front 162

When the nurse is aware of her or his own cultural beliefs, the beliefs and practices of other cultures, and has the ability to interact effectively with individuals from other cultures, the nurse is said to be:

Back 162

1. stereotyping
2. ethnocentric
3. culturally aware
4. culturally competent

Hint 162

culturally competent

Front 163

Before implementation of any newly prescribed procedure, the nurse notices that the family of an older adult pt always consults the eldest son. The social organization of this family is most likely:

Back 163

1. Hispanic in origin
2. patriarchal
3. male dominated
4. traditional nuclear

Hint 163

patriarchal

Front 164

According to Piaget, thinking during the first few months is primarily based on:

Back 164

1. imitation
2. intuition
3. logical operations
4. reflex behavior

Hint 164

reflex behavior

Front 165

The first socializing agent for the child is:

Back 165

1. daycare
2. family
3. school
4. play groups

Hint 165

family

Front 166

At 4 years of age, a child is working on Erikson's task of:

Back 166

1. trust vs mistrust
2. industry vs inferiority
3. autonomy vs shame and doubt
4. initiative vs guilt

Hint 166

initiative vs guilt

Front 167

Which type of play is most common at ages 4 and 5?

Back 167

1. solitary
2. parallel
3. competitive
4. make-believe

Hint 167

make-believe

Front 168

Growth during the school-age period:

Back 168

1. occurs at a rate similar to that during infancy
2. is slow and consistent
3. is mainly in the body's upper region
4. is more rapid than during the preschool period

Hint 168

is slow and consistent

Front 169

An 8yo loves to draw and do craft projects. Her need for praise and encouragement for her work efforts demonstrates her development of Erikson's task of:

Back 169

1. autonomy
2. initiative
3. industry
4. identity

Hint 169

industry

Front 170

Peak physical strength and endurance occurs during:

Back 170

1. adolescence
2. early adulthood
3. middle adulthood
4. late adulthood

Hint 170

early adulthood

Front 171

Menopause usually occurs:

Back 171

1. in the early 30s
2. by age 40
3. in the late 50s
4. in the late 40s to early 50s

Hint 171

in the late 40s to early 50s

Front 172

In correcting the myths about aging, the nurse recognizes that healthy older adults:

Back 172

1. have periods of confusion
2. are likely to become senile
3. have few or no sexual needs
4. have a slower reaction time

Hint 172

have a slower reaction time

Front 173

The principle that describes the direction of growth beginning at the head and moving to the lower extremities is call:

Back 173

1. integrated
2. proximodistal
3. cephalocaudal
4. differential

Hint 173

cephalocaudal

Front 174

The cognitive approach to understanding development is explained by __________ theory.

Back 174

1. Maslow's
2. Piaget's
3. Erikson's
4. Skinner's

Hint 174

Piaget's

Front 175

Following fertilization, the newly formed structure is known as a:

Back 175

1. gene
2. chromosome
3. zygote
4. germ cell

Hint 175

zygote

Front 176

According to Erikson, when the infant is cuddled, fed, and loved, the infant will develop:

Back 176

1. autonomy
2. trust
3. industry
4. identity

Hint 176

trust

Front 177

The type of play typical of the preschool child is:

Back 177

1. parallel play
2. imaginary play
3. organized, team play
4. cognitive play

Hint 177

imaginary play

Front 178

According to Piaget, the child between 7 and 11 years of age is in the:

Back 178

1. sensorimotor stage
2. preoperational stage
3. stage of concrete operation
4. stage of formal operation

Hint 178

stage of concrete operation

Front 179

In the female, the onset of postpuberty period is marked by the onset of:

Back 179

1. breast development
2. appearance of pubic and axillary hair
3. menarche
4. mood changes

Hint 179

menarche

Front 180

The typical adolescent is likely to:

Back 180

1. reject peer pressure
2. try to be different from the crowd
3. reject the advice of elders
4. attempt to copy his or her peers

Hint 180

reject the advice of elders

Front 181

According to Erikson, the task for the young adult is:

Back 181

1. trust vs mistrust
2. identity vs confusion
3. generativity vs stagnation
4. intimacy vs isolation

Hint 181

identity vs confusion

Front 182

Which are health-promoting behaviors the nurse will recommend? (Select all that apply)

Back 182

1. regular medical checkups
2. appropriate prescription use
3. sedentary lifestyle
4. eating low-cholesterol foods

Hint 182

regular medical checkups, appropriate prescription use, eating low-cholesterol foods

Front 183

Which segment of the population is currently the fastest growing?

Back 183

1. Baby boomers
2. from 65-70 years of age
3. from 71-80 years of age
4. older than 85 years of age

Hint 183

older than 85 years of age

Front 184

A 2yo's negative behavior is normal for her age. It is helping her to meet her need for:

Back 184

1. discipline
2. trust
3. independence
4. love

Hint 184

independence

Front 185

The period of cognitive development when the child's knowledge comes about through sensory impressions is called:

Back 185

1. preoperational
2. sensorimotor
3. concrete operational
4. formal operational

Hint 185

sensorimotor

Front 186

Growth during the school-age period can best be described as:

Back 186

1. irregular and slow
2. steady and slow
3. regular and fast
4. irregular and fast

Hint 186

steady and slow

Front 187

Typical behavior for toddlers includes:

Back 187

1. role modeling
2. ritualistic behavior
3. competitiveness
4. industry

Hint 187

ritualistic behavior

Front 188

During early adulthood, individuals are physically:

Back 188

1. beginning to deteriorate
2. already slowing down
3. increasing lung capacity and muscle strength
4. fairly stable at optimal level of function

Hint 188

fairly stable at optimal level of function

Front 189

To counteract the effect of aging, ________ will help to increase the flow of ________.

Back 189

1. rest; blood
2. sleeping; oxygen
3. exercise; oxygen
4. carbohydrates; oxygen

Hint 189

exercise; oxygen

Front 190

Teach pts that influenza immunization:

Back 190

1. produces an immediate effect
2. is effective against all strains of influenza
3. has a lifelong effect
4. is contraindicated for use by people who are allergic to eggs or egg products

Hint 190

is contraindicated for use by people who are allergic to eggs or egg products

Front 191

Advise older adults in nutritional counseling to:

Back 191

1. eat more fats and proteins
2. eat a diet low in fiber and high in carbohydrates
3. eat a diet low in saturated fats and carbohydrates
4. rely on food supplements for all nutrient needs

Hint 191

eat a diet low in saturated fats and carbohydrates

Front 192

According to Erikson, the developmental tasks for older adults are:

Back 192

1. intimacy vs isolation
2. generativity vs stagnation
3. ego integrity vs despair
4. initiative vs guilt

Hint 192

ego integrity vs despair

Front 193

Which developmental skill is commonly accomplished by the fourth month of life?

Back 193

1. sitting up unsupported
2. holding head up at 90-degree angle
3. creeping
4. transferring objects from one hand to the other

Hint 193

holding head up at 90-degree angle

Front 194

The introduction of solid foods to the infant should rely on:

Back 194

1. introducing several foods at once
2. limiting foods to those preferred by the family
3. introducing one new food at a time
4. mixing new foods together to conceal certain tastes

Hint 194

introducing one new food at a time

Front 195

Nighttime bottles should be avoided since milk and juice during the night lead to:

Back 195

1. dental caries
2. dental malocclusion
3. otitis media
4. lactose intolerance

Hint 195

dental caries

Front 196

Preschool children need to be tested for amblyopia. This condition may lead to:

Back 196

1. blindness
2. deafness
3. muscle weakness
4. paralysis

Hint 196

blindness

Front 197

During end of shift report, it is stated that an 86yo pt is dying as a result of end stage renal disease. The nurse recalls that dying is considered:

Back 197

1. undesirable at any time
2. a failure for the nurse
3. impossible with modern medical devices
4. the final stage of human growth and development

Hint 197

the final stage of human growth and development

Front 198

A nurse attempts to avoid caring for a 92yo pt who is dying of heart failure. If the nurse cannot avoid caring for this pt, she provides care but in a detached manner. This nurse is demonstrating:

Back 198

1. poor nursing care
2. grief reaction
3. withdrawal
4. bereavement

Hint 198

withdrawal

Front 199

A 65yo pt has been admitted with various physical complaints resulting from unresolved grief. During her morning care, she says, "It's been 6 months since Harry died. When is it going to get easier?" An appropriate answer by the nurse concerning grief work completion would be that grief work is completed:

Back 199

1. when the family returns to work, school, and social activities
2. after the funeral, wake, or memorial services
3. as soon as the bereaved can talk freely
4. on an individualized basis

Hint 199

on an individualized basis

Front 200

A 77yo pt has been admitted with pneumonia. Her husband asks the nurse about the living will. The nurse remembers that living wills:

Back 200

1. allow the courts to decide when care can be given
2. allow the individual to express his or her wishes regarding care
3. are legally binding in all states
4. allow health care workers to withhold fluids and medications

Hint 200

allow the individual to express his or her wishes regarding care

Front 201

The pt's daughter remained at the bedside of her dying mother throughout the night. When her mother died the following morning, the daughter cried out angrily at the nurse and the physician. The nurse's most appropriate action would be to:

Back 201

1. explain that everything possible was done for her mother
2. remain with the daughter and listen to what she is saying
3. leave the daughter in privacy and allow her to work through her grief
4. notify a clergyman and call other family members

Hint 201

remain with the daughter and listen to what she is saying

Front 202

A newly licensed nurse is assigned to his first pt. The nurse would be best prepared to care for this pt if he:

Back 202

1. had completed a course dealing with death and dying
2. is able to control his own emotions about death
3. had experienced the death of a loved one
4. has resolved the matter of his own mortality

Hint 202

has resolved the matter of his own mortality

Front 203

A nurse is assigned to a pt who was recently diagnosed with a terminal illness. While the nurse was assisting her with morning care, the pt asked about organ donation. The most appropriate action would be to:

Back 203

1. assist her in obtaining the necessary information to make this decision
2. have the pt first discuss the subject with her family
3. suggest she delay making a decision at this time
4. contact the physician so consent can be obtained from the family

Hint 203

assist her in obtaining the necessary information to make this decision

Front 204

A person experiences anticipatory grief when he:

Back 204

1. faces the possibility of losing a loved one
2. has placed the death of a loved one in perspective
3. displays grief responses after a loved one's death
4. has difficulty making decisions after a loved one's death

Hint 204

faces the possibility of losing a loved one

Front 205

The phases of bereavement:

Back 205

1. usually do not occur in order
2. are all present at the same time
3. occur before anticipatory grief
4. usually begin with reorganization

Hint 205

usually do not occur in order

Front 206

When preparing a deceased pt for family viewing, the nurse:

Back 206

1. covers the body with a warm bucket, if possible
2. removes all equipment (tubes, drains, etc.) unless an autopsy has been ordered
3. restricts family members from viewing a pt who has been disfigured
4. covers the deceased pt's arms and hands

Hint 206

removes all equipment (tubes, drains, etc.) unless an autopsy has been ordered

Front 207

Which is an appropriate therapeutic listening technique?

Back 207

1. saying, "I know just how you feel."
2. saying, "Her death was for the best."
3. never crying in front of family members
4. talking slowly and encouraging family members to share their feelings

Hint 207

talking slowly and encouraging family members to share their feelings

Front 208

The nurse helps family members to make difficult decisions by:

Back 208

1. discussing autopsy and organ donation at he time of the loved one's death
2. addressing one matter at a time, giving them adequate time to discuss each issue
3. publicly discussing issues with other hospital staff
4. addressing all of the issues at once

Hint 208

addressing one matter at a time, giving them adequate time to discuss each time

Front 209

Which phrase is most likely to help a grieving family member express himself or herself more easily?

Back 209

1. "Tell me how you're feeling."
2. "I know just how you feel."
3. "Things will get better."
4. "Time heals all wounds."

Hint 209

"Tell me how you're feeling."

Front 210

If a bereaved family member has an unresolved issue with a deceased pt, the nurse should tell him:

Back 210

1. that he is simply experiencing normal anticipatory grief
2. that he missed his chance to make amends and now it is too late
3. to verbalize his thoughts and feelings to his loved one
4. not to worry, and explain that he is just going through the searching and yearning phase of bereavement

Hint 210

to verbalize his thoughts and feelings to his loved one

Front 211

For those who work with grief, death, and dying, it is essential to have constant vigilance over their:

Back 211

1. pts
2. own issues
3. schedules
4. colleagues

Hint 211

own issues

Front 212

Nurses care for all types of pts with various conditions, including those with a terminal illness. Which statement is true?

Back 212

1. Death from terminal illness is sudden and unexpected
2. Physicians know when death will occur
3. An illness is terminal when there is no reasonable hope of recovery
4. All severe injuries result in death

Hint 212

Death from terminal illness is sudden and unexpected

Front 213

Many forces influence living and dying. Which psychological force influences living and dying?

Back 213

1. hope and the will to live
2. reincarnation and belief in the afterlife
3. denial and anger
4. bargaining and depression

Hint 213

hope and the will to live

Front 214

There are many issues related to dying and death. One of the more controversial is euthanasia. Euthanasia is defined as:

Back 214

1. a sudden or unexpected death
2. the belief that the spirit or soul is reborn into another human body or another form of life
3. an "easy death"
4. perinatal death

Hint 214

an "easy death"

Front 215

Special considerations for children are necessary when dealing with death. Children between ages 5 and 7 years view death as:

Back 215

1. temporary
2. final
3. something adults do
4. going to sleep

Hint 215

final

Front 216

Following the death of a pt, the nurse leaves the room quickly and is found sobbing in the utility room. Which action is the most supportive?

Back 216

1. sending the nurse home for the rest of the shift
2. reassigning the nurse to an area where it is unlikely a pt will die
3. sitting with her and allowing her to express herself
4. insisting that she perform postmortem care for the pt

Hint 216

sitting with her and allowing her to express herself

Front 217

The type of care that allows pts to make more informed choices, achieve better alleviation of symptoms, and have more opportunity to work on issues of like closure is:

Back 217

1. acute care
2. mourning care
3. palliative care
4. terminal care

Hint 217

palliative care

Front 218

A factor that uniquely influences an older adult's grief response is:

Back 218

1. cultural background
2. socioeconomic resources
3. sense of contribution in life
4. support available from family members

Hint 218

sense of contribution in life

Front 219

A healthy 25yo who sustained a head injury during a MVA is in the ER. The pt has no brain activity and is on life support. The family has expressed an interest in organ donation. The nurse is aware that:

Back 219

1. organ donations can only occur if the pt has given prior consent
2. vital organs such as the heart and pancreas must be harvested while the pt remains on the ventilator
3. brain death can be reversed, so the family should be informed to take more time in making their decision
4. the attending physician will be present int the operating room during harvesting of the organs

Hint 219

vital organs such as the heart and pancreas must be harvested while the pt remains on the ventilator

Front 220

A bereaved widow of 3 months tells the nurse she has clearly smelled her deceased husband's aftershave scent as she sat in church recently. She questions if she might be "going crazy." The nurse can help her to understand she is experiencing:

Back 220

1. intrusive memories
2. dysfunctional or complicated grief
3. sense of presence
4. grief attacks

Hint 220

sense of presence

Front 221

When giving postmortem care, if the pt is in the supine position, it is best to place:

Back 221

1. one hand on top of the other across the pt's abdomen
2. one hand on top of the other across the pt's chest
3. arms at the sides of the body with the palms facing down
4. arms at the sides of the body with the palms facing up

Hint 221

arms at the sides of the body with the palms facing down

Front 222

Following the dx of a terminal illness, the nurse educates the pt and the family members about palliative care. The nurse explains that palliative care should be initiated:

Back 222

1. as soon as possible after learning of the dx of the terminal illness
2. during the last 3-6 months of life
3. during the last 3-6 weeks of life
4. anytime following the dx of the terminal illness

Hint 222

anytime following the dx of the terminal illness

Front 223

The adult children of a dying pt, who is alert and orient, disagree on the pt's choice of a DNR order. The children ask the opinion of the nurse, who has cared for this pt over an extended period. The nurse's best response is to:

Back 223

1. encourage the children to speak with the physician regarding their concerns
2. remind the children that this is the wish of their parent
3. ask the pt to speak with the children regarding their concerns
4. listen to the children's concerns and encourage them to talk to their parent

Hint 223

encourage the children to speak with the physician regarding their concerns

Front 224

During the registration process, the admission clerk is responsible for:

Back 224

1. informing the pt of the Pt's Bill of Rights
2. obtaining a list of pt allergies
3. informing the pt of current physician's orders
4. ensuring the pt has an allergy band

Hint 224

ensuring the pt has an allergy band

Front 225

A 36yo schoolteacher is admitted for observation and various diagnostic tests. The initial nursing action in her admission process is to:

Back 225

1. introduce self and roommates
2. measure VS
3. help her get undressed and into bed
4. notify the physician

Hint 225

introduce self and roommates

Front 226

A 90yo great-grandfather has been hospitalized with pneumonia. It is necessary to reorient him to his surroundings periodically. The nurse assisting him with his morning care remembers that to call an older male pt "Gramps" is:

Back 226

1. just fine if he has grandchildren
2. acceptable if you cannot remember his name
3. acceptable if you feel comfortable calling him "Gramps"
4. never appropriate

Hint 226

never appropriate

Front 227

A pt has been transferred out of the ICU to a medical unit. A nurse has been assigned to complete the transfer. This type of transfer is called a(n):

Back 227

1. pt-initiated transfer
2. interagency transfer
3. business office transfer
4. intraagency transfer

Hint 227

intraagency transfer

Front 228

A 52yo pt is being transferred to the surgical unit from the recovery room following extensive surgery as the result of trauma from an automobile accident. The nurse assigned to complete his care remembers that when admitting, transferring, or discharging a pt:

Back 228

1. the pt is a human being deserving dignity, courtesy, and respect
2. the pt is ill and unable to make decisions or give accurate information
3. the nurse knows best and should tell the pt what to do
4. families get in the way and should be encouraged not to get involved in the pt's care

Hint 228

the pt is a human being deserving dignity, courtesy, and respect

Front 229

A 45yo pt has been recently diagnosed and hospitalized for type 1 DM. The multidisciplinary health care team has been preparing her for dismissal. The purpose of discharge planning is to:

Back 229

1. make certain the pt takes her medication as prescribed
2. provide medical treatment
3. provide ongoing pt education
4. ensure continuity of care

Hint 229

ensure continuity of care

Front 230

An 84yo pt has been hospitalized for 6 days with a dx of a stroke. The nurse knows planning for the pt's dismissal should begin:

Back 230

1. when his condition has stabilized
2. on his admission to the hospital
3. when he begins to ask questions
4. when his family asks for information

Hint 230

on his admission to the hospital

Front 231

A pt is determined to leave the hospital. His physician is not aware of his intent, nor is it in his best interest to be discharged at this time. When a pt chooses to leave a health care facility without a physician's written order, the nurse should:

Back 231

1. call the family so they can expect the pt at home
2. allow the pt to leave because no one can be held against his or her will
3. call security because there must be a physician's order before a pt may leave
4. explain the risks of leaving and request that the pt sign a paper accepting responsibility for problems that may occur

Hint 231

explain the risks of leaving and request that the pt sign a paper accepting responsibility for problems that may occur

Front 232

The nurse is admitting a pt to the nursing unit. The nurse's first action is to:

Back 232

1. greet the pt by name
2. ask the pt his or her name
3. tell the pt everything will be all right
4. introduce the roommate

Hint 232

greet the pt by name

Front 233

The pt is being discharged. The nurse should:

Back 233

1. tell the pt everything will be all right
2. encourage the pt not to worry
3. wish the pt well
4. introduce the pt to the office staff

Hint 233

wish the pt well

Front 234

A pt is being admitted to the hospital for stabilization of her heart condition. Before arriving on the nursing unit, the admissions dept will:

Back 234

1. have the pt sign consent for treatment
2. itemize the pt's belongings
3. measure the pt's VS
4. review the physician's orders

Hint 234

have the pt sign consent for treatment

Front 235

When a pt arrives on the nursing unit, the LPN is probably responsible for:

Back 235

1. admission charting
2. admission interview
3. formulating nursing dx
4. obtaining VS

Hint 235

obtaining VS

Front 236

Nursing documentation at discharge should include a:

Back 236

1. summary account of the hospital stay
2. account of all financial obligations
3. method of discharge
4. summary of personnel who cared for the pt

Hint 236

method of discharge

Front 237

The services of a transition specialist for pt discharge often leads to an increase in:

Back 237

1. insurance reimbursement rates for facilities
2. continuity of care from hospital to home
3. completion of hospital documentation requirements
4. readmitting of pts to hospitals

Hint 237

continuity of care from hospital to home

Front 238

A 24yo was admitted to a medical unit with the dx of hepatitis A and placed in contact isolation. The purpose of this is to:

Back 238

1. prevent transmission of infectious microorganisms
2. control the environment of the pt
3. protect the pt from infectious microorganisms
4. protect only the family

Hint 238

prevent transmission of infectious microorganisms

Front 239

The nurse is working in a clinical medical area with a census of 15. Each pt has a different illness. The most important skill the nurse can use to protect each pt from health care-associated infections is:

Back 239

1. wearing a gown
2. placing each pt in isolation
3. hand hygiene
4. wearing gloves

Hint 239

hand hygiene

Front 240

The nurse caring for the pt in isolation wears latex gloves. Which is an important consideration?

Back 240

1. first assess the pt for potential latex allergy
2. vinyl gloves actually provide higher barrier protection than latex
3. the cost of latex gloves is significantly higher than that of synthetic gloves
4. latex gloves are so reliable as barriers that hand hygiene is not required

Hint 240

first assess the pt for potential latex allergy

Front 241

The nurse notes that the pt understands proper technique for hand hygiene when the pt states:

Back 241

1. "The water I wash my hands with should be as hot as I can tolerate to kill all of the germs on my skin."
2. "If there isn't time to completely wash my hands, it will be all right to rinse them quickly in warm water."
3. "After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water."
4. "I will put soap into a basin of warm water, lather my hands for 15 seconds, and then rinse them in the basin."

Hint 241

"After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water."

Front 242

Identification of the chain of infection allows health care providers to:

Back 242

1. test pts for resistance to communicable diseases
2. request more money for building isolation hospitals
3. work with the physician to identify the most appropriate antibiotic
4. determine points at which the infection can be stopped or prevented

Hint 242

determine points at which the infection can be stopped or prevented

Front 243

A pt in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate?

Back 243

1. allow visitors to remove masks while in the pt's room
2. leave the door of the negative-pressure room open slightly
3. remind the pt that the isolation is for his or her own benefit
4. set specific times when the nurse will return to the pt's room

Hint 243

set specific times when the nurse will return to the pt's room

Front 244

A 45yo man was admitted to the hospital with cellulitis of the right foot. Three days later, he developed bacterial pneumonia. This type of bacterial infection is classified as:

Back 244

1. acute primary
2. health care-associated
3. interstitial
4. mycoplasmic

Hint 244

health care-associated

Front 245

Which statement is true of sterile technique?

Back 245

1. sterilization is the practice that helps confine or reduce the number of microorganisms
2. when an item has been disinfected, it is to be considered sterile
3. recently opened wrappers are considered sterile to within 1 inch of their edges
4. surgical asepsis and clean technique are the same

Hint 245

recently opened wrappers are considered sterile to within 1 inch of their edges

Front 246

Because sterile technique is used in many procedures of pt care, it is important for the nurse to remember to hold sterile objects:

Back 246

1. close to shoulder level
2. just below waist level
3. anywhere as long as they are handled with sterile gloves
4. above waist level

Hint 246

above waist level

Front 247

Although surgical asepsis is practiced in the operating room and in other specialty areas, the nurse will at times also use surgical aseptic technique at the pt's bedside. For which procedure will the nurse employ surgical asepsis?

Back 247

1. inserting an IV
2. performing perineal care
3. performing oral care
4. obtaining a sputum specimen

Hint 247

inserting an IV

Front 248

The nurse is performing a surgical hand scrub. During a surgical hand scrub, the hands are held:

Back 248

1. above the elbows
2. with the fingers pointing down
3. whichever way is convenient
4. just below the waist

Hint 248

above the elbows

Front 249

To practice strict surgical asepsis, the nurse will:

Back 249

1. adhere to principles of sterile technique
2. perform routine environmental cleaning
3. disinfect surfaces that come into contact with body fluids
4. maintain proper hand hygiene before and after pt care

Hint 249

adhere to principles of sterile technique

Front 250

When donning sterile gloves, the nurse will:

Back 250

1. touch only the inside surface of the first glove while pulling it onto the hand
2. place the fingers of the dominant hand into the outside cuff of the first glove
3. let the cuff of the glove roll up over the hand as it is being pulled onto the hand
4. begin the procedure by pulling the first glove upward and over the nondominant hand

Hint 250

touch only the inside surface of the first glove while pulling it onto the hand

Front 251

To remove gloves at the end of a procedure, the nurse will:

Back 251

1. pull each finger from each of the gloves first, then roll the glove back over the hand.
2. remove the glove from the nondominant hand by reaching inside the glove and pulling it off
3. remove one glove, then use the bare fingers to push the remaining glove off from inside the cuff
4. hold both gloved hands under running water and roll the gloves down to keep microorganisms contained

Hint 251

remove one glove, then use the bare fingers to push the remaining glove off from inside the cuff

Front 252

Which is a principle of surgical asepsis?

Back 252

1. Any sterilized item is considered unsterile once it is allowed to fall below knee height
2. sterile fields and sterilized items are no longer sterile if they contact a clean surface
3. a person not wearing sterile garments can come no closer to a sterile field than 3 feet
4. the front and back of a sterile gown being worn are considered sterile from shoulders to knees

Hint 252

sterile fields and sterilized items are no longer sterile if they contact a clean surface

Front 253

A patient isolated for pulmonary tuberculosis seems to be angry, but the nurse knows this is a normal response to isolation. The best intervention would be to:

Back 253

1. provide a dark, quiet room to calm the patient
2. explain isolation procedures and provide meaningful stimulation
3. reduce the level of precautions to keep the pt from becoming angry
4. limit family and other caregiver visits to reduce the risk of spreading the infection

Hint 253

explain isolation procedures and provide meaningful stimulation

Front 254

After administering care to a pt, the nurse needs to remove a tray of soiled instruments from the room and "bag" the materials. Some of the items are metal, whereas others are made of plastic. The nurse knows that:

Back 254

1. it is acceptable to place everything into one bag as long as it is labeled properly
2. it is necessary to bag the metal items and send them for autoclaving, and acceptable to dispose of the plastic items
3. it is necessary to separate the items: plastic goes into one bag for gas sterilization, and metal into another to be autoclaved
4. the type of bag doesn't matter as long as it is labeled "isolation"

Hint 254

it is necessary to separate the items: plastic goes into one bag for gas sterilization, and metal into another to be autoclaved

Front 255

The nurse is assisting the physician with an irrigation of a draining abdominal wound by preparing the sterile tray. It is necessary to maintain sterility of the tray at all times. During the process the nurse will:

Back 255

1. use sterile forceps while reaching across it to move the contents around
2. wear clean gloves to handle the contents of the tray
3. allow the open tray to stand unattended for 20 minutes, then cover it with a towel
4. put on sterile gloves to handle the contents of the tray

Hint 255

put on sterile gloves to handle the contents of the tray

Front 256

The nurse is assigned to represent the unit on the infection prevention and control committee. The committee is discussing the CDC's hand hygiene recommendations for implementation in the hospital. Which statement demonstrates and understanding of the CDC's recommendation?

Back 256

1. health care providers will wear gloves at all times when providing pt care
2. disinfecting hands following glove removal is not necessary
3. alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids
4. it is necessary to remove waterless alcohol-based hand cleaner with paper towels to remove pathogens from hands

Hint 256

alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids

Front 257

The nurse just completed a sterile dressing change on a pt's postoperative incision, and is preparing to measure the pt's VS. In regard to the gloves worn during application of the sterile dressing, the nurse should:

Back 257

1. leave the gloves on , since they are sterile, and measure the VS
2. remove the gloves and perform hand hygiene before measuring the VS
3. remove the gloves, and leave the room to perform hand hygiene
4. remove the gloves, measure the VS, and then perform hand hygiene

Hint 257

remove the gloves, and perform hand hygiene before measuring the VS

Front 258

The nurse will wear a gown during care of an infected wound for any patient in this type of isolation:

Back 258

1. airborne precautions
2. droplet precautions
3. contact precautions
4. TB precautions

Hint 258

contact precautions

Front 259

The nurse is preparing to change the tracheostomy ties on a pt. Which precaution would necessitate wearing a mask?

Back 259

1. airborne precautions
2. droplet precautions
3. contact precautions
4. standard precautions

Hint 259

droplet precautions

Front 260

The nurse is preparing to open the outer sterile wrap of a Foley (indwelling catheter) tray. Which flap of the wrap (in which direction) should be opened first?

Back 260

1. the flap that opens away from the nurse
2. the flap that opens to the left
3. the flap that opens to the right
4. the flap that opens toward the nurse

Hint 260

the flap that opens away from the nurse

Front 261

The patient asks the nurse how his skin will be sterilized before his surgery. The nurse's best response is:

Back 261

1. "We will use alcohol to sterilize your skin."
2. "It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms."
3. "There are a series of steps used in sterilizing your skin in order to prevent you from getting an infection."
4. "We will use Betadine solution to sterilize your skin."

Hint 261

"It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms."

Front 262

The pt has just returned from the postanesthesia care (PAC) unit. During report, the nurse is told that the pt has a Penrose drain in the LLQ. The purpose of a Penrose drain is:

Back 262

1. to instill solution for wound irrigation
2. to prevent blockage of a passageway
3. to drain the wound area by suction
4. to drain the wound area by gravity

Hint 262

to drain the wound area by gravity

Front 263

Which nursing intervention would be appropriate should the pt's abdominal wound eviscerate?

Back 263

1. place her in high Fowler's position
2. give her fluids to prevent shock
3. replace dressings with sterile fluffy pads
4. apply warm, moist sterile dressings

Hint 263

apply warm, moist sterile dressings

Front 264

The nurse prepares to irrigate a pt's wound. The primary reason for performing this procedure is to:

Back 264

1. remove debris from the wound
2. decrease scar formation
3. improve circulation from the wound
4. decrease irritation from wound drainage

Hint 264

remove debris from the wound

Front 265

What is the best indicator that a wound has become infected?

Back 265

1. palpation of the wound reveals excess fluid under its edges
2. wound cultures are positive
3. purulent drainage is coming from the wound area
4. the wound has a distinct odor

Hint 265

purulent drainage is coming from the wound area

Front 266

Which nursing entry is the most complete in its description of a wound?

Back 266

1. wound appears to be healing well, dressing dry and intact
2. wound well approximated with minimal drainage
3. drainage size of a quarter; wound pink; 4x4 applied
4. incisional edges approximated without erythema or exudate; two 4x4s applied

Hint 266

incisional edges approximated without erythema or exudate; two 4x4s applied

Front 267

A pt has peripheral edema that causes the left calf of the leg to swell. Which is the most appropriate technique for applying a bandage around the affected extremity?

Back 267

1. increase tension with each successive turn when applying the bandage
2. place clips and tape over the area with the most swelling to prevent slippage
3. assess the skin integrity carefully before reapplying each new bandage
4. encourage peripheral blood flow by beginning bandaging at the proximal end and working to the distal area

Hint 267

assess the skin integrity carefully before reapplying each new bandage

Front 268

Which statement is correct in regard to the use of an abdominal binder?

Back 268

1. it replaces the need for underlying dressings
2. it should be kept loose for pt comfort
3. the pt has to be sitting or standing when it is applied
4. the pt must have adequate ventilatory capacity

Hint 268

the pt must have adequate ventilatory capacity

Front 269

The first step in packing a wound is to:

Back 269

1. assess its size, shape, and depth
2. prepare a sterile field
3. select gauze packing material
4. irrigate the wound

Hint 269

assess its size, shape, and depth

Front 270

The correct procedure for the wet-to-dry dressing method is to:

Back 270

1. place dry gauze into the wound and remove it when it is wet
2. medicate the pt for pain after you change the dressing
3. complete this type of dressing change just once a day
4. place moist gauze into the wound and remove it when it is dry

Hint 270

place moist gauze into the wound and remove it when it is dry

Front 271

Serious drainage from a wound is described as:

Back 271

1. fresh bleeding
2. thick and yellow
3. clear, water plasma
4. beige to brown and foul smelling

Hint 271

clear, water plasma

Front 272

A binder placed around a surgical pt with a new abdominal wound is indicated for:

Back 272

1. collection of wound drainage
2. reduction of abdominal swelling
3. reduction of stress on the abdominal incision
4. stimulation of peristalsis from direct pressure

Hint 272

reduction of stress on the abdominal incision

Front 273

The purpose of a wet-to-dry dressing is:

Back 273

1. debridement
2. cooling
3. comfort
4. antiinfection

Hint 273

debridement

Front 274

A surgical wound infection can be reduced by:

Back 274

1. adhering to the principles of hand hygiene
2. cleansing the incision from the least contaminated to the most contaminated area
3. leaving the incision open to the air
4. changing the dressing using sterile technique

Hint 274

changing the dressing using sterile technique

Front 275

When changing a pt's dressing, which nursing action is correct?

Back 275

1. enclose the soiled dressing within a latex glove
2. clean the wound in circles towards the incision
3. free the tape by pulling it away from the incision
4. remove the soiled dressing with sterile gloves

Hint 275

free the tape by pulling it away from the incision

Front 276

When emptying the drainage in a Hemovac reservoir, which nursing action is essential for reestablishing the negative pressure within this drainage device?

Back 276

1. fill the reservoir with sterile normal saline
2. secure the reservoir to the skin near the wound
3. compress the reservoir and close the vent
4. open the vent, allowing the reservoir to fill with air

Hint 276

compress the reservoir and close the vent

Front 277

Which pt is more at risk for wound dehiscence?

Back 277

1. the pt who smokes
2. the obese pt
3. the pt with a hx of peripheral vascular disease
4. the immunocompromised pt

Hint 277

the obese pt

Front 278

Which wound drain is classified as providing gravity-assisting drainage?

Back 278

1. Jackson-Pratt
2. Hemovac
3. Penrose
4. Wound VAC system

Hint 278

Penrose

Front 279

The physician has ordered all sutures on an abdominal hysterectomy pt be removed on the tenth postoperative day, and Steri-Strips applied. During suture removal the nurse notices the incision edges are slightly separating. The nurse's best action is to:

Back 279

1. continue removing the sutures and apply the Steri-Strips
2. stop the suture removal and contact the physician immediately
3. continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing
4. stop the suture removal, apply Steri-Strips where sutures have already been removed and notify the physician

Hint 279

stop the suture removal and contact the physician immediately

Front 280

When providing care to a pt with a Hemovac drain, the nurse should:

Back 280

1. record the appearance of the drainage in the nursing progress notes and include the amount in the intake and output calculations
2. clamp the tubing during pt ambulation and activity in order to prevent excess drainage during these times
3. empty the bulb drainage receptacle when it is one fourth full
4. pin the bulb above the insertion site to assist in proper drainage of exudate

Hint 280

record the appearance of the drainage in the nursing progress notes and include the amount in the intake and output calculations

Front 281

During assessment of a pt following abdominal surgery, the nurse suspects internal hemorrhaging based on which finding?

Back 281

1. the dressing is saturated with bright red sanguineous drainage, and the pt has an increased urinary output
2. the dressing is dry and intact, and the pt's blood pressure has decreased and pulse and respirations have increased
3. the dressing is saturated with serosanguineous drainage, and the pt is diaphoretic with a decrease in pulse and respirations
4. the dressing is dry and intact, and the pt complains of SOB and has an elevated termperature

Hint 281

the dressing is saturated with bright red sanguineous drainage, and the pt has an increased urinary output

Front 282

On the transfer sheet of a pt admitted to a health care facility is the order "restrain prn." SRDs are used in the hospital setting to prevent pt injury. Which statement is correct?

Back 282

1. SRDs often decrease anxiety because the pt feels safer
2. all older adult pts needs some type of SRD at night
3. allow as much freedom of movement as possible when applying SRDs
4. when using soft SRDs to prevent injury from falling out of bed, tie them to the side rail

Hint 282

allow as much freedom of movement as possible when applying SRDs

Front 283

In the situation of previous question, what is an appropriate goal (expected outcome) for the pt requiring a physical restraint?

Back 283

1. pt will remain free of injury
2. pt will allow SRDs to be used
3. nurse will check SRD every 30 minutes
4. use least restrictive form of SRD possible

Hint 283

pt will remain free of injury

Front 284

Documentation related to use of an SRD is required to include:

Back 284

1. the nurse's feelings about having used the SRD
2. the specific type of SRD used
3. confirmation of a prn order for use of the SRD
4. evidence that the pt was assessed every 8 hours

Hint 284

the specific type of SRD used

Front 285

When caring for the pt who requires the use of an SRD, the nurse remembers that an appropriate nursing intervention when caring for a pt who needs an SRD is to:

Back 285

1. monitor the skin for signs of impairment
2. remove the SRD once every 24 hours
3. secure the ends of the ties to the side rails
4. ensure that the SRD is in place at all times

Hint 285

monitor the skin for signs of impairment

Front 286

The nurse discovers smoke in a soiled utility room and remembers that the initial step taken to protect the patient in the event of a fire is to:

Back 286

1. notify the fire dept
2. disconnect the oxygen supply
3. use any extinguisher on the fire
4. remove the pt from the area

Hint 286

remove the pt from the area

Front 287

The patient who requires the use of an extremity SRD has an edematous extremity. The most appropriate nursing action is to:

Back 287

1. elevate the involved extremity
2. increase the padding around the extremity
3. notify the physician for a different type of SRD
4. remove the SRD and watch the patient more closely

Hint 287

remove the SRD and watch the patient more closely

Front 288

A type C fire extinguisher is required for which of the following types of fire:

Back 288

1. paper
2. cloth
3. grease
4. electrical

Hint 288

electrical

Front 289

When assessing a pt's knowledge of the fire safety precautions, which action indicates the need for further fire safety instruction?

Back 289

1. fire exits and corridors are kept clear
2. a NO SMOKING sign is posted when oxygen is in use
3. a heating pad cord is taped when a frayed area is noted
4. facility smoking policies are a part of the admission procedure

Hint 289

a heating pad cord is taped when a frayed area is noted

Front 290

Which factor places a child at greatest risk for specific types of injuries?

Back 290

1. sex of the child
2. overall health
3. educational level
4. developmental level

Hint 290

developmental level

Front 291

During the 7am to 3pm shift on the adult surgical unit, the code is announced for an external disaster emergency. Which even best represents this type of situation?

Back 291

1. a school bus accident
2. a bomb threat in the mail room
3. a hostage-taking even in the emergency dept
4. an electrical fire in the maintenance dept

Hint 291

a school bus accident

Front 292

Vomiting is most likely to be induced if poisoning is related to the ingestion of which substance(s)?

Back 292

1. lye
2. petroleum products
3. household cleaners
4. salicylates, such as aspirin

Hint 292

salicylates, such as aspirin

Front 293

A 63yo pt is brought to the emergency dept for treatment of an accidental poisoning. The first step in the treatment is to:

Back 293

1. induce vomiting
2. assess the pt
3. place the pt in an upright position
4. notify the poison control center

Hint 293

place the pt in an upright position

Front 294

Which is the greatest safety issue for caregivers of older adults?

Back 294

1. accidental poisoning
2. electrical shock
3. accidental falls
4. thermal burns

Hint 294

accidental falls

Front 295

A potential environmental health threat is the possibility of:

Back 295

1. bioterrorism
2. noise pollution
3. water pollution
4. air pollution

Hint 295

bioterrorism

Front 296

In the event of a mercury spill, which statement is true?

Back 296

1. it is acceptable to clean the mercury spill with alcohol and ordinary cleaning cloths
2. close all windows and doors to prevent the mercury spill from spreading out of the area
3. do not vacuum the spill
4. place the recovered mercury in a plastic bag and close tightly

Hint 296

do not vacuum the spill

Front 297

The nurse is assigned to care for an 82yo pt who weighs 252 pounds and is a bilateral below-the-knee amputee. The safest method to transfer this patient from bed to chair would be:

Back 297

1. log-rolling
2. using two nurses to lift
3. a hydraulic lift with a Hoyer sling
4. a gurney lift

Hint 297

a hydraulic lift with a Hoyer sling

Front 298

The nurse helps ambulate an 84yo pt who has peripheral vascular disease that caused a severe stasis ulcer. The pt becomes very weak, complains of feeling faint, and begins to fall. The most appropriate action to prevent injury to the pt would be to:

Back 298

1. support her while falling and allow her to sit on the floor
2. carefully attempt to return her to her room
3. tell her to hold onto the wall and that you will get more assistance
4. ask her to take deep breaths and look straight ahead

Hint 298

support her while falling and allow her to sit on the floor

Front 299

A 56yo pt had an open cholecystectomy. The nurse is going to dangle the pt before ambulation. After sitting him on the edge of the bed, which nursing intervention should the nurse perform before proceeding with the ambulation?

Back 299

1. assess his temperature
2. assess his pulse and respirations
3. perform an oximetry check
4. remove antiembolism stockings

Hint 299

assess his pulse and respirations

Front 300

The pt accidentally knocks the emesis basin to the floor. When picking up the emesis basin, the nurse will use proper body mechanics to:

Back 300

1. lower his or her body by flexing the knees and bending the hips
2. bend from the waist and hips
3. flex the knees and bend at the waist
4. keep his or her legs straight and flex the waist

Hint 300

flex the knees and bend at the waist

Front 301

A 72yo pt with a stroke has slid to the foot of the bed. To use appropriate body mechanics, the nurse maintains a wide base of support and faces the pt in the direction of movement, thus allowing the nurse to:

Back 301

1. use the back muscles
2. use the large muscles across the scapula
3. exert less physical effort
4. use the gluteal muscles

Hint 301

exert less physical effort

Front 302

An 82yo pt has had a right total hip replacement. On the first postoperative day, the nurse repositions the pt to her left side, placing a pillow between her legs and another to her back. The nurse assesses the proper placement of the pt's body to evaluate:

Back 302

1. base of support
2. body alignment
3. head and chin tilt
4. gluteal pressure

Hint 302

body alignment

Front 303

It is the pt's first night after an abdominal hysterectomy. She has not voided for 9 hours, and the nurse is to insert a 16-F Foley catheter into her bladder. The preferred position is:

Back 303

1. dorsal recumbent
2. lithotomy
3. Sims'
4. prone

Hint 303

dorsal recumbent

Front 304

The nurse is assigned to care for a 64yo pt who was admitted for exacerbation of COPD and pneumonia. He has dyspnea and is unable to rest in a supine position. The nurse elevates the head of the bed to 90 degrees, places a pillow on the overbed table, and assists the pt to lean forward, placing his head on the pillow. This position is called:

Back 304

1. semi-Fowler's
2. dorsal
3. Sims'
4. orthopneic

Hint 304

orthopneic

Front 305

The nurse explains to the pt that the log-rolling technique will be used to help the pt change position by stating:

Back 305

1. "Log-rolling will help you keep your hips slightly flexed toward your chest."
2. "By having you dangle your legs at the bedside, you will be more comfortable."
3. "Because of your injury, it is extremely important that the head of your bed remain up at all times."
4. "It is important to keep your neck and spin in straight alignment while we help you move onto your side."

Hint 305

"It is important to keep your neck and spin in straight alignment while we help you move onto your side."

Front 306

The nurse and an assistant are to move a dependent pt from the supine to the lateral position and will:

Back 306

1. move the pt to the center of the bed first
2. ensure that the upper arm and leg are supported with pillows
3. place a firm pillow at the abdomen and chest for additional support
4. turn the patient's shoulders to one side and hips towards the other side

Hint 306

move the pt to the center of the bed first

Front 307

An older adult pt has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. The nurse will:

Back 307

1. express concern that she is uncomfortable and promise to come back later
2. assess the pt's need for pain medication before helping her changing position
3. explain to the pt that if she doesn't move now, she will develop pneumonia
4. find another nurse to help move the pt to the lateral position immediately

Hint 307

assess the pt's need for pain medication before helping her change position

Front 308

A principle of good body mechanics includes:

Back 308

1. keeping the knees in a locked position
2. maintaining a wide base of support and bending at the knees
3. bending at the waist to maintain one's balance
4. holding objects away from the body for improved leverage

Hint 308

maintaining a wide base of support and bending at the knees

Front 309

A pt becomes faint while sitting on the side of the bed. To prevent injury to the pt, the nurse will:

Back 309

1. call for assistance
2. lay pt straight back and support head
3. allow pt to lower head to rest on your abdomen
4. find an emesis basin as pt will probably vomit

Hint 309

lay pt straight back and support head

Front 310

A pt has been immobilized for 5 days because of extensive abdominal surgery. When getting this pt out of bed for the first time, a nursing dx related to the safety of the pt would be:

Back 310

1. pain
2. impaired skin integrity
3. altered tissue perfusion
4. risk for activity intolerance

Hint 310

risk for activity intolerance

Front 311

Which assistive device allows the pt to pull with the upper extremities to raise his trunk off the bed, to assist in transfer from bed to wheelchair, or to perform upper arm exercises?

Back 311

1. trapeze bar
2. trochanter roll
3. hand rolls
4. footboard

Hint 311

trapeze bar

Front 312

In which position is the pt lying face down or chest down?

Back 312

1. supine
2. lateral
3. prone
4. fowler's

Hint 312

prone

Front 313

A necessary safety precaution when helping a pt to ambulate is to:

Back 313

1. have family members present
2. have pt wear well-fitting rubber-soled shoes or slippers
3. have at least two people present to assist the pt
4. be sure no pain medication was given for at least 3 hours before ambulation

Hint 313

have pt wear well-fitting rubber-soled shoes or slippers

Front 314

Active and passive ROM exercises benefit the pt by preventing:

Back 314

1. contractures
2. arthritis
3. muscle strain
4. atrophy of surrounding tissue

Hint 314

contractures

Front 315

A footboard can prevent footdrop, also known as:

Back 315

1. plantar flexion of the foot
2. dorsiflexion of the foot
3. ankle extension
4. ankle hyperextension

Hint 315

plantar flexion of the foot

Front 316

When using a drawsheet to assist in moving a pt up in bed, ask the pt to:

Back 316

1. bend knees to assist in moving
2. keep hands at sides
3. raise arms above the bed
4. maintain straight body position

Hint 316

maintain straight body position

Front 317

Following surgery for a total knee replacement, a pt was given an epidural catheter for fentanyl epidural analgesia. An important nursing intervention is to:

Back 317

1. administer additional analgesic medications prn
2. change the epidural dressing every shift
3. assess respiratory rate carefully
4. encourage unassisted ambulation

Hint 317

assess respiratory rate carefully

Front 318

A 52 yo pt admitted for DVT of the left internal iliac vein complains of excruciating pain in his left leg. The most appropriate nursing response is to reassure him by stating:

Back 318

1. "Pain is what you say it is; I will assist you in whatever way I can."
2. "Your pain is an unpleasant sensation caused by inflammation of the vein and difficult to control."
3. "Your pain is one of the cardinal signs of inflammation."
4. "I know you are in pain, but it is important that we guard against possible addiction to opioids."

Hint 318

"Pain is what you say it is; I will assist you in whatever way I can."

Front 319

A 63yo pt is first day postoperative after a lower anterior bowel resection. A common central nervous system analgesic often prescribed for control pain is:

Back 319

1. aspirin
2. acetaminophen
3. morphine
4. ibuprofen

Hint 319

morphine

Front 320

A drug delivery system to control pain via a portable computerized pump with a chamber for a syringe is called:

Back 320

1. patient-controlled analgesia
2. transcutaneous electric nerve stimulation
3. a venous access device
4. a placebo

Hint 320

patient-controlled analgesia

Front 321

The gate control theory of pain suggests that:

Back 321

1. the body contains a natural supply of a morphinelike substance called endorphins
2. there are specific nerve fibers that transmit pain impulses to the brain
3. pain impulses are regulated or even blocked by mechanisms located along the CNS
4. pain is a manifestation of an intricate chain of electrochemical events

Hint 321

pain impulses are regulated or even blocked by mechanisms located along the CNS

Front 322

A pt admitted with severe cellulitis of the left breast states,"", "I have severe burning pain, and it feels like my breast is on fire." She rates her pain as 7 on the 0-10 pain assessment scale. This collection of data by the nurse in assessing the pt's pain would be:

Back 322

1. deductive
2. speculative
3. objective
4. subjective

Hint 322

subjective

Front 323

The nurse listens attentively while the pt describes her angina pectoris pain as radiating down her left inner arm to the little finger and upward to the jaw and the shoulder. This type of pain is called:

Back 323

1. precisely localized
2. referred
3. intermittent
4. chronic

Hint 323

referred

Front 324

The nurse is assessing the pt's description of his back pain. He states that it is "immobilizing, intense, and on a scale of 0-10, it is an 8." The pain assessment scale the pt is using is called:

Back 324

1. visual analog
2. categorical
3. functional
4. numerical

Hint 324

numerical

Front 325

People who have less pain than others from a similar injury have a:

Back 325

1. higher level of endorphins
2. lower level of endorphins

Hint 325

higher level of endorphins

Front 326

Research shows nurses treating pain have a tendency to:

Back 326

1. overtreat
2. undertreat

Hint 326

undertreat

Front 327

A pt was admitted to the orthopedic section for acute back pain. The physician chose to use cutaneous stimulation management, in which the analgesic effects are achieved by closing the gate to pain impulses and release of endorphins. An example of this pain control method is:

Back 327

1. epidural analgesia
2. transcutaneous electric nerve stimulation (TENS)
3. NSAIDs
4. patient-controlled analgesia

Hint 327

transcutaneous electric nerve stimulation (TENS)

Front 328

Unrelieved pain is:

Back 328

1. to be expected after major surgery
2. to be expected in a person with cancer
3. dangerous and can lead to many physical and psychological complications
4. an annoying sensation, but it is not as important as other physical care needs

Hint 328

dangerous and can lead to many physical and psychological complications

Front 329

An important nursing responsibility related to pain is to:

Back 329

1. leave the pt alone to rest
2. help the pt appear to not be in pain
3. believe what the pt says about pain
4. assume responsibility for eliminating the pt's pain

Hint 329

believe what the pt says about pain

Front 330

A nurse believes that pts with the same type of tissue injury will have the same amount of pain. This statement reflects:

Back 330

1. a belief that will contribute to appropriate pain management
2. a belief that will have no effect on the type of care provided to people in pain
3. an accurate statement about pain mechanisms and an expected goal of pain therapy
4. the nurse's lack of knowledge about pain mechanisms and is likely to contribute to poor pain management

Hint 330

the nurse's lack of knowledge about pain mechanisms and is likely to contribute to poor pain management

Front 331

Research indicates that the risk of clinically significant opioid-induced respiratory depression is:

Back 331

1. less than 1%
2. 5%
3. 20%
4. 30%

Hint 331

less than 1%

Front 332

Which route is most appropriate for treating rapidly escalating severe pain?

Back 332

1. oral
2. IM
3. IV
4. transdermal

Hint 332

IV

Front 333

Which opioid is no longer a drug of choice for managing pain because of its toxic complications, such as causing seizures?

Back 333

1. codeine
2. morphine
3. meperidine
4. fentanyl

Hint 333

meperidine

Front 334

Which are reasons that the patient-controlled analgesia (PCA) pumps are frequently used for postoperative pain management?
(Select all that apply)

Back 334

1. PCAs increase patient satisfaction
2. PCAs decrease the frequency of patient complaints
3. PCAs control the patient's use of opioids and reduce the chance of addiction
4. PCAs encourage the use of pain analgesic before the patient experiences severe pain

Hint 334

PCAs encourage the use of pain analgesic before the patient experiences severe pain

Front 335

In selecting alternative therapies, acupressure may be most effective with which patient?

Back 335

1. restless, anxious patient
2. patient with ulcerative colitis
3. pregnant woman
4. psychiatric patient

Hint 335

restless, anxious patient

Front 336

The nurse's presentation on alternative therapies for a community group states that herbal therapies are:

Back 336

1. approved by the US Food and Drug Administration under the Food, Drug, and Cosmetic Act
2. sold as medicines in most stores because they lack major side effects
3. allowed to be packaged as dietary supplements if they are without health claims
4. consistent in their standards for concentrations of major ingredients and additives

Hint 336

allowed to be packaged as dietary supplements if they are without health claims

Front 337

A pt asks about different herbal therapies that may promote physical endurance and reduce stress. On which would the nurse provide information?

Back 337

1. ginseng
2. ginger
3. echinacea
4. chamomile

Hint 337

ginseng

Front 338

When assessing a pt's use of alternative therapies, the nurse asks:

Back 338

1. "What herbal supplements have you taken?"
2. "Have you ever used relaxation therapy?"
3. "What types of activities or remedies do you use when you do not feel well?"
4. "Do you use holistic treatments?"

Hint 338

"What types of activities or remedies do you use when you do not feel well?"

Front 339

Which statement is correct regarding complementary and alternative medicine?

Back 339

1. one third to one half of the US population uses one or more forms of alternative therapy
2. decreasing amounts of insurance coverage are available to meet the needs of alternative therapies
3. discussion of alternative therapies is still not provided in traditional medical journals
4. integration of alternative therapies is regulated by state and national agencies

Hint 339

one third to one half of the US population uses one or more forms of alternative therapy

Front 340

A benefit that the pt can gain from relaxation therapy is a decrease in:

Back 340

1. receptivity
2. peripheral skin temperature
3. oxygen consumption
4. alpha brain activity

Hint 340

oxygen consumption

Front 341

Which factor makes accurate administration of precise dosages of herbs difficult?

Back 341

1. multiple clinical trials are under way
2. availability in many different forms
3. infrequent usage by consumers
4. excessive standardization by international organizations

Hint 341

availability in many different forms

Front 342

Which instruction should be included when teaching a pt about safe herbal product usage?

Back 342

1. "Combine several herbs to maximize the benefits."
2. "Believe all claims made by the manufacturer."
3. "Continue using herbs if side effects develop because they will diminish."
4. "Inform your primary care provider of all herbal products you use."

Hint 342

"Inform your primary care provider of all herbal products you use."

Front 343

A method of stimulating certain points on the body by the insertion of special needles to modify the perception of pain, normalize physiologic functions, or treat or prevent disease is known as:

Back 343

1. acupressure
2. magnet therapy
3. acupuncture
4. chiropractic therapy

Hint 343

acupuncture

Front 344

Patient teaching about herbal therapies should address which statement?

Back 344

1. inform the primary care provider of any drugs being used, including herbal remedies
2. active ingredients per dose are always the same
3. there are numerous clinical trials on the benefits and side effects of herbs, enabling clinicians to be well informed in recommending an herb or cautioning against it
4. taking herbs does not require cautious use and results in few side effects

Hint 344

inform the primary care provider of any drugs being used, including herbal remedies

Front 345

Which is a contraindication for the use of reflexology?

Back 345

1. taking chemotherapy for cancer
2. general "tune-up"
3. pregnancy, presurgical status, and postsurgical status
4. presence of heart problems, blood pressure problems, epilepsy, or diabetes

Hint 345

presence of heart problems, blood pressure problems, epilepsy, or diabetes

Front 346

Many complementary therapies, such as acupuncture, use diagnostic and therapeutic methods specific to their field, whereas others, such as _______, are more easily learned and applied.

Back 346

1. massage therapy
2. Chinese medicine
3. shamanism
4. breathwork and imagery

Hint 346

breathwork and imagery

Front 347

What does holistic nursing address and treat?

Back 347

1. mind, body, and spirit of the pt
2. disease, spirit, and family
3. desires and emotion of the pt
4. muscles, nerves, and spinal disorders

Hint 347

mind, body, and spirit of the pt

Front 348

One of the principles of complementary and alternative medicine (CAM) therapies is that the individual becomes:

Back 348

1. actively involved in the treatment
2. a total believer in what is being taught
3. submissive to the practitioner
4. less competent in his or her own care

Hint 348

actively involved in the treatment

Front 349

The herb comfrey is sometimes used by patients for its wound healing properties. It is important that the nurse inform the patient that this herb:

Back 349

1. should be taken internally
2. may cause cancer
3. can only be used externally
4. is a known antiseptic

Hint 349

is a known antiseptic

Front 350

Patients with certain medical diagnoses should avoid chiropractic treatment. These diagnoses include:

Back 350

1. joint sublaxation
2. vertigo
3. osteoporosis
4. hypertension

Hint 350

osteoporosis

Front 351

Imagery is used to:

Back 351

1. gain relief for skin diseases
2. control and relieve pain
3. treat cardiac dysrhythmias
4. gain relief from alcohol addiction

Hint 351

control and relieve pain

Front 352

A pt tells the nurse that he takes the herb St. John's wort for mild depression. It is important that the nurse inform the pt that he should avoid consuming:

Back 352

1. foods high in salt or sodium
2. milk products
3. anything containing barley, such as beer
4. aged cheese and red wine

Hint 352

anything containing barley, such as beer

Front 353

When preparing for pt care, a student nurse learns that microorganisms are spread by:

Back 353

1. fresh air and sunshine
2. carrying linens away from one's uniform
3. placing soiled linens on the floor
4. using a common handwashing station

Hint 353

placing soiled linens on the floor

Front 354

During the bed bath, the pt is covered with a bath blanket:

Back 354

1. to prevent skin impairment
2. for cosmetic purposes
3. to prevent the spread of microorganisms
4. to prevent chilling

Hint 354

to prevent chilling

Front 355

A pt with sever, crippling rheumatoid arthritis is confined to bed for extended periods. An erythematous and edematous area over the coccyx that has potential to become an open lesion is noted. This is referred to as:

Back 355

1. an inflammatory ulcer
2. a pressure ulcer
3. a stasis ulcer
4. the inner canthus

Hint 355

a pressure ulcer

Front 356

A 64yo pt with terminal cancer is too weak to perform her own perineal care. The student nurse will include bathing which areas as part of perineal care?

Back 356

1. back and buttocks
2. eyes, ears, and nose
3. upper torso and thighs
4. upper thighs, genitalia, and anal area

Hint 356

upper thighs, genitalia, and anal area

Front 357

Which patient would be at greatest risk for skin impairment?

Back 357

1. child on bed rest
2. infant with cool skin temperature
3. young man with diarrhea
4. a 60yo in a body cast

Hint 357

child on bed rest

Front 358

A 52yo pt is in her second postoperative day after an abdominal hysterectomy. The nurse plans to give the pt a bed bath. When caring for the patient's face, the nurse will:

Back 358

1. use only water
2. ask the pt her preference
3. use soap in all areas except the eyes
4. use a cleansing cream

Hint 358

ask the pt her preference

Front 359

When bathing a 12yo pt with a leg cast, the nurse is aware that proper eye care would be:

Back 359

1. to wash from the outer canthus to inner canthus
2. to cleanse dried exudate with hot water
3. to avoid drying out circumorbital area after washing
4. to use a different section of washcloth for each eye

Hint 359

to use a different section of washcloth for each eye

Front 360

A pt with heart failure is stabilizing well and states that he would enjoy a tub bath. The nurse assists the pt with filling the bathtub. The correct water temperature is:

Back 360

1. 109.4F
2. 110 to 115F
3. 98 to 100F
4. 85-98C

Hint 360

109.4F

Front 361

An 11 month old infant is admitted with a tympanic temperature of 105F. The physician orders a tepid sponge bath. The purpose of the tepid sponge bath is to:

Back 361

1. reduce temperature in febrile patients
2. cleanse the pt's groin and axillary areas
3. stimulate circulation to the skin
4. calm and relax the pt

Hint 361

reduce temperature in febrile pts

Front 362

An 80yo uncircumcised man is in the first postoperative day after a transurethral prostatectomy. When administering perineal care, the nurse will:

Back 362

1. retract the foreskin, cleanse the penis, and allow the foreskin to return to its former position
2. sprinkle powder under the foreskin to facilitate retraction
3. leave the foreskin slightly damp to allow retraction to its former state
4. retract the foreskin, cleanse the penis, and return the foreskin with a gentle forward motion

Hint 362

retract the foreskin, cleanse the penis, and return the foreskin with a gently forward motion

Front 363

A 50yo pt was discharged home with a Foley catheter. The student nurse instructs the pt in the proper procedure for cleansing the female perineal area by teaching her to:

Back 363

1. cleanse the area in circular motions around the rectum
2. cleanse from the rectum toward the pubis
3. cleanse from the pubis toward the rectum
4. cleanse in circular motions around the vaginal area

Hint 363

cleanse from the pubis toward the rectum

Front 364

Which pt is most at risk for complications of the feet?

Back 364

1. a young man in a career that requires standing
2. a disoriented, older adult man
3. a 60yo person with DM
4. a 62yo pt with total hip replacement

Hint 364

a 60yo person with DM

Front 365

An 82yo pt is unconscious and requires meticulous oral hygiene. The optimal position for providing oral hygiene to the pt is ______ to prevent choking.

Back 365

1. high Fowler's position
2. high Fowler's position with the head hyperextended
3. supine with the head lowered
4. side-lying with head facing to the side

Hint 365

side-lying with head facing to the side

Front 366

A 72yo pt has diffuse pancreatitis. The nurse will cleanse her ears while giving her a soothing bed bath. Which intervention for cleansing her ears is correct?

Back 366

1. cleansing the outer ear with the washcloth during the bath
2. retracting the outer ear downward to loosen visible cerumen
3. irrigating to remove tenacious cerumen
4. using cotton-tipped applicators to remove cerumen

Hint 366

cleansing the outer ear with the washcloth during the bath

Front 367

The student nurse has completed her educational instructions on the correct procedures for bedmaking. Which intervention is correct for bedmaking?

Back 367

1. preparing a closed bed for receiving postoperative pts
2. shaking soiled linen before placement in the hamper
3. mitering the corners of the bottom fitted sheet
4. washing hands thoroughly after handling soiled linen

Hint 367

washing hands thoroughly after handling soiled linen

Front 368

A retired dentist has been admitted to the hospital for thrombophlebitis of his left leg. Which stroke will you use when finishing his back rub?

Back 368

1. long, firm strokes across the width of the back
2. light strokes while moving up the back in a circular motion
3. long, smooth strokes along the length of the back
4. circular motion upward from buttocks to shoulder

Hint 368

long, smooth strokes along the length of the back

Front 369

An 82yo pt is in his first postoperative day after lysis of adhesions. As part of his morning care, the nurse will remove and cleanse his dentures. Which of the following techniques is correct?

Back 369

1. work over an open sink convenient to the water faucet
2. rinse dentures thoroughly with hot water
3. brush dentures with a soft toothbrush
4. hold dentures securely in the palm of the hand

Hint 369

brush dentures with a soft toothbrush

Front 370

The nurse will position the patient in the 30 degree lateral position to prevent pressure ulcers over the:

Back 370

1. spinous processes
2. ischial tuberosities
3. greater trochanters
4. occipital prominence

Hint 370

greater trochanters

Front 371

Stage III pressure ulcers are identified as:

Back 371

1. nonblanchable reddened areas where the skin is intact
2. full-thickness skin loss extending to but not through the fascia
3. extensive destruction of skin and muscle with possible sinus tracts
4. areas of full-thickness skin loss with possible extension to the bone

Hint 371

full-thickness skin loss extending to but not through the fascia

Front 372

The pt has been changing a dressing on a pressure ulcer for several days and is now being seen in the physician's office. The pt states, "There is a lot of pink tissue at the base of the ulcer." The nurse expects this is due to:

Back 372

1. improper dressing technique and probable infection
2. presence of a layer of eschar that has to be removed
3. development of a fungal overgrowth interfering with healing
4. the normal process of healing with healthy granulation tissue

Hint 372

the normal process of healing with healthy granulation tissue

Front 373

In addition to bathing, which intervention is likely to best promote patient comfort?

Back 373

1. books or tapes
2. back rub
3. snacks
4. postural drainage

Hint 373

back rub

Front 374

Pts will experience conditions that threaten the integrity of oral mucosa; therefore:

Back 374

1. less oral hygiene is needed
2. more frequent mouth care is needed
3. no mouth care is to be performed
4. no antiinfective agents are to be used

Hint 374

more frequent mouth care is needed

Front 375

The goal of meticulous foot care for pts is to:

Back 375

1. prevent injury to the toes and feet
2. provide routine cleaning of the feet and nails
3. monitor the healing process of foot ulcers
4. determine if the pt's shoes are the proper size

Hint 375

prevent injury to the toes and feet

Front 376

When providing hygiene to the older adult, it is important to remember that the older adult's skin is:

Back 376

1. fragile with decreased elasticity
2. fragile with increased elasticity
3. fragile with increased circulation
4. fragile with increased muscle mass

Hint 376

fragile with decreased elasticity

Front 377

Which tissues are most vulnerable to pressure?

Back 377

1. skin and cartilage
2. skin and muscle tissue
3. skin and subcutaneous tissue
4. muscle and subcutaneous tissue

Hint 377

skin and muscle tissue

Front 378

Which statement about moisture is correct?

Back 378

1. topical moisture barriers protect the skin from breakdown and impairment
2. evidence indicates that topical moisture barriers cause skin rashes
3. excess moisture promotes wound healing and prevent skin impairment
4. dry skin is resistant to breakdown

Hint 378

topical moisture barriers protect the skin from breakdown and impairment

Front 379

The color of eschar is:

Back 379

1. pink or red
2. pale, almost white
3. tan, brown, or black
4. yellow, gray, or green

Hint 379

tan, brown, or black

Front 380

When assessing the skin of a pt with dark skin, it is best to have which source of light?

Back 380

1. halogen
2. fluorescent
3. soft
4. sunlight

Hint 380

fluorescent

Front 381

Staging a pressure ulcer is not possible if:

Back 381

1. the ulcer is full thickness and the wound bed is covered with brown eschar
2. skin is intact with a blood-filled blister present that is cool to the touch
3. bone is exposed with yellow slough present in parts of the wound bed
4. subcutaneous fat is visible, along with tissue undermining

Hint 381

skin is intact with a blood-filled blister present that is cool to the touch

Front 382

A 64yo pt who is newly diagnosed with DM has been learning how to perform her own blood glucose monitoring. The nurse is aware that having the pt hold her arm at her side for 30 seconds before obtaining a blood sample to measure glucose will:

Back 382

1. increased blood to the site
2. provide easy access to device
3. prepare the site
4. prevent needle puncture of the nurse

Hint 382

increased blood to the site

Front 383

A sputum specimen has been ordered for a 75yo pt admitted with possible pneumonia of the right lower lobe. The pt is not able to cough. For pts who cannot expectorate sputum from deep in the bronchial tree, it is necessary to collect the specimen by:

Back 383

1. pharyngeal suctioning
2. nasotracheal suctioning
3. oropharyngeal suctioning
4. percussion and vibration

Hint 383

nasotracheal suctioning

Front 384

The physician has ordered a stool specimen for blood that it is not possible to see with the naked eye. This examination is for:

Back 384

1. profuse bleeding
2. gross blood
3. melena
4. occult blood

Hint 384

occult blood

Front 385

A 46yo pt is seen by the physician for recurrent symptoms of cystitis. He is to have a urine culture and sensitivity determination and a 24 hour urine collection for laboratory analysis. A urine culture study is required to:

Back 385

1. identify the causative organisms
2. determine the presence of malignant cells
3. analyze the elements present in the urine
4. localize the site of the inflammatory process

Hint 385

identify the causative organisms

Front 386

To obtain a 24 hour urine specimen, which instruction should be given to the pt?

Back 386

1. collect each voiding in separate containers for the next 24 hours
2. discard the first voided specimen and then collect the total volume of each voiding for 24 hours
3. for the next 24 hours, retain a 30mL specimen of each voiding after recording the amount voided
4. keep a record of the time and the amount of each voiding for 24 hours

Hint 386

discard the first voided specimen and then collect the total volume of each voiding for 24 hours

Front 387

A 72yo pt has an indwelling urinary catheter. A sterile urine specimen has been ordered for a culture and sensitivity. The nurse will obtain the sterile specimen by:

Back 387

1. obtaining 60mL of urine from the collection bag
2. removing the present catheter, having the pt void, and then recatherterizing
3. disconnecting the tubing from the catheter and draining 2mL of urine
4. aspirating 10mL of urine with a sterile syringe from the tubing port

Hint 387

aspirating 10mL of urine with a sterile syringe from the tubing port

Front 388

A pt performing a fingerstick for blood glucose determination asks why the side of the fingertip is advised as the preferred site. The nurse knows that it is because:

Back 388

1. the blood supply is greater in this area
2. it is easier for the self-determination method
3. the side of the finger is less responsive to pain than other sites
4. it leaves more room for other site selection

Hint 388

the side of the finger is less responsive to pain than other sites

Front 389

An important preexamination nursing intervention for the pt undergoing an invasive diagnostic examination is:

Back 389

1. a cleansing bath with Hibiclens
2. obtaining the informed consent
3. encouraging the pt to drink several glasses of water
4. instructing the pt not to wear deodorant, powder, or lotion

Hint 389

obtaining the informed consent

Front 390

A pt is scheduled for an upper GI series and a barium enema. The nurse explains that because of the procedure for an upper GI study and barium enema, the pt can expect to:

Back 390

1. be NPO after midnight and have a series of enemas
2. have coffee and toast the morning of the test
3. take radiographic dye tablets
4. have a needle inserted into the liver

Hint 390

be NPO after midnight and have a series of enemas

Front 391

The physician has ordered a urine sample to be collected. The nurse will have to:

Back 391

1. verify whether this is to be a sterile sample
2. instruct the pt to save all urine for the next 24 hours
3. choose a 20mL syringe to aspirate urine from the catheter bag
4. request that the pt use the bedpan for collection of the sample

Hint 391

verify whether this is to be a sterile sample

Front 392

Before obtaining a blood sample, the nurse will first:

Back 392

1. verify the pt identification
2. ask the pt which arm is best to use
3. reassure the pt that the procedure will not be painful
4. clean the pt's skin thoroughly according to agency protocol

Hint 392

verify the pt identification

Front 393

On evaluation of the pt after a venipuncture, the nurse notes which occurrence as an unexpected outcome?

Back 393

1. pt's heart rate is 80 and regular
2. soft lump is noted under the skin at the venipuncture site
3. pt complains of a stinging sensation after the needle is removed
4. small amount of blood is noted on the skin over the venipuncture site

Hint 393

soft lump is noted under the skin at the venipuncture site

Front 394

The pt tells the nurse, "i have a very hard time getting a drop of blood from my finger for the blood sugar test." The nurse will:

Back 394

1. ask the physician to order a different type of blood glucose monitoring system
2. suggest that the pt use warm water on the finger just before using the blood lancet
3. instruct the pt to use the same puncture site several times in a row for best results
4. remind the pt that it is acceptable to skip blood glucose monitoring once in a while

Hint 394

suggest that the pt use warm water on the finger just before using the lancet

Front 395

The nurse notes that the pt does not require further teaching regarding home use of stool testing for occult blood when the pt states:

Back 395

1. "It is best if I can get two separate samples from the same stool."
2. "I need to apply a very thick smear of stool onto the guaiac slide."
3. "There is an electronic meter or blood sample required for this test."
4. "If the paper turns white after the stool is on it, I need to call my doctor."

Hint 395

"It is best if I can get two separate samples from the same stool."

Front 396

The nurse has just completed attaching the leads for an electrocardiogram. The next step is to:

Back 396

1. perform hand hygiene and don clean gloves
2. position the pt lying supine
3. obtain the tracing
4. raise the side rail and lower bed to lowest position

Hint 396

obtain the tracing

Front 397

When obtaining a midstream urine specimen from a female pt, which instructions will be most important to tell the pt?

Back 397

1. start voiding directing into the sterile cup
2. discard the last of the stream of urine into the stool
3. wash hands before obtaining specimen
4. wipe from front to back when cleansing the urethral area

Hint 397

wipe from front to back when cleansing the urethral area

Front 398

When nursing action is essential before a chest x-ray film is obtained?

Back 398

1. make certain the pt doesn't eat or drink
2. remove the pt's metal necklace
3. have the pt swallow contrast medium
4. administer a dose of medication for pain relief

Hint 398

remove the pt's metal necklace

Front 399

A nursing student asks the nurse to explain the difference in testing between a midstream urine specimen and a urinalysis. The nurse explains that the midstream specimen is commonly used to perform a test for:

Back 399

1. culture and sensitivity of the urine specimen
2. measuring the specific gravity of the urine
3. determining the presence of glucose and ketones in the urine
4. checking the urine for the presence of WBCs and RBCs

Hint 399

culture and sensitivity of the urine specimen

Front 400

Which method will determine the correct distance to insert a nasogastric tube?

Back 400

1. measure from center of forehead to top of nose to end of sternum
2. measure from tip of nose to tip of earlobe to end of sternum
3. measure from lips to tip of ear to just below the umbilicus
4. measure from tip of ear to midway between end of sternum and umbilicus

Hint 400

measure from tip of nose to tip of earlobe to end of sternum

Front 401

After inserting a nasogastric tube, it is possible to be certain it is in the proper place if:

Back 401

1. the pt no longer complains of pain or nausea
2. it is possible to inject 30mL of normal saline with ease
3. bubbles occur when the tube is submerged into water
4. gastric contents are aspirated with cone-tipped syringe

Hint 401

gastric contents are aspirated with cone-tipped syringe

Front 402

A pt diagnosed with throat cancer is 2 days postoperative and has a tracheostomy. Which part of the tracheostomy tube is removed for cleaning?

Back 402

1. outer cannula
2. inner cannula
3. single lumen tube
4. double lumen tube

Hint 402

inner cannula

Front 403

What safety precaution must be taken for a pt who has a tracheostomy tube?

Back 403

1. keep a crash cart in the room
2. be prepared to put him on a ventilator
3. keep curved hemostat at the bedside
4. be prepared to remove the tube

Hint 403

keep curved hemostat at the bedside

Front 404

If, when suctioning the pt, it becomes necessary to repeat the interventions, it is recommended that the nurse wait at least 3 minutes to allow for:

Back 404

1. overcoming fatigue
2. numbing of mucous membranes
3. replenishing oxygen
4. subsiding of pain

Hint 404

replenishing oxygen

Front 405

Preoperatively the physician orders "enemas until clear." The maximum number of enemas the nurse can give without further orders is:

Back 405

1. two
2. three
3. five
4. unlimited

Hint 405

three

Front 406

The most serious problem that is possible to develop with the use of a condom catheter is:

Back 406

1. skin impairment resulting from accumulation of moisture
2. restriction of blood supply to the penis
3. pt will perhaps not be able to keep the catheter as clean as necessary
4. urine leakage resulting from an ill-fitting catheter

Hint 406

restriction of blood supply to the penis

Front 407

What is the most suitable method for the nurse to use to prevent transmission of HIV or hepatitis B, C, and D during procedures associated with IV therapy?

Back 407

1. wear gloves
2. wear goggles
3. use povidone-iodine for preparing the skin
4. use sterile tape for dressings over venipuncture site

Hint 407

wear gloves

Front 408

Ear irrigation is a common procedure implemented to remove cerumen from the external ear canal. When irrigating the ear:

Back 408

1. proceed in a gentle manner
2. insert the entire tip of the syringe into the ear canal
3. use enough force to remove the wax or foreign body
4. position the pt on the unaffected side

Hint 408

proceed in a gentle manner

Front 409

A pt is receiving oxygen at a rate of 1.5L/min via NC. Which nursing intervention is indicated because the patient has a NC?

Back 409

1. assess nares for skin impairment every 6 hours
2. assess patency of the cannula every 2 hours
3. inspect the oral cavity every 6 hours
4. check oxygen flow and orders every 24 hours

Hint 409

assess patency of the cannula every 2 hours

Front 410

A more precise oxygen concentration is possible to achieve using a:

Back 410

1. nasal cannula
2. simple face mask
3. venturi mask system
4. plastic face mask and inflated reservoir bag

Hint 410

venturi mask system

Front 411

The unit manager orienting a new staff nurse evaluates which technique as appropriate for nasotracheal suctioning?

Back 411

1. placing the pt in a supine position
2. preparing for a clean or unsterile technique
3. suctioning the oropharyngeal area first, then the nasotracheal area
4. applying intermittent suctioning for 10 seconds during catheter removal

Hint 411

applying intermittent suctioning for 10 seconds during catheter removal

Front 412

What is a priority for the nurse when teaching a family about home oxygen therapy?

Back 412

1. pathophysiology of the patient
2. use of the equipment
3. oximetry readings
4. length of time the oxygen is to be used

Hint 412

use of the equipment

Front 413

what is important in the site selection for a new IV line?

Back 413

1. starting with the most proximal site
2. looking for hard, cordlike veins
3. using sites away from a dialysis graft
4. selecting the dominant arm

Hint 413

using sites away from a dialysis graft

Front 414

A pt has IV therapy for the administration of antibiotics and states that the IV site hurts and is swollen. Which data will tend to confirm phlebitis as opposed to infiltration?

Back 414

1. intensity of pain
2. warmth of skin surrounding IV site
3. amount of subcutaneous edema
4. skin discoloration resembling bruising

Hint 414

warmth of skin surrounding IV site

Front 415

A pt complains of a headache and nausea and vomiting during a blood transfusion. Which action is it necessary for the nurse to take immediately?

Back 415

1. check the VS
2. stop the blood transfusion
3. slow down the rate of blood flow
4. notify the physician and the blood bank personnel

Hint 415

stop the blood transfusion

Front 416

Which is the least invasive alternative to urethral catheterization?

Back 416

1. suprapubic catheterization
2. reinsertion of a Foley catheter
3. catheter irrigation
4. condom catheterization

Hint 416

condom catheterization

Front 417

What is appropriate for the nurse to incorporate into the teaching plan for a pt with an incontinent urinary diversion?

Back 417

1. the pt will need to order special clothing to fit around the stoma
2. a stomal pouch will need to be worn only at night
3. special skin care is a priority
4. a reduction in physical activity will be planned

Hint 417

special skin care is a priority

Front 418

The nursing instructor is supervising a student during the catheterization of a female pt. What is determined to be an appropriate part of the technique?

Back 418

1. keeping both hands sterile throughout the procedure
2. reinserting the catheter if it was initially misinserted into the vagina
3. inflating the balloon to test it before catheter insertion
4. advancing the catheter 7 to 8 inches

Hint 418

inflating the balloon to test it before catheter insertion

Front 419

A bladder retraining program for a pt in an extended care facility will properly include:

Back 419

1. providing negative reinforcement when the pt is incontinent
2. having the pt wear adult diapers as a preventive measure
3. putting the pt on a q2h toilet schedule during the day
4. promoting the intake of caffeine to stimulate voiding

Hint 419

putting the pt on a q2h toilet scheduling during the day

Front 420

When irrigating a colostomy, the nurse will use a cone that fits properly to prevent:

Back 420

1. introducing air into the colon
2. leaking of the solution from the stoma
3. administering the solution too rapidly
4. introducing bacteria into the stoma

Hint 420

leaking of the solution from the stoma

Front 421

The nurse recognizes which as true concerning ostomies?

Back 421

1. an ileostomy pt will have solid, formed stool
2. a double-barrel ostomy refers to one created for the ileum and one for the colon
3. some pts will have control over when they can evacuate their colon
4. family members or significant others will need to learn the care

Hint 421

some pts will have control over when they can evacuate their colon

Front 422

To secure a condom catheter to the penile shaft appropriately, it is important to apply the device so that the catheter is:

Back 422

1. tight and drained well
2. dependent and draining well
3. secured with adhesive tape applied in a circular pattern
4. snug and secure, but does not cause constriction to blood flow

Hint 422

snug and secure, but does not cause constriction to blood flow

Front 423

In order to maintain proper drainage of an indwelling catheter, it is important to:

Back 423

1. irrigate the catheter every 2 to 4 hours
2. ensure that the collection device is below the bladder level
3. place the tubing under the pt's leg to prevent pulling on the bladder neck
4. demonstrate to the pt how to disconnect the device while ambulating

Hint 423

ensure that the collection device is below bladder level

Front 424

Fecal impactions are best treated by:

Back 424

1. a clear liquid diet
2. cleansing enemas
3. limiting the pt fluid intake
4. oil-retention enemas

Hint 424

oil-retention enemas

Front 425

For optimal results, in which position will the nurse place the pt when administering a cleansing enema?

Back 425

1. supine
2. dorsal recumbent
3. left Sims'
4. prone

Hint 425

left Sims'

Front 426

Which nursing intervention is the most important in preventing the introduction of microorganisms to the pt when initiating an IV?

Back 426

1. hand hygiene
2. checking the identification of the pt
3. ensuring the six rights of medication administration
4. carefully checking the order for the correct IV solution

Hint 426

hand hygiene

Front 427

When assessing an IV site, indications that phlebitis has occurred in include:

Back 427

1. paleness and coolness
2. bleeding from the site
3. slowing of the flow of solution
4. pain and erythema

Hint 427

pain and erythema

Front 428

The ideal needle gauge for a rapid whole blood transfusion is:

Back 428

1. 14- to 16-gauge
2. 18- to 20-gauge
3. 22- to 24-gauge
4. 26- to 28-gauge

Hint 428

18- to 20-gauge

Front 429

It has been 15 minutes since a unit of blood infusion was initiated. Which is most indicative that the pt is experiencing a blood transfusion reaction?

Back 429

1. the pt's blood pressure decreases
2. the pt feels an urgent need to void
3. the pt's skin is pale at the infusion site
4. localized edema is noticed at the infusion site

Hint 429

the pt's blood pressure decreases

Front 430

The nurse is administering a routine enema to an adult pt. The pt complains of cramping and the urge to defecate. Which nursing intervention is the best to carry out?

Back 430

1. quickly finish instilling the rest of the solution
2. briefly stop the instillation
3. instruct the pt to hold his or her breath and bear down
4. immediately discontinue the instillation and withdraw the enema tubing from the rectum

Hint 430

briefly stop the installation

Front 431

When providing indwelling catheter care, what areas are most important to be cleansed?

Back 431

1. the perineal area
2. the area surrounding the urinary meatus
3. the labia majora and the labia minora
4. the perineal area and 2 inches of the catheter

Hint 431

the area surrounding the urinary meatus

Front 432

Which pt will be at the greatest risk of complications from heat or cold therapy?

Back 432

1. a diabetic pt with peripheral neuropathy
2. a cardiac pt with peripheral vascular disease
3. a pt who is unconscious following a motor vehicle accident
4. a pt who is hard of hearing and is unable to speak

Hint 432

a pt who is unconscious following a motor vehicle accident

Front 433

The Infusion Nurses Society (INS) suggests changing IV tubing on peripheral lines in a facility with an IV-related infection rate of 3% every:

Back 433

1. 24 hours
2. 48 hours
3. 72 hours
4. 96 hours

Hint 433

24 hours

Front 434

A 35yo pt is healthy but wishes to lose weight because her BMI is 27. Which suggestions are more appropriate for her?

Back 434

1. this BMI is too low for good health; the pt will possibly need to supplement her diet to increase her weight
2. this is an acceptable BMI, and it is best to maintain weight at this level for continued good health
3. appropriate weight loss is possible with a healthy, reduced calorie diet and incorporating at least 30 minutes of physical activity into each day
4. this BMI is elevated to the point that adjunct treatments, such as surgery, will be of possible benefit

Hint 434

appropriate weight loss is possible with a healthy, reduced calorie diet and incorporating at least 30 minutes of physical activity into each day

Front 435

A 10yo has an elevated BMI. Which suggestions are most appropriate to help him with his weight management?

Back 435

1. encourage a low calorie diet that allows for moderate weight loss of no more than 2 pounds per week
2. encourage the avoidance of sweets and snack food and limit eating to only three meals per day
3. encourage using the www.mypyramid.gov website to help plan a healthy diet,and suggest limiting TV viewing time
4. encourage family therapy to assess the reasons for excessive weight gain in such a young person

Hint 435

encourage using the www.mypyramid.gov website to plan a healthy diet, and suggest limiting TV viewing time

Front 436

A pt takes medication for hypertension and asks if there is anything possible to do with his diet to help reduce his blood pressure. The best response is:

Back 436

1. "A low fat, low cholesterol diet with only a limited amount of simple sugars will have the greatest effect on your blood pressure."
2. "A salt free diet will have the greatest effect on your blood pressure. Don't add salt in your cooking or at the table."
3. "Adequate calcium and potassium intake, as well as lower sodium intake, offers some possibility of helping your blood pressure. Eat plenty of fruits, vegetables, and low fat milk products."
4. "Discontinue the use of processed foods, and buy only natural foods. That way, you will have less sodium in your diet."

Hint 436

"Adequate calcium and potassium intake, as well as lower sodium intake, offers some possibility of helping your blood pressure. Eat plenty of fruits, vegetables, and low fat milk products."

Front 437

A cancer pt is experiencing anorexia and weight loss. Which suggestions are most likely to help him increase intake and prevent weight loss?

Back 437

1. encourage him to eat double portions at each meal
2. suggest he snack often on high kilocalorie foods
3. encourage him to eat the lower kilocalorie foods first
4. suggest that he decrease his exercise

Hint 437

suggest he snack often on high kilocalorie foods

Front 438

A pt with type 2 diabetes obese and has an elevated blood cholesterol. Which goals for nutrition therapy are most appropriate for this pt?

Back 438

1. encourage her to focus her efforts on achieving healthy blood glucose and lipid levels and to include regular exercise
2. educate her on how to adjust her insulin injections to better integrate with her usual eating and exercise patterns
3. train her on how to recognize and treat hypoglycemia
4. encourage her to reduce sodium intake and increase potassium intake to help control blood pressure

Hint 438

encourage her to focus her efforts on achieving healthy blood glucose and lipid levels and to include regular exercise

Front 439

A pt with lactose intolerance still wants to include dairy products in her diet. Which suggestions offer the possibility of enabling her to do this?

Back 439

1. consume vitamin C at the same times as dairy products to increase absorption
2. take calcium supplements with each meal
3. consume small portions of fermented dairy products such as cheese or yogurt
4. use skim milk rather than whole milk products

Hint 439

consume small portions of fermented dairy products such as cheese or yogurt

Front 440

A pt with iron deficiency anemia started taking iron supplements but is also trying to increase iron absorption. What will enhance iron absorption?

Back 440

1. drinking milk or taking calcium supplements at the same time as eating iron rich foods
2. taking iron supplements with coffee, tea, or red wine
3. consuming vitamin C rich foods at the same meal with iron containing foods
4. taking iron supplements with a high fiber bran cereal

Hint 440

taking iron supplements with coffee, tea, or red wine

Front 441

A pt with arthritis has been using aspirin on a daily basis for the past 5 years. What effect does aspirin sometimes have on nutritional status?

Back 441

1. it will sometimes increase energy metabolism, thus increasing kilocalorie needs
2. it will sometimes cause loss of appetite and taste bud changes
3. it will sometimes lead to decreased excretion of potassium
4. it will sometimes increase excretion of vitamin C and possibly lead to loss of iron from the GI tract

Hint 441

it will sometimes increase excretion of vitamin C and possibly lead to loss of iron from the GI tract

Front 442

A newly married pt planning for pregnancy has heard that some experts recommend folic acid supplements for women of childbearing age. What is the reason for this recommendation?

Back 442

1. folic acid may help prevent neural tube defects in the developing fetus
2. folic acid provides extra kilocalories for the synthesis of new cells
3. it is impossible to receive adequate amounts of folic acid in the diet
4. folic acid will help increase iron absorption in the GI tract

Hint 442

folic acid may help prevent neural tube defects in the developing fetus

Front 443

A pt is trying to substitute unsaturated fats in place of saturated fats in his diet. He asks how to identify an unsaturated fat. What are properties of unsaturated fats that will help him?

Back 443

1. they are bonded together with chemical bonds that the body is not able to digest
2. they include tropical oils and hydrogenated fats and are solid at room temperature
3. they are from plant sources and are liquid at room temperature
4. they contain dietary cholesterol

Hint 443

they are from plant sources and are liquid at room temperature

Front 444

A nurse is caring for a pt who has just been diagnosed with type 2 DM. The pt is concerned about the dietary changes she will need to make for her condition and asks the nurse to tell her about the diet. Which actions are appropriate and within the scope of practice for a nurse?

Back 444

1. review the pt's chart, and recommend a calorie and carbohydrate intake based on blood glucose and lipid values
2. discuss the rationale for and the general principles of the diabetic diet with the pt, and then communicate the pt's concerns to the registered dietitian and physician
3. locate the physician's diet order in the medical chart, and then obtain a preprinted diet sheet showing the exchange lists for meal planning and a menu pattern based on the prescribed calorie level
4. decline to comment on the diet because the nurse is not a trained professional in the area of nutrition; refer all questions to a registered dietitian

Hint 444

discuss the rationale for and the general principles of the diabetic diet with the pt, and then communicate the pt's concerns to the registered dietitian and physician

Front 445

A 40yo pt was recently diagnosed with type 2 diabetes. He is in the hospital for tests and is receiving a diabetic diet. His wife expresses concern because she notices cookies on his lunch tray. Which response best describes current recommendations for the use of concentrated sweets in the diabetic diet?

Back 445

1. "Sugars and sweets are permitted in moderation in the diabetic diet. The important thing is that the total carbohydrate content of the meal is controlled and balanced with your husband's medication and nutrient needs."
2. "I can understand your concern. Sugars are more rapidly absorbed and have the capacity to raise blood glucose levels more quickly than other carbohydrates. I will check with the kitchen and see if your husband received the wrong tray."
3. "I'm sure that if the cookies were on the meal tray that they must be allowed in the diet. They are probably low in sugar. There is likely no need for concern."
4. "Sugar is used to treat hypoglycemia-low blood sugar. Perhaps your husband had a low blood sugar reading before breakfast, and the dietitian sent up the cookies to give him some extra sugar on his lunch meal tray."

Hint 445

"Sugars and sweets are permitted in moderation in the diabetic diet. The important thing is that the total carbohydrate content of the meal is controlled and balanced with your husband's medication and nutrient needs."

Front 446

The physician has recommended that the pt increase the amount of fiber in her diet to help control her blood cholesterol levels. Which guidelines are most appropriate for increasing water-soluble fiber in the diet?

Back 446

1. choose a daily fiber supplement that contains no artificial additives and preservatives; follow the instructions on the container, and be sure to drink plenty of water.
2. choose foods that are closer to their whole state rather than refined or processed, including more fruits, oats, and legumes to increase soluble fiber; and drink plenty of water
3. choose more vegetables, vegetable juices, whole wheat, and whole wheat products to increase soluble fiber; and drink plenty of water
4. choose more fruit juices to provide both fluid and fiber; and include iron fortified breakfast cereals to enhance the absorption of fiber from the fruit juice.

Hint 446

choose foods that are closer to their whole state rather than refined or processed, including more fruits, oats, and legumes to increase soluble fiber; and drink plenty of water

Front 447

A pt is controlling his blood cholesterol through diet. He is familiar with food sources of saturated fat and cholesterol, but is confused about trans fatty acids. Which group of foods contributes the most TRANS fatty acids?

Back 447

1. butter, cream, fats in meats, and tropical oils such as palm and coconut oils
2. fish oils, nuts and seeds, and vegetable oils such as olive oil and canola oil
3. stick margarines, shortening, deep fried restaurant foods, and commercially prepared baked goods
4. liquid margarines, vegetable oil spreads, and vegetable oils such as corn, soybean, and cottonseed

Hint 447

stick margarines, shortening, deep fried restaurant foods, and commercially prepared baked goods

Front 448

A pt with a family hx of osteoporosis is taking calcium supplements and practicing good health habits to reduce her risk of developing osteoporosis. Which practice would negatively affect calcium balance?

Back 448

1. taking small doses of calcium throughout the day rather than one large dose
2. choosing plenty of milk products, and avoiding excess caffeine intake
3. consuming a high protein diet
4. consuming a diet that is moderate in sodium

Hint 448

consuming a high protein diet

Front 449

A 14yo pt is a good student and has been actively involved in school activities and sports. Currently her weight is an appropriate range for her age and height; however, her mother has been concerned that the pt is developing an eating disorder and describes some of her behaviors to the nurse. Which set of symptoms and signs will give cause to investigate the possibility of an eating disorder?

Back 449

1. change of peer groups. spending less time at home and participating in fewer family meals. staying out past curfew with friends. challenging the family rules
2. increased interest in appearance-spending long periods in the morning getting ready for school. feeling embarrassed about changes in her body. consuming more fast foods and snack foods and eating less at mealtimes
3. increased competitive drive to perform well in both athletics and school with increased amount of time spent in training for sports. choosing to eliminate meat from her diet. criticism of family meal choices
4. increased interest in preparing foods for others and calorie counting. exhibiting peculiar eating rituals at the table. expressing disgust with body size. gradual withdrawal from friends and social activities

Hint 449

increased interest in appearance-spending long periods in the morning getting ready for school. feeling embarrassed about changes in her body. consuming more fast food and snack foods and eating less at mealtimes

Front 450

A 14yo trauma pt has just been started on nasogastric tube feedings. Shortly after administration of the formula begins, the pt complains of nausea and abdominal cramps. What should the nurse suspect?

Back 450

1. the formula rate, strength, or volume is possibly too great.
2. the temperature of the formula is too high, and it is best to chill the formula before administration
3. gastric emptying has been delayed, and it is necessary to stop the tube feeding
4. perhaps the feeding tube is emptying into the lung rather than the stomach

Hint 450

the formula rate, strength, or volume is possibly too great

Front 451

A pt in the early stages of pregnancy is experiencing some nausea and vomiting. Which suggestion would NOT be appropriate for the nurse to recommend?

Back 451

1. limit foods with strong odors, and avoid food odors that bother you
2.take a high dose vitamin B6 supplement three times a day
3. try consuming five or six smaller meals each day, and include a source of protein in each meal
4. try not to let your stomach get completely empty. eat before you are overly hungry

Hint 451

try consuming five or six smaller meals each day, and include a source of protein in each meal

Front 452

A pt has been breastfeeding her infant, who is not 4 months old. She has a family hx of food allergies and asks the nurse for advice regarding the introduction of solid foods. Choose the best response in this situation.

Back 452

1. "When your baby can sit with help or support, it is all right for you to begin introducing solid foods. Be sure to introduce the foods one at a time and wait a few days before introducing another food to observe for any allergic reactions."
2. "Keep feeding only breast milk to your baby for as long as possible. Then begin by introducing fruit juices in a bottle to supplement your breast milk."
3. "When your baby learns to sit up without help or support, it is all right for you to start introducing solid foods. Begin with wheat cereals and egg products, and supplement meals with whole cow's milk from a cup."
4. "As soon as your baby is able to crawl, it is all right for you to begin introducing solid foods. Be sure to avoid all foods for which you know your family has allergic reactions."

Hint 452

"When your baby can sit with help or support, it is all right for you to begin introducing solid foods. Be sure to introduce the foods one at a time and wait a few days before introducing another food to observe for any allergic reactions."

Front 453

The public health nurse is conducting a screening for metabolic syndrome. Which pt has a cluster of risk factors that meets the diagnostic criteria for metabolic syndrome?

Back 453

1. Mrs. JP: BP of 146/78mmHg; triglycerides of 85mg/dL; HDL cholesterol of 46mg/dL; fasting blood glucose of 64mg/dL; waist circumference of 32 inches
2. Mrs. LB: waist circumference of 42 inches; fasting blood glucose of 102mg/dL; bP of 128/80mmHg; triglycerides of 148mg/dL; HDL cholesterol of 46mg/dL
3. Mr. B: triglycerides of 78mg/dL, on lipid lowering medication; HDL cholesterol of 55mg/dL; BP of 110/66mg/dL; waist circumference of 36 inches; fasting blood glucose of 90mg/dL
4. Mrs. M: waist circumference of 38 inches; fasting blood glucose of 96mg/dL, on glucose lowering medication; BP of 136/72mmHg; triglycerides of 160mg/dL; HDL cholesterol of 40mg/dL

Hint 453

Mrs. M: waist circumference of 38 inches; fasting blood glucose of 96mg/dL, on glucose lowering medication; BP of 136/72mmHg; triglycerides of 160mg/dL; HDL cholesterol of 40mg/dL

Front 454

Adequate nutrition is important in a pt's recovery and overall health. An older adult stroke pt who has lost the use of his dominant hand is having trouble eating without help. In this situation, which of the following actions will be the most helpful to encourage intake?

Back 454

1. tell the pt where each food is located on his plate by using the number on a clock as a reference
2. ask the pt which foods he desires assistance with. encourage the pt to take part in his eating as much as possible
3. after the consistency of the food by pureeing or grinding the foods for ease of chewing
4. stand close to the pt and face him while you feed him

Hint 454

ask the pt which foods he desires assistance with. encourage the pt to take part in his eating as much as possible

Front 455

A middle age pt is in the early stage of renal failure. His physician has recommended that he limit his protein intake to slow the progression of his renal disease. To keep his protein intake adequate, but not excessive, his dietitian has recommended that he choose high quality protein sources to meet his needs. Which group of foods contains the most high quality (or complete) proteins?

Back 455

1. legumes, whole wheat products, oats
2. nuts and seeds, peanut butter, gelatin
3. olive oil, canola oil, flaxseed oil
4. eggs, meats, milk

Hint 455

eggs, meats, milk

Front 456

A pt has just started a weight reduction diet and is aware that increasing physical activity is important for weight loss. She asks the nurse how much and what type of exercises are best for her to incorporate into her weight reduction efforts. Select the answer that best reflects current guidelines:

Back 456

1. "For weight loss, it is recommended that you include 60-90 minutes of physical activity on most days of the week. It may sound like a lot, but you don't have to do it all at once. It is fine to include two or three shorter bouts of activity during the day if it's easier for you. A variety of activities such as walking, gardening, and weight lifting, can count toward your total."
2. "Try to accumulate at least 30 minutes of moderate physical activity most days of the week. Aerobic activities will be the most important for burning calories. Exercises like walking, swimming, cycling, and jogging are aerobic."
3. "For weight loss, it is recommended that you engage in 30 to 60 minutes of vigorous aerobic activity on most days of the week. Vigorous activity will burn the most calories, so it is important to really push yourself in order to reach a point where you are burning fat calories during your workout. One long bout of exercise is probably better than multiple shorter bouts."
4. "When you diet, you often lose muscle mass. As muscle mass decreases, your basal metabolic rate (BMR) may also decrease. The best exercise would be about 30 minutes of daily weight lifting to help prevent muscle loss and keep your BMR from dropping."

Hint 456

"For weight loss, it is recommended that you include 60-90 minutes of physical activity on most days of the week. It may sound like a lot, but you don't have to do it all at once. It is fine to include two or three shorter bouts of activity during the day if it's easier for you. A variety of activities such as walking, gardening, and weight lifting, can count toward your total."

Front 457

An 80yo retired farmer is normally congenial and alert, but when the home health nurse visits he is irritable and appears disoriented. The nurse notices that his eyes appear sunken, he has poor skin turgor, and his mouth is dry. What is the most likely cause of these symptoms?

Back 457

1. heart attack
2. high blood pressure
3. dehydration
4. alcohol abuse

Hint 457

dehydration

Front 458

A 66yo pt has recently been experiencing excessive edema in his feet. The nurse discusses with the pt the dietary changes that are perhaps causing the water retention associated with the pt's edema. Which electrolyte has the greatest influence on water balance in the body?

Back 458

1. sodium (Na+)
2. potassium (K+)
3. chloride (Cl-)
4. calcium (Ca++)

Hint 458

sodium (Na+)

Front 459

Which regulatory system is the body's first line of defense in keeping the pH within normal limits?

Back 459

1. buffers in the blood
2. respiratory system
3. renal system
4. blood pressure

Hint 459

buffers in the blood

Front 460

The most accurate method to use in determining water balance in the body is to:

Back 460

1. weigh the pt daily at the same time each day
2. record an accurate 24 hour I&O
3. ask the pt to document on an I&O form left at the bedside
4. have the same nurse care for the pt each day

Hint 460

weigh the pt daily at the same time each day

Front 461

A pt is concerned about giving her family adequate amounts of potassium in their diets. She asks the nurse to help plan a meal containing foods with potassium. Which diet contains foods with the most potassium?

Back 461

1. baked chicken, green salad, and fresh fruit plate
2. macaroni and cheese, cornbread, and gelatin
3. tacos, chips and salsa, and ice cream
4. seafood plate, marinated vegetables, sponge cake

Hint 461

baked chicken, green salad, and fresh fruit plate

Front 462

The major route of excretion of all electrolytes from the body is via the:

Back 462

1. skin
2. lungs
3. kidneys
4. feces

Hint 462

kidneys

Front 463

Fluid movement in the cells equalizes the ions or the molecules on each side of the the semipermeable membrane. The movement of water from an area of lower concentration to an area of higher concentration occurs through:

Back 463

1. diffusion
2. filtration
3. active transport
4. osmosis

Hint 463

osmosis

Front 464

Tee largest fluid compartment in the body is the:

Back 464

1. intracellular
2. extracellular
3. interstitial
4. intravascular

Hint 464

intracellular

Front 465

Diffusion, osmosis, and filtration are all examples of:

Back 465

1. active transport
2. passive transport
3. ATP energy
4. Krebs cycle

Hint 465

passive transport

Front 466

The term used to indicate hydrogen ion concentration in the body is:

Back 466

1. mEq
2. ATP
3. pH
4. mL

Hint 466

pH

Front 467

The most common cause of hypocalcemia involves a dysfunction of:

Back 467

1. antidiuretic hormone
2. growth hormone
3. parathyroid hormone
4. thyroid hormone

Hint 467

parathyroid hormone

Front 468

A pt has a positive Chvostek's sign. The nurse will expect laboratory tests to reveal:

Back 468

1. total serum calcium of less than 8.9mEq/L
2. total serum calcium of greater than 10.0mEq/L
3. ionized calcium of greater than 5.1mg/dL
4. total serum potassium of less than 3mEq/L

Hint 468

total serum calcium of less than 8.9mEq/L

Front 469

Potassium is responsible for:

Back 469

1. building muscle mass
2. building bone structure and strength
3. neuromuscular and cardiac function
4. maintaining normal blood glucose levels

Hint 469

neuromuscular and cardiac function

Front 470

Neuromuscular signs and symptoms of hypokalemia include:

Back 470

1. confusion and irritability
2. diminished deep tendon reflexes
3. parkinsonian type of tremors
4. carpopedal spasms

Hint 470

diminished deep tendon reflexes

Front 471

Medications to be given when treating hyperkalemia include:

Back 471

1. sodium succinate and mannitol
2. mannitol and regular insulin
3. sodium polystyrene sulfonate (Kayexalate)
4. antacids

Hint 471

sodium polystyrene sulfonate (Kayexalate)

Front 472

Because 1L of fluid equals 2.2 pounds (1kg), a weight change of 2kg (4.4 pounds)will reflect a loss or gain of

Back 472

2 liters

Front 473

When the body senses hypoxemia or hypercapnia (greater than normal amounts of carbon dioxide in the blood), the chemoreceptors in the medulla of the brain stem respond by:

Back 473

1. slowing the respiratory rate
2. decreasing the heart rate
3. increasing the depth and rate of respirations
4. lowering the blood pressure

Hint 473

increasing the depth and rate of respirations

Front 474

Which statements concerning a pt with severe hyperkalemia are correct?

Back 474

1. cardiac arrest is possible, especially when serum potassium levels reach 7mEq/L
2. administer Kayexalate as prescribed by the physician
3. report a urinary output less than 30mL/hr
4. monitor vital signs every 12 hours

Hint 474

cardiac arrest is possible, especially when serum potassium levels reach 7mEq/L; administer Kayexalate as prescribed by the physician; report a urinary output less than 30mL/hr

Front 475

In acute respiratory acidosis, the renal compensatory mechanisms begin to operate within:

Back 475

1. 4 to 6 hours
2. 24 hours
3. 2 to 3 days
4. 1 to 2 hours

Hint 475

24 hours

Front 476

Daily water intake and output (I&O) is approximately how many mL?

Back 476

1. 1500
2. 3500
3. 6500
4. 2500

Hint 476

2500

Front 477

It is necessary for the kidneys to secrete a minimum of how many mL/hr of urine to eliminate waste products from the body?

Back 477

1. 30mL/hr
2. 60mL/hr
3. 20mL/hr
4. 100mL/hr

Hint 477

30mL/hr

Front 478

The normal pH of blood is approximately _________.

Back 478

7.35-7.45

Front 479

Ketoacid accumulation in diabetic ketoacidosis often results in which type of respirations?

Back 479

1. Cheyne-Stokes respirations
2. Kussmaul's respirations
3. Bradypnea
4. Apnea

Hint 479

Kussmaul's respirations

Front 480

The physician has ordered 0.5g of ceftriaxone (Rocephin). The nurse has available a vial labeled 250mg/mL. How many mL will the nurse give the pt?

Back 480

1. 2mL
2. 0.2mL
3. 0.05mL
4. 0.5mL

Hint 480

2mL

Front 481

Digoxin (Lanoxin) 0.125mg is ordered. On hand is Lanoxin 0.5mg/mL. How many mL will the nurse give?

Back 481

1. 3mL
2. 0.25mL
3. 2.5mL
4. 0.025mL

Hint 481

0.25mL

Front 482

The pt's mother is to give her child 6mL of a liquid medication. Her only measuring tool in her new apt is a teaspoon. How many teaspoons of the medication will she give?

Back 482

1. 1tsp
2. 2tsp
3. 3tsp
4. 1/2tsp

Hint 482

1tsp

Front 483

The pediatrician has requested the pediatric pt's weight in kilograms. The scales say that the pt weighs 30 pounds. How many kilograms will be reported to the physician?

Back 483

1. 20.6kg
2. 15kg
3. 13.6kg
4. 22kg

Hint 483

13.6kg

Front 484

Ordered is 1L of D5 1/2 NS to run over 8 hours. The drip factor stated on the IV tubing is 15gtt/mL. How many mL will be infused every hour?

Back 484

1. 100mL/hr
2. 125mL/hr
3. 150mL/hr
4. 175mL/hr

Hint 484

125mL/hr

Front 485

An IV of 1L of D5 1/2 NS is to run at 150mL/hr. How long will this IV run?

Back 485

1. 6 hours
2. 6.6 hours
3. 7.5 hours
4. 8 hours

Hint 485

6.6 hours

Front 486

At 1500, an 8 hour bag of 1L D5 LR (lactated Ringer's), which was started at 0900, has 100mL left in it. Does this infusion have to run slower or faster, or is it running at the correct rate?

Back 486

1. has to infuse slower
2. has to infuse faster
3. is at the correct rate
4. has to be discontinued

Hint 486

has to infuse slower

Front 487

Which intramuscular injection site is no longer recommended to be used because of the nearness of the sciatic nerve to the muscle and potential for permanent or partial paralysis of the involved leg?

Back 487

1. ventrogluteal site
2. deltoid site
3. vastus lateralis site
4. dorsogluteal site

Hint 487

dorsogluteal site

Front 488

The physician ordered 125mg of acetaminophen fora 2 month old infant who weighs 10 pounds. Is this the appropriate (the average adult dose is 500mg)

Back 488

1. it is appropriate
2. it is a little too much
3. it is an extreme overdose
4. it is not enough

Hint 488

it is an extreme overdose

Front 489

The average dose of a medication is 0.4mg (gr 1/150) for an adult. What is the dosage for a 12yo?

Back 489

1. 2mg
2. 0.002mg
3. 0.02mg
4. 0.2mg

Hint 489

0.2mg

Front 490

An adult dose of diazepam (Valium) is 5mg. How many mL is appropriate for a child who weighs 27kg?

Back 490

1. 2mg
2. 1.5mg
3. 3mg
4. 2.5mg

Hint 490

2mg

Front 491

A 71yo pt with hypertension, heart failure, anxiety, and a productive cough is to receive his medications at 8am daily. Which medication will be given last?

Back 491

1. lasix tablet
2. coreg tablet
3. robitussin cough syrup
4. paxil tablet

Hint 491

robitussin cough syrup

Front 492

The LPN is asked by the RN to take an unlabeled container of solution to the operating room. The LPN's best response is to say:

Back 492

1. "Of course, I'll take it right away!"
2. "What is in the container?"
3. "I will have the orderly take it."
4. "I am not permitted to transport an unlabeled container."

Hint 492

"I am not permitted to transport an unlabeled container."

Front 493

After a possible exposure to tuberculosis, a 25yo health worker receives a TB skin test. The skin test will be given by the following type of injection:

Back 493

1. intramuscular
2. intradermal
3. subcutaneous
4. intravenous

Hint 493

intradermal

Front 494

The physician orders vitamin B12 IM for a 70yo with a hx of pernicious anemia. The nurse is choosing from the following gauges of needles. Which one is most appropriate?

Back 494

1. 22 guage
2. 25 gauge
3. 18 gauge
4. 16 gauge

Hint 494

22 gauge

Front 495

Insulin is to be given to a well nourished 55yo man admitted for DM. His insulin is to be given via subcutaneous injection. What angle is acceptable for the injection?

Back 495

1. 45 degrees
2. 90 degrees
3. 15 degrees only
4. 35 degrees only

Hint 495

90 degrees

Front 496

The nurse is deciding on the angle used in delivering subcutaneous heparin. The decision will be based on the:

Back 496

1. amount of solution in the syringe
2. length and the gauge of the needle
3. amount of subcutaneous tissue of the pt
4. needle length and the amount of subcutaneous tissue available

Hint 496

amount of subcutaneous tissue of the pt

Front 497

The pt complains of nausea after having a total abdominal hysterectomy. The nurse prepares an injection of promethazine (Phenergan) 25mg for IM injection and selects a needle length of:

Back 497

1. 1 to 1 1/2 inches
2. 3/8 inch
3. 5/8 inch
4. 1/4 inch

Hint 497

1 to 1 1/2 inches

Front 498

A 6 month old is to be immunized for diphtheria, tetanus, and pertussis. His IM injection will be given in which muscle?

Back 498

1. deltoid
2. ventrogluteal
3. gluteus maximus
4. vastus lateralis

Hint 498

vastus lateralis

Front 499

Epinepherine contained in 0.3mL is ordered for an 18yo who had an anaphylactic reaction to a bee sting. Which syringe is the best choice for delivering this volume of fluid?

Back 499

1. 1mL tuberculin syringe
2. 100 units per 1mL syringe
3. 3mL syringe
4. 5mL syringe

Hint 499

1mL tuberculin syringe

Front 500

A 96yo nursing home resident is to receive several medications at 2100. These medications are for emphysema, peripheral vascular disease, and heart failure. The nurse realizes that the dosages for an older adult are:

Back 500

1. the same as for pediatric pts
2. the same as average adult dosages
3. higher than average adult dosages
4. lower than average adult dosages

Hint 500

lower than average adult dosages

Front 501

When obtaining information about a specific drug, what book is published annually and contains information from drug manufacturers?

Back 501

1. Nurse's Drug Handbook
2. Drug Facts and Comparisons Guide
3. Physicians' Desk Reference (PDR)
4. Pharmacy Policy Manual

Hint 501

Physician's Desk Reference (PDR)

Front 502

What is the acceptable time range to administer an 8am medication?

Back 502

1. 0800 to 1000
2. 0700 to 0900
3. 0800 to 0830
4. 0730 to 0830

Hint 502

0800 to 0830

Front 503

What is true regarding nursing responsibilities with controlled substances?

Back 503

1. medications that have a high degree of addiction or abuse are double locked
2. it is the nurse's responsibility to count all controlled substances between shifts
3. if another nurse is not available when you are discarding an unused portion of a controlled substance, it is acceptable to tell the other nurse about it later or have the other nurse co-sign
4. only statements 1 and 2 are true
5. statements 1, 2 and 3 are true

Hint 503

only statements 1 and 2 are true

Front 504

Documentation of medication administration is extremely important. What information will the nurse include in the documentation?
(Choose all that apply)

Back 504

1. drug name, dose, and time of administration
2. patient's response to all prn medications
3. location of intramuscular injections
4. all of the above

Hint 504

all of the above

Front 505

The first action to take when a medication error takes place is to:

Back 505

1. call the physician
2. call the supervisor
3. complete an incident report
4. check the pt

Hint 505

check the pt

Front 506

If a medication is ordered orally, and the pt is NPO (nothing by mouth), which action does the nurse take?

Back 506

1. give the medication by injection
2. give the medication rectally
3. omit the medication and note on chart
4. consult the nurse in charge

Hint 506

consult the nurse in charge

Front 507

The physician orders 1g of kanamycin sulfate po every 6 hours for a 60yo hospitalized pt. The pt's last dose of kanamycin was at 0600. The nurse in this situation is legally responsible for:
(Choose all that apply)

Back 507

1. administering 1g of kanamycin by mouth to the pt at noon
2. knowing the expected action and average does of kanamycin and the reason that the pt is receiving the drug
3. discontinuing the kanamycin if the pt complains of nausea
4. documenting the administration of kanamycin and evaluating the therapeutic effect

Hint 507

1, 2, and 4

Front 508

When reading a medication label, the nurse should:
(Choose all that apply)

Back 508

1. check the expiration date
2. compare the medication order with the label
3. read the label when removing the medication from the container
4. request a second nurse to check dosage on label

Hint 508

1, 2, 3

Front 509

The physician writes the order for oxycodone (Roxicodone) one or two tablets orally q3-4h prn for pain. How will the nurse interpret this order?

Back 509

1. administer the Roxicodone every 3-4 hours around the clock
2. administer the Roxicodone whenever the pt asks for it, because it is prn
3. administer the Roxicodone only if the pt asks for it
4. inform the pt that the medication is available to take every 3 to 4 hours as needed for pain

Hint 509

inform the pt that the medication is available to take every 3 to 4 hours as needed for pain

Front 510

Prescribed medications are prepared and administered during which phase of the nursing process?

Back 510

1. assessment
2. planning
3. implementation
4. evaluation

Hint 510

implementation

Front 511

A pt hospitalized with newly diagnosed hypertension is on enalapril (Vasotec) 5mg po bid. His next dose is at 0900. When taking his VS, the nurse discovers the pt's BP is 90/42. What should the nurse do?

Back 511

1. hold the medication and inform the physician of a change in the pt's bp
2. give the medication on time (the bp is within normal limits)
3. ask the pt how he is feeling; if he is not having adverse signs or symptoms of low bp, give him the medication
4. give half the dose ordered

Hint 511

hold the medication and inform the physician of a change in the pt's bp

Front 512

The priority assessment to make of a victim at the scene of a car accident is whether or not:

Back 512

1. the victim is actively bleeding
2. the victim has a patent airway
3. there is an apical pulse
4. there are signs of head trauma

Hint 512

the victim has a patent airway

Front 513

When caring for a victim who has a head injury and is developing shock, the nurse should:

Back 513

1. elevate the victim's head
2. lower the victim's feet
3. elevate the victim's upper body
4. leave the victim in a flat position

Hint 513

leave the victim in a flat position

Front 514

The nurse finds an unconscious woman in a car that is on fire. She is breathing, her arm is fractured, and she has several lacerations that are bleeding profusely. What should the nurse do first?

Back 514

1. splint the fractured arm
2. get the woman out of the car
3. give mouth-to-mouth resuscitation
4. stop the bleeding

Hint 514

get the woman out of the car

Front 515

A neighbor tells the nurse that her 12yo daughter has been burned with scalding water. The arm is red and starting to blister. In addition to advising her to see a doctor, what will the nurse tell the neighbor to apply to the burn?

Back 515

1. hydrogen peroxide
2. petroleum jelly
3. cool compress
4. saltwater compress

Hint 515

cool compress

Front 516

A pt is found on the floor of her room. She fell while crawling over the side rails of her bed. She is conscious and has a large laceration to the head that is bleeding profusely. The nurse's first priority is to:

Back 516

1. notify the physician
2. apply direct pressure to the laceration to the pt's head
3. check the pt's VS
4. ensure that the pt has an open airway

Hint 516

ensure that the pt has an open airway

Front 517

A man is found walking next to his car after an automobile accident. He is breathing rapidly and has cool, clammy skin. The man is possibly suffering from:

Back 517

1. shock
2. head trauma
3. peripheral vascular injury
4. spinal injury

Hint 517

shock

Front 518

The nurse is swimming at the lake and hears people calling for help. On arrival, the nurse finds that a 12yo boy was water-skiing when he lost control and was hit in the head with a ski. He is lying on the shore, unconscious. The nurse notices that the boy is cyanotic and has a laceration on his head that is bleeding. The first priority is to:

Back 518

1. control the bleeding
2. immobilize the neck and spine
3. move him to a warmer area
4. ensure there is an open airway

Hint 518

ensure there is an open airway

Front 519

The nurse comes across a one car automobile accident. The driver of the car is walking around with a dazed look on his face. He states that he was wearing his seatbelt, but is unsure of what happened exactly. He has no visible injury. After checking his VS, the nurse finds bp 84/56, p 110, r 32. Another bystander says that an ambulance is on the way. The nurse's first priority will be to:

Back 519

1. complete a neurologic assessment
2. instruct him to get back in the car and rest
3. position him on his back on the ground with feet elevated
4. assess for any wounds

Hint 519

position him on his back on the ground with feet elevated

Front 520

The nurse is told in report that one of the pts has been very depressed lately. On checking the unit, the nurse finds the pt in the bathroom with one wrist bleeding profusely. The pt states that she broke a glass and used it to cut her wrist in a suicide attempt. After sending someone to call for help, the nurse should:

Back 520

1. attempt to find out what has been causing her depression
2. apply a tourniquet above the injury
3. use 4 inch by 4 inch gauze pads to apply direct pressure
4. thoroughly wash the wound

Hint 520

use 4 inch by 4 inch gauze pads to apply direct pressure

Front 521

A 44yo pt is brought to the emergency department with a gunshot wound to the chest. On examination, the nurse finds that he is conscious and complaining of pain. There is slight bleeding at the entrance wound, and there is no exit wound. VS are bp 100/76, p 100, r 40. If the pt complains of having difficulty breathing, the nurse's first priority will be to:

Back 521

1. obtain pulse oximetry reading and start oxygen via NC
2. give morphine sulfate to control the pain
3. position him flat on his back with feet elevated
4. apply pressure to the entrance wound

Hint 521

obtain pulse oximetry and start oxygen via NC

Front 522

A neighbor tells the nurse that her 5yo son has ingested one of her liquid cleaning supplies. The child is in no distress at this time. The mother shows the nurse the bottle; the nurse is unfamiliar with the ingredients. The nurses' first priority would be to:

Back 522

1. give syrup of ipecac to induce vomiting
2. give milk to neutralize any acids
3. give water to dilute the poison
4. call the poison control center

Hint 522

call the poison control center

Front 523

A new potential environmental health threat is the possibility of:

Back 523

1. bioterrorism
2. noise pollution
3. water pollution
4. air pollution

Hint 523

bioterrorism

Front 524

When giving one or two person CPR to adults and children, the nurse should use the universal compression: ventilation ratio of ____ chest compressions for every ____ breaths.

Back 524

30, 2

Front 525

The compression rate for one or two rescuer CPR for adults and children is approximately _____ compressions per minute.

Back 525

100

Front 526

In the case of multiple injuries, pts are quickly surveyed for severity of injuries so that life-threatening problems can be treated first. This process is called:

Back 526

1. secondary survey
2. high resource intensity
3. triage
4. collaborative care

Hint 526

triage

Front 527

Shock is best defined as:

Back 527

1. cardiovascular collapse
2. loss of sympathetic tone
3. inadequate tissue perfusion
4. blood pressure less than 90mmHg systolic

Hint 527

inadequate tissue perfusion

Front 528

A 25yo woman comes to the clinic and says she thinks she is pregnant. Her last period was July 20. Based on this fact, what would be the expected date of birth (EDB)?

Back 528

1. April 13
2. April 27
3. May 20
4. March 27

Hint 528

April 27

Front 529

The pt reports experiencing nausea, vomiting and breast tenderness along with missing her period. These symptoms are considered to be what type of signs of pregnancy?

Back 529

1. probable
2. positive
3. presumptive
4. possible

Hint 529

presumptive

Front 530

A pregnant pt at her third office visit asks the nurse, "What can I do when my leg goes into a cramp?" The pt demonstrates understanding of the nurse's instruction regarding relief of leg cramps if she:

Back 530

1. wiggles and points her toes during the cramp
2. applies cold compresses to the affected leg
3. extends her leg and dorsiflexes her foot during the cramp
4. avoids weight bearing on the affected leg during the cramp

Hint 530

extends her leg and dorsiflexes her foot during the cramp

Front 531

The pt asks the nurse how she will know when she first feels the baby move. The best explanation is that the movement:

Back 531

1. will feel like cramps
2. is rhythmic and called Goodell's sign
3. is flutterlike and is called quickening
4. is like a thud and is called Hegar's sign

Hint 531

is flutterlike and is called quickening

Front 532

While giving a health hx to the nurse, the pt reports that she usually has a glass of wine with dinner. What is the safe level of alcohol intake for her during her pregnancy?

Back 532

1. no alcohol
2. wine only-one or two glasses daily with meals
3. up to 4 ounces daily
4. beer or wine only after the first trimester

Hint 532

no alcohol

Front 533

The nurse explains to the pt that she should contact her health care provider if she experiences any of the danger signs of pregnancy. Which symptom is a danger sign during pregnancy?

Back 533

1. urine frequency
2. severe headaches
3. backache
4. heartburn

Hint 533

severe headaches

Front 534

During the third trimester, pts often complain of various discomforts. Which discomfort would not be expected at this time?

Back 534

1. dyspnea
2. insomnia
3. ankle edema
4. dysuria

Hint 534

dysuria

Front 535

A test that may be done in late pregnancy to determine fetal well-being is the nonstress test. This test is based on which phenomenon?

Back 535

1. fetal heart rate increases in connection with fetal movement
2. Braxton Hicks contractions cause an increase in fetal heart rate
3. fetal heart rate slows in response to contractions
4. fetal movement causes an increase in maternal heart rate

Hint 535

fetal heart rate increases in connection with fetal movement

Front 536

Constipation is a frequent complaint as a pregnancy progresses. Which measure would be best to recommend to relieve constipation?

Back 536

1. drink 6 to 8 glasses of water daily
2. take an over the counter laxative
3. take an iron supplement only every other day
4. take mineral oil at bedtime

Hint 536

drink 6 to 8 glasses of water daily

Front 537

At one of her prenatal visits, the pt is scheduled for a sonogram. Sonography cannot be used to assess:

Back 537

1. number of fetuses
2. gestational age of fetus
3. Down syndrome
4. congenital anomalies

Hint 537

Down syndrome

Front 538

Which symptom would be considered a first trimester warning sign and should be reported immediately to the health care provider?

Back 538

1. nausea with occasional vomiting
2. fatigue
3. urinary frequency
4. vaginal bleeding

Hint 538

vaginal bleeding

Front 539

A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her that:

Back 539

1. "You do not need to modify your exercising anytime during your pregnancy."
2. "Stop exercising because it will harm the fetus."
3. "You may find that you need to modify your exercising to walking later in your pregnancy, around the 7th month."
4. "Jogging is too hard on your body; switch to walking now."

Hint 539

"You may find that you need to modify your exercising to walking later in your pregnancy, around the 7th month."

Front 540

A woman at 23 weeks of gestation calls to tell the nurse she thinks she is leaking fluid from her vagina. The nurse should tell her:

Back 540

1. "As long as the baby is still moving around, there is nothing to worry about."
2. "Come to the office right away."
3. "Call me back in 2 hours, and tell me if there is any change in the leakage."
4. "We can wait until your next appointment to check you."

Hint 540

"Come to the office right away."

Front 541

A woman admitted in labor has an obstetric hx indicating that she has had 3 children, all of whom are living. One was born at 39 weeks of gestation, another at 34 weeks of gestation, and another at 35 weeks of gestation. What are her gravidity and parity using the five digit GTPAL system?

Back 541

1. 4-1-1-1-3
2. 4-1-2-0-3
3. 3-0-3-0-3
4. 3-1-2-0-3

Hint 541

4-1-2-0-3

Front 542

The nurse teaches a pregnant woman about the presumptive, probably, and positive signs of pregnancy. The woman demonstrates understanding of the nurse's instructions if she states that a positive sign of pregnancy is:

Back 542

1. a positive pregnancy test
2. fetal movement palpated by the primary caregiver
3. Braxton Hicks contractions
4. nausea and vomiting

Hint 542

fetal movement palpated by the primary caregiver

Front 543

___________ woman who is pregnant

Back 543

gravida

Front 544

_________ woman who is pregnant for the first time

Back 544

primagravida

Front 545

_________ woman who has had two or more pregnancies

Back 545

multigravida

Front 546

________ capacity to live outside the uterus

Back 546

viability

Front 547

An expectant father confides in the nurse that his pregnant wife (10 weeks of gestation) is driving him crazy. "One minute she seems happy and the next minute she seems unhappy, and the next she is crying over nothing at all. Is there something wrong with her?" The nurse's best response would be:

Back 547

1. "This is normal behavior and should begin to subside by the second trimester."
2. "She may be having difficulty relating to the pregnancy. I will refer her to a counselor I know."
3. "This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will subside as she adjusts to being pregnant."
4. "You seem impatient with her. Perhaps this is precipitating her behavior."

Hint 547

"This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will subside as she adjusts to being pregnant."

Front 548

When planning a diet with a pregnant woman, the nurse's first action would be to:

Back 548

1. review the woman's dietary intake
2. teach the woman about the MyPyramid food guide
3. caution the woman to avoid large doses of vitamins, especially those that are fat soluble
4. instruct the woman to limit the intake of fatty foods

Hint 548

review the woman's dietary intake

Front 549

A pregnant woman at 32 weeks of gestation complains of feeling dizzy and lightheaded while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to:

Back 549

1. assess the woman's bp and pulse
2. have the woman breathe into a paper bag
3. raise the woman's leg
4. turn the woman on her side

Hint 549

turn the woman on her side

Front 550

When obtaining a reproductive health hx from a female pt, the nurse should:

Back 550

1. limit the time spend on exploration of intimate topics
2. explain the purpose of questions asked and how they will be used
3. avoid asking questions that may embarrass the pt
4. use only acceptable medical terminology when referring to body parts and functions

Hint 550

explain the purpose of questions asked and how they will be used

Front 551

After admitting a new pt to the maternity unit, the nurse writes a care plan. This process of determining outcomes and interventions is which stage of the nursing process?

Back 551

1. assessment
2. planning
3. implementation
4. evaluation

Hint 551

planning

Front 552

A 23yo primigravida arrives on the labor unit in early labor. Which assessment finding would indicate that labor has begun?

Back 552

1. decreased vaginal secretions
2. weight gain of 1 to 3 pounds
3. bloody show
4. increased fetal movement

Hint 552

bloody show

Front 553

To determine fetal lie, presentation, and position, the caregiver uses which assessment technique?

Back 553

1. abdominal ultrasonography
2. fetal heart tone auscultation
3. palpation of contractions
4. leopold's maneuvers

Hint 553

leopold's maneuvers

Front 554

During the initial assessment, the nurse determines that the fetal position is ROA. Where is the fetal presenting part in relation to the maternal pelvis?

Back 554

1. the occiput is facing the right side and the front of the maternal pelvis
2. the mentum is facing the right side and the front of the maternal pelvis
3. the occiput is facing the left side and the back of the maternal pelvis
4. the sacrum is facing the right side and the front of the maternal pelvis

Hint 554

the occiput is facing the right side and the front of the maternal pelvis

Front 555

A woman is having regular contractions. To assess the frequency of her labor contractions, time:

Back 555

1. the interval between the peaks of the contractions
2. the beginning of one contraction to the beginning of the next
3. the end of one contraction to the beginning of the next
4. how many contractions she has in a 15 minute period

Hint 555

the beginning of one contraction to the beginning of the next

Front 556

A woman asks the nurse when she will have an internal fetal monitor applied. The best answer is:

Back 556

1. "Because you have had a low risk pregnancy, you are not considered a candidate for internal monitoring."
2. "Your health care provider decides when to apply the internal monitor."
3. "Your cervix must be 2 to 3cm dilated and your membranes ruptured before an internal monitor can be applied."
4. "We can apply the internal monitor at any time after your membranes rupture."

Hint 556

"Your cervix must be 2 to 3cm dilated and your membranes ruptured before an internal monitor can be applied

Front 557

A woman tells the nurse she thinks her membranes have ruptured. What action by the nurse will best validate rupture of membranes?

Back 557

1. feel the draw sheet for wetness
2. perform a nitrazine test
3. insert a foley catheter into her bladder
4. have her cough

Hint 557

perform a nitrazine test

Front 558

A woman has progressed through her labor without difficulty. However, the fetal heart rate has been decreasing with each contraction for the past 15 minutes. The rate decreases from 150 to 125bpm after the peak of the contraction and returns to 150bpm 15 seconds after the contraction is finished. The nurse concludes that the pt is having:

Back 558

1. variable decelerations
2. early decelerations
3. late decelerations
4. combination decelerations

Hint 558

late decelerations

Front 559

When the woman enters the transition phase to active labor, which behaviors would the nurse expect to see?

Back 559

1. a desire for personal contact and touch
2. sleepiness and quietness, with a desire for touch
3. responsiveness to teaching
4. irritability, resistance to touch, withdrawal

Hint 559

irritability, resistance to touch, withdrawal

Front 560

As the woman's labor progresses, which assessment finding would indicate that the second stage of labor has begun?

Back 560

1. passage of mucous plug
2. bearing down reflex
3. dilation of the cervix to 7cm
4. change in shape of the uterus

Hint 560

bearing down reflex

Front 561

Which fetal heart rate finding would be as a concern during the woman's labor?

Back 561

1. accelerations
2. early decelerations
3. average FHR of 126bpm
4. late decelerations

Hint 561

late decelerations

Front 562

Which maternal cardiovascular finding is expected during labor?

Back 562

1. increased cardiac output
2. increased pulse rate
3. decreased wbc count
4. decreased bp

Hint 562

increased cardiac output

Front 563

The nurse notes accelerations with fetal movement. These:

Back 563

1. are reassuring
2. are caused by umbilical cord compression
3. warrant close observation
4. are caused by uteroplacental insufficiency

Hint 563

are reassuring

Front 564

The pt delivers an 8 pound, 1 ounce boy. Ten minutes later there is a sudden gush of blood from her vagina. At the same time the woman's uterus becomes globular in shape and the umbilical cord lengthens. What do these findings probably indicate?

Back 564

1. separation of the placenta
2. uterine hemorrhage
3. cervical or vaginal laceration
4. uterine involution

Hint 564

separation of the placenta

Front 565

A woman pregnant for the first time is dilated 3cm, with contractions every 5 minutes. She is groaning and perspiring excessively and states that she did not attend childbirth classes. The most important nursing action is to:

Back 565

1. notify the woman's health care provider
2. administer the prescribed narcotic analgesic
3. ensure that her labor will be overseen
4. give simple breathing and relaxation instructions

Hint 565

give simple breathing and relaxation instructions

Front 566

When planning care for a woman whose membranes have ruptured, the nurse recognizes that the woman's risk for which of the following has increased?

Back 566

1. intrauterine infection
2. hemorrhage
3. precipitous labor
4. supine hypotension

Hint 566

intrauterine infection

Front 567

Identify as true labor or false labor:

____ contractions rarely follow a pattern

Back 567

false labor

Front 568

____ contractions frequently stop with ambulation or position change

Back 568

false labor

Front 569

____ contractions seem to start in the lower back and then travel to the lower abdomen

Back 569

true labor

Front 570

____ the cervix softens, effaces, and dilates

Back 570

true labor

Front 571

____ there is no significant change in fetal position

Back 571

false labor

Front 572

A woman has delivered her first baby, a boy, vaginally after 6 hours of labor. She had an uneventful pregnancy and is in good general health. She is transferred from the recovery room to the postpartum unit. Routine care of the postpartum pt includes all the following except:

Back 572

1. maintaining intake and output until the pt is voiding in sufficient quantities
2. massaging the fundus firmly every 15 minutes
3. assessing the emotional status of the new mother
4. checking breasts for engorgement and cracking of nipples

Hint 572

massaging the fundus firmly every 15 minutes

Front 573

The nurse is performing a routine postpartum assessment. Before measuring the height of the pt's fundus, the nurse should:

Back 573

1. massage the uterus
2. apply pressure to the fundus to check for clots
3. elevate the head of the bed
4. ask the pt to empty her bladder

Hint 573

ask the pt to empty her bladder

Front 574

The nurse finds bright red bleeding on a pt's peripad. The stain is about 6 inches long. What is the correct description of the character and amount of lochia?

Back 574

1. lochia rubra, moderate
2. lochia serosa, heavy
3. lochia rubra, heavy
4. lochia serosa, light

Hint 574

lochia rubra, moderate

Front 575

The nurse is teaching breast care for the lactating woman. It should include all the following except:

Back 575

1. exposing the nipples to air for 20 to 30 minutes daily
2. wearing a supportive bra 24 hours a day for the first few weeks
3. washing breasts and nipples with soap and water before each feeding
4. avoiding use of plastic liners in bra

Hint 575

washing breasts and nipples with soap and water before each feeding

Front 576

A woman asks the nurse how she will know her baby is getting enough milk. The nurse's response is based on her knowledge that a good determinant is the baby:

Back 576

1. awakens every 4 to 6 hours to eat
2. stops nursing when full
3. has 6 to 10 wet diapers per day
4. will cry when hungry

Hint 576

has 6 to 10 wet diapers per day

Front 577

In evaluating maternal adjustment, which behavior would lead the nurse to believe that the pt is still in the taking in phase? She:

Back 577

1. states she is "starving" and can't wait to eat
2. spends the majority of her time talking about her delivery experience
3. takes a shower and washes her hair
4. asks to learn how to give her baby a bath

Hint 577

spends the majority of her time talking about her delivery experience

Front 578

A baby boy is 1 hour old when admitted to the newborn nursery. He weighs 7 pounds, 3 ounces; is 21 inches long; has irregular respirations of 42 breaths/min with adequate chest movement, a heart rate of 145bpm, and a temperature of 35.6C, axillary; and is acrocyanotic. What would be an appropriate goal for this baby within the next 2 hours, based on these findings?

Back 578

1. color will remain unchanged
2. respirations will slow
3. temperature will stabilize at 36.5 to 37C
4. heart rate will decrease to 100bpm

Hint 578

temperature will stabilize at 36.5 to 37C

Front 579

When teaching parents how to bathe their baby, which point should the nurse stress?

Back 579

1. do not immerse the baby in water until after the umbilical cord has fallen off
2. use only mild medicated or scented soap
3. apply baby powder after the bath to keep the skin dry
4. apply baby oil after the bath to keep the skin soft and smooth

Hint 579

do not immerse the baby in water until after the umbilical cord has fallen off

Front 580

The nurse teaches parents about care of the umbilical cord. What is not a part of this care?

Back 580

1. cleaning the cord with an alcohol swab
2. keeping the diaper folded below the cord
3. applying triple dye to the cord
4. keeping the cord moist to promote healing

Hint 580

keeping the cord moist to promote healing

Front 581

A baby has a Gomco circumcision. What instruction would the nurse give his parents for care of the circumcised penis?

Back 581

1. soak the penis in warm water daily
2. cover the glans with a petroleum gauze dressing
3. clean the glans with alcohol to promote healing
4. remove any yellowish exudate that forms within 24 hours

Hint 581

cover the glans with a petroleum gauze dressing

Front 582

On examining a woman who gave birth 5 hours previously, the nurse finds that the woman has saturated a perineal pad within 15 minutes. The nurse's first action is to:

Back 582

1. increase the drip rate of an IV infusion of Ringer's lactate solution
2. assess the pt's VS
3. call the pt's primary health care provider
4. palpate the woman's fundus

Hint 582

palpate the woman's fundus

Front 583

A woman gave birth 48 hours ago to a healthy baby girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. The pt should be advised that this is best treated by:

Back 583

1. running warm water over her breasts for comfort
2. applying ice to the breasts for comfort
3. expressing small amounts of milk from the breasts to relieve pressure
4. wearing a loose fitting bra to prevent nipple irritation

Hint 583

applying ice to the breasts for comfort

Front 584

A first time mother is to be discharged from the hospital tomorrow with her baby girl. Which behavior indicates a need for further intervention by the nurse before she can be discharged? The woman:

Back 584

1. leaves the baby on her bed while she takes a shower
2. continues to hold and cuddle her baby after she has fed her
3. reads a magazine while her baby sleeps
4. changes her baby's diaper, then shows the nurse the contents of the diaper

Hint 584

leaves the baby on her bed while she takes a shower

Front 585

The nurse observes several interactions between a postpartum woman and her new son. Which behavior, if exhibited by this woman, would the nurse identify as maladaptive regarding parent-infant attachment?

Back 585

1. talks and coos to her son
2. seldom makes eye contact with her son
3. cuddles her son close to her
4. tells visitors how well her son is feeding

Hint 585

seldom makes eye contact with her son

Front 586

The nurse can help a father in his transition to parenthood by:

Back 586

1. pointing out that the infant turned to his voice
2. encouraging him to go home to get some sleep
3. taping the baby's diaper a different way
4. suggesting that he let the baby sleep in the bassinet

Hint 586

pointing out that the infant turned to his voice

Front 587

When performing a postpartum assessment, the nurse should:

Back 587

1. assist the pt into a lateral position with upper leg flexed forward to facilitate examination of her perineum
2. assist the pt into a supine position with her arms above her head and her legs extended for the examination of her abdomen
3. instruct the pt to avoid urinating just before the examination since a full bladder will facilitate funda position
4. wash hands and put on sterile gloves before beginning

Hint 587

assist the pt into a lateral position with upper leg flexed forward to facilitate examination of her perineum

Front 588

The nurse helps the breastfeeding woman change her newborn's diaper after the baby's first bowel movement. The mother expresses concern since there is a large amount of sticky, dark green-almost black-stool. She asks the nurse if something is wrong. The nurse's best response is to:

Back 588

1. tell the woman not to worry since all breastfed babies have this type of stool
2. explain that this type of stool is called meconium and is expected for the first few bowel movements of all newborns
3. ask the woman what she ate at her last meal before giving birth
4. suggest that the mother ask her pediatrician to explain newborns' stool patterns

Hint 588

explain that this type of stool is called meconium and is expected for the first few bowel movements of all newborns

Front 589

_____ refers to the process whereby an infant's behavior and characteristics call forth a corresponding set of maternal behaviors and characteristics

Back 589

bonding

Front 590

____ refers to the face-to-face position in which a parent's and infant's faces are approximately 20cm apart and on the same plane or level

Back 590

enface

Front 591

_____ is a term applied to a parent's absorption, preoccupation, and interest in his or her infant; the term typically is used to describe the father's intense involvement with his newborn.

Back 591

engrossment

Front 592

_____ is the phase of maternal postpartum adjustment characterized by a woman's need to review her labor and birth experiences with the nurse who cared for her while she was in labor. Other behaviors exhibited include reliance on others to help her meet needs, excitement, and talkativeness

Back 592

taking-in

Front 593

A pt is admitted to the hospital with a dx of hyperemesis gravidarum. What is the cause of this condition?

Back 593

1. neurologic disorder
2. inadequate nutrition
3. unknown cause
4. hyperglycemia

Hint 593

unknown cause

Front 594

A pt is admitted to the hospital with a 3 day hx of right abdominal pain. Her admitting dx is suspected ectopic pregnancy. The nurse knows an ectopic pregnancy occurs:

Back 594

1. outside the uterus
2. in the fallopian tube
3. early in ovulation
4. during cervical implantation

Hint 594

outside the uterus

Front 595

A pt has been diagnosed with placenta previa. Which symptom is considered the classic diagnostic criterion for placenta previa?

Back 595

1. irregular fetal heartbeat
2. uterine irritability
3. elevation of temperature
4. painless vaginal bleeding

Hint 595

painless vaginal bleeding

Front 596

A pt is in labor and suddenly complains of sharp fundal pain. She begins to have vaginal bleeding as well. What is the most likely cause of her symptoms?

Back 596

1. preterm labor
2. abruptio placentae
3. pelvic inflammatory disease
4. placenta previa

Hint 596

abruptio placentae

Front 597

A pt is diagnosed with an inevitable abortion. Which assessment finding distinguishes an inevitable abortion from a threatened abortion?

Back 597

1. uterine cramping
2. vaginal bleeding
3. cervical dilation
4. hx of previous abortions

Hint 597

cervical dilation

Front 598

A pt is suspected of having gestational hypertension. Which assessment step should the nurse take?

Back 598

1. assess her deep tendon reflexes
2. determine when she last ate
3. perform a nitrazine test
4. do a vaginal examination to check for cervical dilation

Hint 598

assess her deep tendon reflexes

Front 599

What is the most common cause of postpartum hemorrhage?

Back 599

1. cervical lacerations
2. uterine atony
3. cesarean birth
4. disseminated intravascular coagulation

Hint 599

uterine atony

Front 600

A baby boy was born at 38 weeks of gestation to a mother with type 1 diabetes. Into which category would this infant most likely fall?

Back 600

1. premature
2. average for gestational age
3. intrauterine growth restriction
4. large for gestational age

Hint 600

large for gestational age

Front 601

A baby girl was born at 34 weeks of gestation. At 3 hours old she is diagnosed with respiratory distress. What is an early symptom of respiratory distress?

Back 601

1. nasal flaring
2. expiratory grunting
3. cyanosis
4. substernal retractions

Hint 601

expiratory grunting

Front 602

A pt is Rh negative and delivers an infant with Rh positive blood. The nurse gives her RhoGAM to:

Back 602

1. stimulate formation of maternal blood antigens
2. stimulate production of maternal blood antibodies
3. prevent production of maternal blood antibodies
4. prevent production of fetal blood antigens

Hint 602

prevent production of maternal blood antibodies

Front 603

After giving birth to a healthy baby boy, a primiparous woman, age 16, is admitted to the postpartum unit. An appropriate nursing dx for her at this time is risk for impaired parenting, related to deficient knowledge of newborn care. In planning for the woman's discharge, the nurse should include what in the care plan?

Back 603

1. tell the woman how to feed and bathe her baby
2. give the woman written information on bathing her baby
3. advise the woman that all mothers instinctively know how to care for their babies
4. provide time for the woman to bathe her baby after she views a baby bath demonstration

Hint 603

provide time for the woman to bathe her baby after she views a baby bath demonstration

Front 604

A newborn is jaundiced and receiving phototherapy. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia who is receiving phototherapy would be to:

Back 604

1. apply an oil-based lotion to the newborn's skin to prevent drying and cracking
2. limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea
3. place eyeshields over the newborn's eyes
4. change the newborn's position every 3 to 4 hours

Hint 604

place eyeshields over the newborn's eyes

Front 605

A 26yo pregnant woman, gravida 2, para 1, is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure?

Back 605

1. amniocentesis for fetal lung maturity
2. ultrasound for placental location
3. contraction stress test
4. internal fetal monitoring

Hint 605

ultrasound for placental location

Front 606

In planning care of a 30yo woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the:

Back 606

1. mother's age
2. number of years since diabetes was diagnosed
3. amount of insulin required prenatally
4. degree of blood glucose control during pregnancy

Hint 606

degree of blood glucose control during pregnancy

Front 607

When caring for a pregnant woman with cardiac problems, the nurse should be alert for signs and symptoms of cardiac decompensation, which include:

Back 607

1. regular heart rate, hypertension
2. increased urinary output, tachycardia, dry cough
3. shortness of breath, bradycardia, hypertension
4. dyspnea, crackles, irregular weak pulse

Hint 607

dyspnea, crackles, irregular weak pulse

Front 608

Human immunodeficiency virus (HIV) may be perinatally transmitted:

Back 608

1. only in the third trimester from maternal circulation
2. only through the ingestion of infected amniotic fluid
3. through the ingestion of breast milk from an infected mother
4. through improper handling of a meconium filled diaper

Hint 608

through the ingestion of breast milk from an infected mother

Front 609

_________________ would be the immediate focus for the care of a pregnant woman at 38 weeks of gestation with marginal placenta previa who has just given birth to a healthy newborn boy.

Back 609

preventing hemorrhage

Front 610

____________ is the gestation of twins, triplets, quadruplets, or more than four infants.

Back 610

multifetal pregnancy

Front 611

____________ is the birth of the fetus through a transabdominal incision of the uterus.

Back 611

caesarian birth

Front 612

___________ has a major effect on the health and well-being of the postpartum woman, her newborn, and the entire family. It is characterized by intense pervasive sadness and mood swings.

Back 612

postpartum depression

Front 613

When counseling the parents of a 6 month old about dental health, the nurse will include which statment(s)?
(Select all that apply.)

Back 613

1. "Begin cleansing the oral cavity by wiping teeth and gums with a damp washcloth."
2. "Avoid toothpaste at this age, especially if it is fluoridated."
3. "Initiate fluoride supplementation at 6 months of age if infant's home water supply is not fluoridated."
4. "It is acceptable to prop a bottle with juice or milk for the infant."

Hint 613

1, 2, 3

Front 614

Many children and adolescents in the US are overweight or obese. One important factor for the pediatric nurse to consider is :

Back 614

1. because more mothers work outside the home, children and adolescents eat only fast foods
2. obese children always become obese adults
3. being overweight or obese sometimes results in major physical and psychological health problems
4. it is best for families to have more meals at home

Hint 614

being overweight or obese sometimes results in major physical and psychological health problems

Front 615

Responsible sexual behavior among young people includes:

Back 615

1. having sexual activity only with someone you know
2. abstaining from sexual activity or properly using condoms
3. having sexual activity once a month
4. requiring sexual partners to be tested for HIV

Hint 615

abstaining from sexual activity or properly using condoms

Front 616

A 15yo male pt states that he does not smoke; however, he does use chewing tobacco. It is the nurse's responsibility to inform him that he:

Back 616

1. is at great risk for lung cancer
2. is at great risk for lip, gum, and throat cancer
3. will be at great risk for becoming a smoker later in life
4. absolutely has to stop using all tobacco products immediately

Hint 616

is at great risk for lip, gum, and throat cancer

Front 617

The US Poison Control Center (PCC) no longer recommends _________ for home treatment of poisoning.

Back 617

syrup of ipecac

Front 618

For infants less than 20 pounds, the car safety seat should face the _______ of the car.

Back 618

rear

Front 619

It is acceptable for children weighing more than ________ pounds to ride in a booster seat facing the front of the car.

Back 619

40

Front 620

The parents of a 10 month old are concerned about motor vehicle safety. In counseling them, the nurse is aware that:

Back 620

1. children weighing more than 35 pounds needs to be secured with a lap and shoulder belt
2. infants from birth to 20 pounds need to be in a rear-facing safety seat
3. when using a lap and shoulder belt, have the lap belt rest above the hip bones
4. when using a lap and shoulder belt, have the shoulder belt fit across the upper abdomen

Hint 620

infants from birth to 20 pounds need to be in a rear-facing safety seat

Front 621

The parents of a 6yo girl want to enroll her in a soccer league. Which statement will the nurse include in advice regarding sports participation for the early school-age child?

Back 621

1. "A preparticipation sports physical is not necessary at this age."
2. "Your daughter should be encouraged to join ballet or tennis and not a team sport."
3. "Sports participation for this age-group should focus on enjoyment rather than competition."
4. "Your daughter should not participate in team sports until she is 9yo."

Hint 621

"Sports participation for this age-group should focus on enjoyment rather than competition."

Front 622

Proper counseling of the parent of a 1yo regarding safety includes which instruction(s)?
(Select all that apply.)

Back 622

1. fence pools with a self locking gate
2. keep drapery cords out of children's reach
3. place infant on back to sleep
4. do not tie pacifies on a string around the infant's neck

Hint 622

1, 2, 4

Front 623

Human papillomavirus (HPV) vaccine is now recommended for girls between what ages?
(Select all that apply.)

Back 623

1. 13 to 26 years, if vaccine not received previously
2. 5 to 8 years
3. 11 to 12 years
4. 18 months to 4 years

Hint 623

1, 3

Front 624

HPV is a leading cause of:

Back 624

1. sterility in women
2. menorrhagia
3. pneumonia
4. cervical cancer

Hint 624

cervical cancer

Front 625

Nursing students learn in class that the man known as the father of pediatrics is:

Back 625

1. Hippocrates
2. Abraham Jacobi
3. James Mott
4. R.E. Behrman

Hint 625

Abraham Jacobi

Front 626

The nurse who founded the Henry Street Settlement in NYC was:

Back 626

1. Florence Nightingale
2. Mari MacPhee
3. Lillian Wald
4. Linn Rogers

Hint 626

Lillian Wald

Front 627

The purpose of pediatric nursing is best stated as:

Back 627

1. treating psychological conditions in children
2. providing social welfare of children
3. promoting the highest possible state of health in children
4. emphasizing isolation and asepsis

Hint 627

promoting the highest possible state of health in children

Front 628

The first White House Conference on Children focused on issues of child labor, dependent children, and infant care. As a result, what was established in 1987 on behalf of children?

Back 628

1. US Children's Bureau
2. Office of Child Development
3. National Commission on Children
4. Women, Infants, and Children program

Hint 628

National Commission on Children

Front 629

Hospitalization is an anxiety producing experience for children and families. A 4yo child is to be hospitalized for the first time. His parents are apprehensive about the unknown. The nurse will best address their concerns by:

Back 629

1. providing information only as needed
2. providing an orientation to all children before hospitalization
3. providing a tour of the entire hospital
4. beginning to provide anticipatory guidance explanations and preparation on first contact

Hint 629

beginning to provide anticipatory guidance explanations and preparation on first contact

Front 630

The single most important influence on growth in the child is thought to be:

Back 630

1. high metabolism
2. nutrition
3. ethnic background
4. genetics

Hint 630

nutrition

Front 631

The most effective method to prepare a child for a pediatric procedure is the:

Back 631

1. problem solving approach
2. sensation based approach
3. symbol based approach
4. autonomy based approach

Hint 631

problem solving approach

Front 632

A 16 month old child was admitted to the pediatric floor following surgery to repair a cleft palate. An elbow SRD was being used for what purpose?

Back 632

1. to monitor excessive pressure to sutures
2. to provide movement in bed
3. to prevent injury to operative area
4. to allow jugular vein puncture with nasogastric tube insertion

Hint 632

to prevent injury to operative area

Front 633

It is essential to know that in pediatric medication administration:

Back 633

1. children and adults are susceptible to toxic effects of medication at the same rate.
2. there are unit doses for children
3. BSA is the most reliable method of calculating children's medications
4. the route of choice is the rectal route

Hint 633

BSA is the most reliable method of calculating children's medications

Front 634

A family centered approach to care is important when caring for any children but is crucial for optimum care for:

Back 634

1. school age children
2. children having minor surgery
3. children with special needs
4. children receiving routine immunizations

Hint 634

children with special needs

Front 635

A 7yo is about to have a fingerstick. The best statement by the nurse to prepare her for the event is:

Back 635

1. "It will hurt bu you are a big girl, so you can just grin and bear it."
2. "It will hurt a lot, and you can cry if you want to."
3. "Some children tell me it feels like a chicken pecking or a cat scratching."
4. "Close your eyes, don't look, and it will be over in a minute."

Hint 635

"Some children tell me it feels like a chicken pecking or a cat scratching."

Front 636

An 18 month old is hospitalized for surgery in the morning. The most helpful intervention to relieve the child's stress associated with hospitalization is:

Back 636

1. maintaining a normal routine
2. providing opportunities for play
3. encouraging parental presence and rooming in
4. encouraging self care activities

Hint 636

encouraging parental presence and rooming in

Front 637

The parent of a 6 month old states that the child's grandmother has expressed concern that the child may be "slow," because she is not crawling. The nurse's role is to:

Back 637

1. assure the parent that grandmothers are often overly concerned when it comes to grandchildren
2. ask the mother at what age her other children began crawling
3. refer the mother for additional evaluation, because most children do crawl by 6 months of age
4. assure the mother that children develop at their own rate, but most children do not crawl at age 6 months

Hint 637

assure the mother that children develop at their own rate, but most children do not crawl at age 6 months

Front 638

An accurate apical heart rate measurement is possible to assess at the _____ intercostal space.

Back 638

5th

Front 639

A new pt is 4yo. On entering the pt's room for the first time, the nurse will:

Back 639

1. speak only to the parents, because the child will be very scared
2. explain all procedures in great detail, because the child will want to know what is going on
3. be careful not to use words that might be misinterpreted by the child, such as "take your temperature"
4. tell the parents they must leave the room until the physical assessment is complete

Hint 639

be careful not to use words that might be misinterpreted by the child, such as "take your temperature"

Front 640

A 5 month old has had abdominal surgery. With regard to pain management, the nurse will consider that:

Back 640

1. the infant will perhaps be comforted by sucking on a pacifier, being swaddled, or being rocked
2. analgesics are best given only if the child will not stop crying
3. at 5 months of age the infant has immature pain receptors, and therefore will not require analgesics
4. the child will have less pain if left alone in the bed for activities

Hint 640

the infant will perhaps be comforted by sucking on a pacifier, being swaddled, or being rocked

Front 641

What is true regarding the toddler's nutrition?

Back 641

1. the toddler needs to eat twice as much as a 6 month old infant
2. the toddler's appetite often decreases, and this is a normal finding
3. the toddler is too busy to eat, so give finger foods like hot dogs, grapes, and nuts
4. the toddler's appetite often increases, and it is appropriate to provide a variety of new foods

Hint 641

the toddler's appetite often decreases, and this is a normal finding

Front 642

The most accurate method to measure urine output in an infant is to:

Back 642

1. weigh the diaper before and after the infant voids
2. weigh the infant after each wet diaper
3. have the parents try to catch the urine in a plastic cup
4. insert a foley catheter for all infants who are not potty trained

Hint 642

weigh the diaper before and after the infant voids

Front 643

What is true of intramuscular injections in children younger than 2 years old?
(Select all that apply)

Back 643

1. not possible to give because of poor muscular development
2. possible to give in the vastus lateralis muscle
3. possible to give in the ventrogluteal muscle
4. possible to give in the deltoid muscle

Hint 643

2,3

Front 644

The most common asymmetry with lateral curvature of the spine in the adolescent is known as _________

Back 644

scoliosis

Front 645

To examine a 6 month old child's ear with an otoscope, the nurse pulls the ear:

Back 645

1. up and back
2. down and forward
3. up and downward
4. down and back

Hint 645

down and back

Front 646

What are the general features of nephrotic syndrome?

Back 646

1. gross hematuria, albuminuria, temperature of 101F to 103F
2. elevated blood pressure, weight loss, hematuria
3. albuminuria, edema, puffiness of face
4. edema, albuminuria, hypertension

Hint 646

albuminuria, edema, puffiness of face

Front 647

Which factor predisposes the urinary tract to infection?

Back 647

1. a short urethra in young females
2. frequent emptying of the bladder
3. an increased fluid intake
4. ingestion of highly acidic juices

Hint 647

a short urethra in young females

Front 648

Which statement best describes acute glomerulonephritis?

Back 648

1. it is a syndrome in which there is impaired reabsorption of bicarbonate or excretion of hydrogen ions
2. it occurs after an antecedent streptococcal infection
3. it is a disorder manifested by gross bacteria
4. it is a disorder associated with a defect in the ability to concentrate urine

Hint 648

it occurs after an antecedent streptococcal infection

Front 649

Which statement regarding Wilms' tumor is true?

Back 649

1. the tumor manifests as a firm, nontender, intra-abdominal mass
2. the tumor is sometimes difficult to distinguish from the spleen
3. the tumor usually crosses the midline
4. if the surgeon successfully removes the tumor without a tear in its capsule, no chemotherapy is needed

Hint 649

the tumor manifests as a firm, nontender, intra-abdominal mass

Front 650

What is an important nursing intervention when caring for a child who is experiencing a seizure?

Back 650

1. describe and record the seizure activity observed
2. restrain the child when seizures occur to prevent bodily harm
3. place a tongue blade between the teeth if they become clenched
4. suction the child during a seizure to prevent aspiration

Hint 650

describe and record the seizure activity observed

Front 651

What clinical manifestations are suggestive of hydrocephalus in a neonate?

Back 651

1. bulging fontanelle, dilated scalp veins
2. depressed fontanelle, decreased blood pressure
3. constant low pitched cry, restlessness
4. closed fontanelle, high pitched cry

Hint 651

bulging fontanelle, dilated scalp veins

Front 652

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results; however, the mother refuses to see or hold her baby. What is the most therapeutic initial approach to the mother?

Back 652

1. restate what the physician has told her about plastic surgery
2. encourage her to express her feelings
3. emphasize the normalcy of her baby and the baby's need for mothering
4. keep the baby and mother apart until the lip has been repaired

Hint 652

encourage her to express her feelings

Front 653

How is Hirschsprung's disease best described?

Back 653

1. absence of paraympathetic ganglion cells in a segment of the colon
2. passage of excessive amounts of meconium in the neonate
3. results in excessive perstaltic movements within the gastrointestinal tract
4. results in frequent evacuation of solids, liquids, and gas

Hint 653

absence of parasympathetic ganglion cells in a segment of the colon

Front 654

Telescoping of one segment of bowel within another is called:

Back 654

1. atresia
2. stenosis
3. herniation
4. intussusception

Hint 654

intussusception

Front 655

Which condition is often associated with severe infantile diarrhea?

Back 655

1. metabolic acidosis
2. metabolic alkalosis
3. respiratory acidosis
4. respiratory alkalosis

Hint 655

metabolic acidosis

Front 656

A 3yo in the emergency evaluation unit has a spiral fracture of the femur. It is important to recognize that:

Back 656

1. spiral fractures are often signs of child abuse
2. spiral fractures are common in 3 year olds
3. the bone will heal quickly without intervention
4. the child will have one leg that is much shorter than the other

Hint 656

spiral fractures are often signs of child abuse

Front 657

A 6 month old is suspected to have cystic fibrosis. The diagnostic test most commonly used for cystic fibrosis is:

Back 657

1. bronchoscopy, with pulmonary washings
2. chest x-ray study
3. upper GI series
4. sweat test

Hint 657

sweat test

Front 658

A 16yo is being treated for acne. The nurse knows that:

Back 658

1. acne is not life threatening and will not affect the adolescent in any way
2. acne, although not life threatening, is likely to have a psychosocial effect on the adolescent
3. all teenagers have acne; therefore it is not of any significance
4. acne is the major cause of psychological problems in adolescents

Hint 658

acne, although not life threatening, is likely to have a psychological effect on the adolescent

Front 659

A 5yo pt is admitted to the pediatric unit in sickle cell crisis. Which nursing intervention(s) will be included?
(Select all that apply.)

Back 659

1. strenuous exercise of the extremities to increase oxygen to the area
2. aministration of IV fluids to improve circulation and hydration
3. administration of analgesics as ordered
4. administration of oxygen as ordered

Hint 659

2, 3, 4

Front 660

Pharmacologic management of nephrotic syndrome usually involves which classification of medications?

Back 660

1. antibiotics
2. diuretics
3. antihypertensives
4. corticosteroids

Hint 660

corticosteroids

Front 661

When interviewing parents of an infant with hypertrophic pyloric stenosis, the nurse will expect the parents to report the symptom of:

Back 661

1. diarrhea
2. projectile vomiting
3. poor appetite
4. constipation

Hint 661

projectile vomiting

Front 662

An 8yo is admitted to the health center with cystic fibrosis. She has a hx of chronic pulmonary and sinus problems. The nurse knows that cystic fibrosis is a hereditary disorder where there is a generalized dysfunction of the exocrine. It especially involves the:

Back 662

1. thyroid gland
2. sebaceous glands
3. mucous glands
4. salivary gland

Hint 662

mucous glands

Front 663

Which assessment fora pt who is 2 1/2yo with Wilms' tumor will the nurse not perform?

Back 663

1. auscultate lung sounds
2. palpate the abdomen
3. check skin turgor
4. palpate femoral and dorsalis pedis pulses

Hint 663

palpate the abdomen

Front 664

Which disorder is not contagious?

Back 664

1. impetigo
2. Staphylococcus aureus infection
3. infantile eczema (atopic dermatitis)
4. pediculosis

Hint 664

infantile eczema (atopic dermatitis)

Front 665

Which disorder presents the greatest risk to the child with hemophilia?

Back 665

1. hematuria
2. hemarthrosis
3. intracranial bleeding
4. anemia

Hint 665

hemarthrosis

Front 666

The highest incidence of iron deficiency anemia occurs in which age-group?

Back 666

1. early infancy
2. 6 and 24 months
3. the preschooler
4. the school age child

Hint 666

6 and 24 months

Front 667

In discussing an 11 month old's diet, which statement by her mother indicates a possible cause for iron deficiency anemia?

Back 667

1. "Formula is so expensive. We switched to regular milk early on."
2. "She almost never drinks water."
3. "She doesn't really like peaches or pears, so we stick to bananas for fruit."
4. "I give her a piece of bread now and then. She likes to chew on it."

Hint 667

"Formula is so expensive. We switched to regular milk early on."

Front 668

A priority of postoperative nursing care for a 9 month old infant who has a cleft palate repair is:

Back 668

1. referral to a parent support group
2. adequate nutrition
3. keeping an intravenous line open
4. continuous sedation

Hint 668

adequate nutrition

Front 669

Which statement made by a 7yo pt with type 1 DM indicates a need for more teaching?

Back 669

1. "My pancreas is sick and needs insulin until it gets better."
2. "I will need to take my insulin every day."
3. "I need to keep a piece of candy in my pocket in case I start to feel shaky."
4. "My mom has to give me insulin shots twice a day."

Hint 669

"My pancreas is sick and needs insulin until it gets better."

Front 670

The nurse is discussing possible causes of a 4yo child's cognitive impairment with his mother. Which should be included?

Back 670

1. metabolic disorders, perinatal anoxia, hyperthyroidism
2. Perinatal infection, metabolic disorders, and postmaturity
3. lead poisoning, prematurity, perinatal anoxia
4. iron overload, toxoplasmosis, maternal drug use

Hint 670

lead poisoning, prematurity, perinatal anoxia

Front 671

A 2 month old is diagnosed with Down syndrome. Which clinical manifestation supports this diagnosis?

Back 671

1. pointed nose
2. small, rounded skull with flat occiput; simian crease
3. small tongue
4. downward-slanting eyes

Hint 671

small, rounded skull with flat occiput; simian crease

Front 672

A 3yo girl has been sexually abused by her uncle. During her evaluation at the emergency department, which is an appropriate nursing intervention?

Back 672

1. avoid touching the child without a parent's permission
2. question the child only when the parent is present
3. ask the child direct questions about the incident to gather factual information
4. document any manifestations of abuse carefully in the medical record

Hint 672

document any manifestations of abuse carefully in the medical record

Front 673

The current term used to describe subaverage intellectual function is:

Back 673

1. mental retardation
2. attention deficit
3. cognitive impairment
4. enuresis

Hint 673

cognitive impairment

Front 674

What are the three broad categories of child abuse?
(Select all that apply)

Back 674

1. physical
2. emotional
3. socioeconomic
4. sexual

Hint 674

1, 2, 4

Front 675

When a child is beginning antidepressant medications, it is important for parents to be alert for signs of _______ ________ for the first 2 weeks of treatment.

Back 675

suicidal tendencies

Front 676

The parents of a 12yo are concerned about the child's recent dx of school avoidance. When supporting them, the nurse will:

Back 676

,