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676 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
The student interested in attending an accredited school for practical nursing knows than an accredited program:
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
is necessary before the graduate is eligible to take the NCLEX-PN
The acute awareness by the health care consumer of preventive medicine has resulted in an increase in:
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)
knowledge and services to promote health and prevent illness (wellness-illness continuum)
The factor that best advanced the practice of nursing in the first century was the:
1. growth of cities
2. better education of nurses
3. teachings of Christianity
4. improved conditions for women
teachings of Christianity
Nursing education programs may seek voluntary accreditation by the appropriate council of the:
1. American Nurses Association
2. International Council of Nurses
3. Congress for Nursing Practice
4. National League for Nursing
National League for Nursing
When developing a definition of "health," a person should consider that health is:
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
a condition of physical, mental, and social well-being and absence of disease
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:
1. the wellness-illness continuum
2. the Pt Care Partnership
3. holistic nursing
4. the health care delivery system
holistic nursing
The student nurse reviewing the history of nursing knows that the "Lady with the Lamp" is:
1. Clara Barton
2. Florence Nightingale
3. Phoebe
4. Lavinia Dock
Florence Nightingale
The American Society of Superintendents of Training Schools of Nursing was established in 1894. The major goal of this organization was:
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
to set educational standards for nurses
The ancient Hebrews, according to the Talmud and the Old Testament, documented several health and disease practices. They are also attributed with:
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
the first practice of public health and home health
The student nurse who is studying the history of health care recognizes that Hippocrates is credited with the development of:
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
the first ethical guide for medical conduct
Care delivered by RNs and LPNs is legally defined as their scope of practice, which is determined by:
1. the nursing process
2. the nurse in charge
3. the Hippocratic Oath
4. the nurse practice act
the nurse practice act
The nursing student knows that the first nursing theorist was:
1. Phoebe
2. Clara Barton
3. Florence Nightingale
4. Sister Calista Roy
Florence Nightingale
The most commonly used model that assists in the understanding of the pt's place on the wellness-illness continuum is:
1. Abraham Maslow
2. Dorothea Dix
3. Clara Barton
4. Theodore Fliedner
Abraham Maslow
The first nurse to train in America was:
1. Lavinia Dock
2. Linda Richards
3. Clara Barton
4. Mary Breckenridge
Linda Richards
The first school dedicated to the training of the practical nurse in the United States was:
1. the Ballard School
2. the YWCA
3. the Thompson Practical Nursing School
4. the Shepard-Gill School
the Ballard School
Health is:
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
a state of complete physical, mental, and social well-being
Men in nursing:
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
are regaining their historical position in the profession as nurses
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:
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
define the scope of nursing practice
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:
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
maintain the pt's right to privacy
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:
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
be found guilty of malpractice
The pt refused to take the medication his doctor ordered for relief of pain. The LPN knows this is a pt right established by:
1. the principle of beneficence
2. the doctrine of negligence
3. specific nurse practice acts
4. the Pt Self-Determination Act
the pt self-determination act
The LPN/LVN knows that that one of the best defenses against a lawsuit is for a nurse to:
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
promote a positive nurse-pt relationship
The nurse believes that all pts should be treated as individual. The ethical principle that this belief reflects is:
1. autonomy
2. beneficence
3. nonmaleficence
4. respect for people
respect for people
LPN/LVNs have a code of professional and personal ethics to follow. The purpose of a code of ethics is to:
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
promote trustworthy, accountable LPN/LVNs
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
1. confidentiality and invasion of privacy
2. informed consent, beneficence, and respect
3. respect for people and personal autonomy
4. nonmaleficence, justice, and liability
confidentiality and invasion of privacy
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:
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
spend time performing value clarification to aid in identifying her feelings about this new role
The LPN knows that the purpose of an advance directive is to:
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
allow a pt to exercise the right of autonomy
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:
1. nonmaleficence
2. justice
3. autonomy
4. beneficence
justice
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:
1. civil battery
2. malicious homicide
3. criminal negligence
4. invasion of privacy
civil battery
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:
1. Nurse Practice Act of the US
2. Nurse Practice Act of NY
3. Universal Nurse Practice Act
4. Nurse Practice Act of Ohio
Nurse Practice Act of Ohio
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:
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
violated the pt's right to privacy
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:
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
has violated HIPAA
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:
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
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
The pt is fearful concerning upcoming surgery. Which statement by the nurse would be most therapeutic?
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."
"Sometimes anxiety is not easy to deal with. Can you tell me what is bothering you the most?"
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:
1. reflection
2. paraphrasing
3. minimal encouragement
4. focusing
focusing
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?
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."
"You're feeling especially nervous?"
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:
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
remain silent and hold the pt's hand
Which of the following is an example of clarification?
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?"
"In other words, you feel that your stomachaches are associated with stress at work?"
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:
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
Show the pt the equipment and illustrations of the process
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?
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."
"You feel that if you had been diagnosed earlier, this situation might be different"
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:
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
face the pt and speak slowly and distinctly
Which statement by the student nurse is an example of assertive communication
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?"
"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?"
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:
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."
"You feel that there is no reason to stop smoking now?"
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?
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?"
"Tell me more about being frightened by having cancer."
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?
1. Closed question
2. Reflection
3. Minimal encouragement
4. Paraphrasing
Closed question
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?
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?"
"Let me show you some ways to make crutch walking easier for you."
Which method would be most appropriate for communicating with an alert pt on a ventilator with an endotracheal tube in place?
1. Open-ended questions
2. Communication board
3. Reflection
4. Restatement
Communication board
The pt is in a coma following a motor vehicle accident. Which statement regarding communication with the pt is most appropriate?
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
Speak to the pt as if he can hear what is being said
Which statement is true?
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
Some form of communication takes place each time there is an interaction between individuals
Which communication technique is always considered appropriate?
1. Active listening
2. Silence
3. Touch
4. Eye contact
Active listening
The nurse is providing discharge instructions to a pt. Which action would provide the most accurate assessment of understanding by the pt?
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
Asking the pt to repeat the instructions
Which nurse-pt interaction usually occurs in the "personal zone" of space surrounding the pt?
1. uretheral catheterization
2. complete bed bath
3. discharge instructions
4. enema administration
discharge instructions
Which approach would be most appropriate for effective communication with a pt with cognitive impairment?
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
Using simple sentences and avoiding detailed explanations
A 44yo pt is undergoing antibiotic therapy for pneumonia. His rectal temperature reading is 101.4F. His oral temperature would be considered to be:
1. 101.6F (38.7C)
2. 100.6F (38.1C)
3. 99.6F (37.5C)
4. 97.6F (36.4C)
100.6F (38.1C)
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:
1. constant
2. intermittent
3. remittent
4. crisis
intermittent
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):
1. carotid pulse
2. radial pulse
3. apical pulse
4. brachial pulse
apical pulse
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:
1. 30 to 60
2. 12 to 20
3. 8 to 12
4. 24 to 30
12 to 20
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:
1. 160/100
2. 140/90
3. 130/70
4. 120/80
120/80
A 65yo man has a hx of emphysema resulting from 30 years of cigarette smoking. He frequently complains of dyspnea. Dyspnea is defined as:
1. pallor
2. absence of retractions
3. cyanosis
4. difficulty breathing
difficulty breathing
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:
1. bradycardia
2. tachycardia
3. tachypnea
4. hypertension
tachycardia
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:
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
question the pt about syncope
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:
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
deflates the cuff rapidly and waits 15 to 30 seconds before reinflating
The nurse has been assigned several pts. Which one of the following pts is more likely to have a higher than normal temperature?
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
a pt experiencing strong emotions
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?
1. 40
2. 88
3. 140
4. 102
88
The nurse is preparing to assess a 2 day old infant's pulse rate. Which site should be used?
1. scalp artery
2. femoral artery
3. apical site
4. radial site
apical site
Nurses often assess for the apical and radial pulses. Which statement is correct concerning the apical and radial pulse measurements?
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
the apical and radial pulses are taken at the same time for 60 seconds
The physician ordered and orthostatic BP measurement. Which statement is correct concerning the orthostatic method of assessing BP?
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
the measurement is taken in the supine position, then sitting up, and then when the pt is standing
The pt's oral temperature is 37C. The nurse reports that the pt is:
1. febrile
2. afebrile
3. hypotensive
4. hypertensive
afebrile
The nurse recalls that an important factor in the measurement of VS is that:
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
all measuring equipment is chosen on the basis of the pt's conditions and characteristics
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:
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
the pt's head injury causing interference with the function of the hypothalamus
A pulse deficit provides information about the heart's ability to adequately perfuse the body. A pulse deficit is:
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
the difference between the radial and the apical pulse rates
The nurse finds that the pt's oral temperature is 98.8F (37.1C). The next nursing action is to:
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
compare this with the pt's baseline
To measure the pt's radial pulse rate, the nurse:
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
palpates a superficial artery at the medial side of the wrist
The assistive personnel report to you that the pt is feeling "funny." The nurse's first action would be to:
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
obtain the pt's VS yourself
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:
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
measure a 60 second apical pulse
When documenting a pt's blood pressure, the systolic pressure is recorded as the point at which the:
1. first Korotkoff sound appears
2. second Korotkoff sound appears
3. fourth Korotkoff sound appears
4.fifth Korotkoff sound appears
first Korotkoff sound appears
Which method of measuring temperature reveals core temperature?
1. skin
2. temporal
3. oral
4. axillary
oral
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:
1. radial artery
2. carotid artery
3. brachial artery
4. femoral artery
carotid artery
When teaching the pt about monitoring his own pulse, the nurse informs the pt that the pulse may be elevated by:
1. taking beta blockers
2. fever
3. sleeping
4. standing up to quickly
fever
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:
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
has a BP above normal range on two subsequent clinic visits
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:
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
a blood pressure cuff that is too small will give inaccurately high readings
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:
1. 5% to 35%
2. 10% to 40%
3. 20% to 50%
4. 30% to 60%
10% to 40%
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:
1. 1L
2. 10L
3. 100L
4. 1000L
1L
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?
1. purulent
2. pus
3. pain
4. pallor
pain
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?
1. posteriorly
2. anteriorly
3. laterally
4. superiorly
posteriorly
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?
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
sit down at eye level with the pt and allow a longer period to answer each question
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:
1. nonpitting edema
2. 2+ pedal pulses
3. 3+ pitting edema
4. 2+ pitting edema
3+ pitting edema
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?
1. head-to-toe assessment
2. focused assessment
3. system-by-system assessment
4. complete assessment
focused assessment
A 72yo man is admitted for chest pain. How would the nurse document the information the pt gives about his symptoms?
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
use the pt's own words in quotation marks
During the review of systems, the nurse questions the 88yo pt about her gastrointestinal system. The nurse will ask about what symptom?
1. wheezing
2. pyrosis (heartburn)
3. polyuria
4. dyspnea
pyrosis (heartburn)
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?
1. assess for LOC and orientation
2. assess the skin
3. listen to lung sounds
4. check for pitting edema
assess for LOC and orientation
A 56yo woman has been admitted for dehydration after a prolonged period of diarrhea. Which finding do you expect to observe in this pt?
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
skin hot, dry, pale, with decreased skin turgor
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):
1. palpation
2. thrill
3. bruit
4. aneurysm
thrill
Which position is not used to assess the female genitalia?
1. high fowler's
2. dorsal recumbent
3. lithotomy
4. sims'
high fowler's
Which risk factor for cardiovascular disease can be modified?
1. age
2. race
3. diet
4. family history
diet
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:
1. sonorous
2. bradypnea
3. tachypnea
4. apnea
tachypnea
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:
1. coarse crackles
2. sonorous wheezes
3. pleural friction rub
4. sibilant wheezes
coarse crackles
The nurse assesses a 72yo pt who complains of a severe headache and vertigo. These data would be classified as:
1. objective data
2. subjective data
subjective data
Which would be included in an assessment of the peripheral vascular system? (Select all that apply)
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+
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+
The normal rate of bowel sounds is _______ per minute
1. 2 to 18
2. 22 to 44
3. 4 to 32
4. 38 to 52
4 to 32
The main reason that auscultation precedes palpation of the abdomen is to:
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
prevent distortion of bowel sounds
Which is a medical diagnosis?
1. acute pain
2. pneumonia
3. activity tolerance
4. ineffective airway tolerance
pneumonia
Which nurse is demonstrating critical thinking?
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)
the nurse who checks the accuracy of an intravenous pump used to deliver medications
The student who plans to use Nursing Interventions Classification material will benefit from a list of:
1. nursing interventions
2. nursing activities
3. nursing outcomes
4. nursing indicators
nursing activities
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:
1. RN team leader
2. social worker
3. case manager
4. physician
case manager
Which diagnosis includes all appropriate components of an actual nursing diagnosis?
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
fear related to separation from support system manifested by statements of being scared, pallor, and increased respirations
"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:
1. an actual nursing diagnosis
2. a risk nursing diagnosis
3. a wellness nursing diagnosis
4. a medical nursing diagnosis
an actual nursing diagnosis
Based on Maslow's hierarchy of needs, which nursing diagnosis label has the highest priority?
1. risk for aspiration
2. deficient fluid volume
3. acute pain
4. stress urinary incontinence
risk for aspiration
Which pt outcome statement meets the necessary criteria?
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
the pt will have a soft, formed bowel movement on the third day after nursing interventions
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?
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
the pt will maintain adequate hydration as evidenced by moist mucous membranes; elastic skin turgor; and voiding of clear dilute urine
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:
1. the nursing process
2. a nursing diagnosis
3. an outcome statement
4. a nursing order
a nursing order
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:
1. the pt's parents
2. the pt
3. the physician
4. the admissions nurse
the physician
A pt who describes his illness is providing:
1. subjective data
2. objective data
3. overt data
4. signs of his illness
subjective data
Defining characteristics:
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
tell how the nursing diagnosis is manifested
The main purpose of cue clustering is to:
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
assist in the formation of a nursing diagnosis
Which nursing diagnostic label would be ranked first in priority?
1. risk for ineffective airway clearance
2. colonic constipation
3. alteration in nutrition: less than body requirements
4. total urinary incontinence
risk for ineffective airway clearance
The phrases used to connect the parts of a nursing diagnosis are:
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"
"due to" and "as evidenced by"
During the last phase of the nursing process, the nurse:
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
compares the desired outcome with the actual outcome
A nursing diagnosis expresses:
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
the pt's needs according to Maslow's hierarchy
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?
1. the pt
2. the pt and his wife
3. the physician
4. the medical record
the pt and his wife
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?
1. unwillingness to ambulate
2. increased swallowing of saliva
3. statements describing acid reflux
4. decreased awareness of his environment
increased swallowing of saliva
Which choice constitutes objective data?
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
7-inch transverse abdominal incision
A newborn has the nursing diagnosis of risk for ineffective thermoregulation. What is the most accurate outcome for this diagnosis?
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
Parents state that they will keep their infant's temperature between 97.5F and 98.6F
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:
1. the nursing diagnosis
2. the etiologic or related factor
3. the defining characteristic
4. not necessary for writing the statement
the defining characteristic
Which example includes all appropriate components of a risk for nursing diagnosis?
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
risk for aspiration related to difficulty swallowing
When documenting care and observations in a pt record:
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
use of approved medical terms and abbreviations is permitted
Patient health care records are:
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
concise, legal records of all care given and responses
When the POMR method is used for documentation:
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
the charting format is SOAPE or SOAPIER
The nurse is using the SOAPE method to chart. In this method the S stands for:
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
subjective information the pt states or feels
When charting, the nurse should:
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
chart as soon and as often as necessary
Understanding that health care personnel must respect the confidentiality of pt's records, the nurse:
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
reads charts only for a professional reason
The use of computers in the hospital by nurses:
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
can save on charting time once nurses are comfortable using computers
When completing an incident report, the nurse is aware that it is necessary to:
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
document facts regarding the incident
Which statement is correct about formats for documentation?
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
charting by exception documents those conditions, interventions, or outcomes outside the norm
Which statement is a recommended guideline for charting?
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
have the pt's name and identification number on every sheet
The 24-hour pt care record-keeping system is useful in:
1. shortening the pt's hospital stay
2. keeping a more detailed account
3. ensuring the pt's privacy
4. consolidating the nursing record
consolidating the nursing record
Acuity charting requires:
1. staff to document their interventions
2. detailed assessment information
3. a pt's successful recovery from surgery
4. a discharge summary
staff to document their interventions
Which statement is a safe principle of computerized charting?
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
do not leave pt information displayed on the monitor
Which accreditation agency specifies guidelines for documentation?
1. The Joint Commission (JTC)
2. American Nurses Association
3. National League of Nursing
4. American Academy of Colleges f Nursing
The Joint Commission (JTC)
The primary purpose of Title II of HIPAA is to:
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
maintain privacy and confidentiality of pt's health information
Which statement is correct about abbreviations?
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
every facility should have an approved abbreviations list
When comparing documentation for acute care in hospitals with documentation for long-term care, major differences are related to:
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
the prospective payment system determining the standards for reimbursement
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:
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
unacceptable because it is vague subjective data without supportive data
The best description of narrative documentation is that it:
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
describes occurrences in chronological order
In most states, pts can gain access to their medical records by:
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
submitting a written request to the facility to view the record
Standards and policies regarding documentation in long-term care facilities is guided by:
1. MDS
2. CBE
3. DARE
4. POMR
MDS
The government reimburses agencies for health care costs incurred by Medicare and Medicaid recipients based on:
1. thorough documentation by the nurse
2. submission of appropriate physician progress notes
3. clinical (critical) pathways
4. diagnosis-related groups (DRGs)
diagnosis-related groups (DRGs)
The nurse works in a community with many Mexican-American families. The best way for her to learn about their culture would be to:
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
conduct a library study or internet search of information on the culture
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?
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
contact an adviser who is familiar with the cultural beliefs of the pt
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:
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
as a Muslim, the pt must keep as much of her body covered as possible
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:
1. biomedical
2. folk
3. holistic
4. a combination of all 3
folk
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:
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
consider that the child may be there to serve as an interpreter
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:
1. subculture oriented
2. stereotyping
3. ethnocentric
4. culturally racist
ethnocentric
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:
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
the pt is a Muslim, so only women should be assigned to care for her
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:
1. fate and God's will
2. socioeconomic class
3. getting what you deserve
4. physiologic changes
physiologic changes
The nurse is planning to do a cultural assessment of a Chinese-American pt. It would be best if the nurse:
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
touches the pt frequently to convey concern
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?
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
understand that he is possibly less tolerant of other races because of his own cultural experiences or he perhaps has disturbed cognitive functions
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:
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
quietly leave the room and give the pt privacy to pray
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:
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
lactose intolerance occurs often among Mexican-Americans
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:
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?"
"You must follow the physician's order if you want to get better."
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:
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
an inability to understand each other is the problem, not impaired verbal communication
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:
1. stereotyping
2. ethnocentric
3. culturally aware
4. culturally competent
culturally competent
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:
1. Hispanic in origin
2. patriarchal
3. male dominated
4. traditional nuclear
patriarchal
According to Piaget, thinking during the first few months is primarily based on:
1. imitation
2. intuition
3. logical operations
4. reflex behavior
reflex behavior
The first socializing agent for the child is:
1. daycare
2. family
3. school
4. play groups
family
At 4 years of age, a child is working on Erikson's task of:
1. trust vs mistrust
2. industry vs inferiority
3. autonomy vs shame and doubt
4. initiative vs guilt
initiative vs guilt
Which type of play is most common at ages 4 and 5?
1. solitary
2. parallel
3. competitive
4. make-believe
make-believe
Growth during the school-age period:
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
is slow and consistent
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:
1. autonomy
2. initiative
3. industry
4. identity
industry
Peak physical strength and endurance occurs during:
1. adolescence
2. early adulthood
3. middle adulthood
4. late adulthood
early adulthood
Menopause usually occurs:
1. in the early 30s
2. by age 40
3. in the late 50s
4. in the late 40s to early 50s
in the late 40s to early 50s
In correcting the myths about aging, the nurse recognizes that healthy older adults:
1. have periods of confusion
2. are likely to become senile
3. have few or no sexual needs
4. have a slower reaction time
have a slower reaction time
The principle that describes the direction of growth beginning at the head and moving to the lower extremities is call:
1. integrated
2. proximodistal
3. cephalocaudal
4. differential
cephalocaudal
The cognitive approach to understanding development is explained by __________ theory.
1. Maslow's
2. Piaget's
3. Erikson's
4. Skinner's
Piaget's
Following fertilization, the newly formed structure is known as a:
1. gene
2. chromosome
3. zygote
4. germ cell
zygote
According to Erikson, when the infant is cuddled, fed, and loved, the infant will develop:
1. autonomy
2. trust
3. industry
4. identity
trust
The type of play typical of the preschool child is:
1. parallel play
2. imaginary play
3. organized, team play
4. cognitive play
imaginary play
According to Piaget, the child between 7 and 11 years of age is in the:
1. sensorimotor stage
2. preoperational stage
3. stage of concrete operation
4. stage of formal operation
stage of concrete operation
In the female, the onset of postpuberty period is marked by the onset of:
1. breast development
2. appearance of pubic and axillary hair
3. menarche
4. mood changes
menarche
The typical adolescent is likely to:
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
reject the advice of elders
According to Erikson, the task for the young adult is:
1. trust vs mistrust
2. identity vs confusion
3. generativity vs stagnation
4. intimacy vs isolation
identity vs confusion
Which are health-promoting behaviors the nurse will recommend? (Select all that apply)
1. regular medical checkups
2. appropriate prescription use
3. sedentary lifestyle
4. eating low-cholesterol foods
regular medical checkups, appropriate prescription use, eating low-cholesterol foods
Which segment of the population is currently the fastest growing?
1. Baby boomers
2. from 65-70 years of age
3. from 71-80 years of age
4. older than 85 years of age
older than 85 years of age
A 2yo's negative behavior is normal for her age. It is helping her to meet her need for:
1. discipline
2. trust
3. independence
4. love
independence
The period of cognitive development when the child's knowledge comes about through sensory impressions is called:
1. preoperational
2. sensorimotor
3. concrete operational
4. formal operational
sensorimotor
Growth during the school-age period can best be described as:
1. irregular and slow
2. steady and slow
3. regular and fast
4. irregular and fast
steady and slow
Typical behavior for toddlers includes:
1. role modeling
2. ritualistic behavior
3. competitiveness
4. industry
ritualistic behavior
During early adulthood, individuals are physically:
1. beginning to deteriorate
2. already slowing down
3. increasing lung capacity and muscle strength
4. fairly stable at optimal level of function
fairly stable at optimal level of function
To counteract the effect of aging, ________ will help to increase the flow of ________.
1. rest; blood
2. sleeping; oxygen
3. exercise; oxygen
4. carbohydrates; oxygen
exercise; oxygen
Teach pts that influenza immunization:
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
is contraindicated for use by people who are allergic to eggs or egg products
Advise older adults in nutritional counseling to:
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
eat a diet low in saturated fats and carbohydrates
According to Erikson, the developmental tasks for older adults are:
1. intimacy vs isolation
2. generativity vs stagnation
3. ego integrity vs despair
4. initiative vs guilt
ego integrity vs despair
Which developmental skill is commonly accomplished by the fourth month of life?
1. sitting up unsupported
2. holding head up at 90-degree angle
3. creeping
4. transferring objects from one hand to the other
holding head up at 90-degree angle
The introduction of solid foods to the infant should rely on:
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
introducing one new food at a time
Nighttime bottles should be avoided since milk and juice during the night lead to:
1. dental caries
2. dental malocclusion
3. otitis media
4. lactose intolerance
dental caries
Preschool children need to be tested for amblyopia. This condition may lead to:
1. blindness
2. deafness
3. muscle weakness
4. paralysis
blindness
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:
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
the final stage of human growth and development
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:
1. poor nursing care
2. grief reaction
3. withdrawal
4. bereavement
withdrawal
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:
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
on an individualized basis
A 77yo pt has been admitted with pneumonia. Her husband asks the nurse about the living will. The nurse remembers that living wills:
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
allow the individual to express his or her wishes regarding care
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:
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
remain with the daughter and listen to what she is saying
A newly licensed nurse is assigned to his first pt. The nurse would be best prepared to care for this pt if he:
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
has resolved the matter of his own mortality
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:
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
assist her in obtaining the necessary information to make this decision
A person experiences anticipatory grief when he:
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
faces the possibility of losing a loved one
The phases of bereavement:
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
usually do not occur in order
When preparing a deceased pt for family viewing, the nurse:
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
removes all equipment (tubes, drains, etc.) unless an autopsy has been ordered
Which is an appropriate therapeutic listening technique?
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
talking slowly and encouraging family members to share their feelings
The nurse helps family members to make difficult decisions by:
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
addressing one matter at a time, giving them adequate time to discuss each time
Which phrase is most likely to help a grieving family member express himself or herself more easily?
1. "Tell me how you're feeling."
2. "I know just how you feel."
3. "Things will get better."
4. "Time heals all wounds."
"Tell me how you're feeling."
If a bereaved family member has an unresolved issue with a deceased pt, the nurse should tell him:
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
to verbalize his thoughts and feelings to his loved one
For those who work with grief, death, and dying, it is essential to have constant vigilance over their:
1. pts
2. own issues
3. schedules
4. colleagues
own issues
Nurses care for all types of pts with various conditions, including those with a terminal illness. Which statement is true?
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
Death from terminal illness is sudden and unexpected
Many forces influence living and dying. Which psychological force influences living and dying?
1. hope and the will to live
2. reincarnation and belief in the afterlife
3. denial and anger
4. bargaining and depression
hope and the will to live
There are many issues related to dying and death. One of the more controversial is euthanasia. Euthanasia is defined as:
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
an "easy death"
Special considerations for children are necessary when dealing with death. Children between ages 5 and 7 years view death as:
1. temporary
2. final
3. something adults do
4. going to sleep
final
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?
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
sitting with her and allowing her to express herself
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:
1. acute care
2. mourning care
3. palliative care
4. terminal care
palliative care
A factor that uniquely influences an older adult's grief response is:
1. cultural background
2. socioeconomic resources
3. sense of contribution in life
4. support available from family members
sense of contribution in life
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:
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
vital organs such as the heart and pancreas must be harvested while the pt remains on the ventilator
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:
1. intrusive memories
2. dysfunctional or complicated grief
3. sense of presence
4. grief attacks
sense of presence
When giving postmortem care, if the pt is in the supine position, it is best to place:
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
arms at the sides of the body with the palms facing down
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:
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
anytime following the dx of the terminal illness
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:
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
encourage the children to speak with the physician regarding their concerns
During the registration process, the admission clerk is responsible for:
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
ensuring the pt has an allergy band
A 36yo schoolteacher is admitted for observation and various diagnostic tests. The initial nursing action in her admission process is to:
1. introduce self and roommates
2. measure VS
3. help her get undressed and into bed
4. notify the physician
introduce self and roommates
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:
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
never appropriate
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):
1. pt-initiated transfer
2. interagency transfer
3. business office transfer
4. intraagency transfer
intraagency transfer
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:
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
the pt is a human being deserving dignity, courtesy, and respect
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:
1. make certain the pt takes her medication as prescribed
2. provide medical treatment
3. provide ongoing pt education
4. ensure continuity of care
ensure continuity of care
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:
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
on his admission to the hospital
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:
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
explain the risks of leaving and request that the pt sign a paper accepting responsibility for problems that may occur
The nurse is admitting a pt to the nursing unit. The nurse's first action is to:
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
greet the pt by name
The pt is being discharged. The nurse should:
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
wish the pt well
A pt is being admitted to the hospital for stabilization of her heart condition. Before arriving on the nursing unit, the admissions dept will:
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
have the pt sign consent for treatment
When a pt arrives on the nursing unit, the LPN is probably responsible for:
1. admission charting
2. admission interview
3. formulating nursing dx
4. obtaining VS
obtaining VS
Nursing documentation at discharge should include a:
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
method of discharge
The services of a transition specialist for pt discharge often leads to an increase in:
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
continuity of care from hospital to home
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:
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
prevent transmission of infectious microorganisms
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:
1. wearing a gown
2. placing each pt in isolation
3. hand hygiene
4. wearing gloves
hand hygiene
The nurse caring for the pt in isolation wears latex gloves. Which is an important consideration?
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
first assess the pt for potential latex allergy
The nurse notes that the pt understands proper technique for hand hygiene when the pt states:
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."
"After washing my hands with soap for at least 15 seconds, I will rinse them thoroughly under running water."
Identification of the chain of infection allows health care providers to:
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
determine points at which the infection can be stopped or prevented
A pt in isolation is experiencing signs of social deprivation. Which intervention by the nurse is appropriate?
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
set specific times when the nurse will return to the pt's room
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:
1. acute primary
2. health care-associated
3. interstitial
4. mycoplasmic
health care-associated
Which statement is true of sterile technique?
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
recently opened wrappers are considered sterile to within 1 inch of their edges
Because sterile technique is used in many procedures of pt care, it is important for the nurse to remember to hold sterile objects:
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
above waist level
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?
1. inserting an IV
2. performing perineal care
3. performing oral care
4. obtaining a sputum specimen
inserting an IV
The nurse is performing a surgical hand scrub. During a surgical hand scrub, the hands are held:
1. above the elbows
2. with the fingers pointing down
3. whichever way is convenient
4. just below the waist
above the elbows
To practice strict surgical asepsis, the nurse will:
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
adhere to principles of sterile technique
When donning sterile gloves, the nurse will:
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
touch only the inside surface of the first glove while pulling it onto the hand
To remove gloves at the end of a procedure, the nurse will:
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
remove one glove, then use the bare fingers to push the remaining glove off from inside the cuff
Which is a principle of surgical asepsis?
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
sterile fields and sterilized items are no longer sterile if they contact a clean surface
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:
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
explain isolation procedures and provide meaningful stimulation
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:
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"
it is necessary to separate the items: plastic goes into one bag for gas sterilization, and metal into another to be autoclaved
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:
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
put on sterile gloves to handle the contents of the tray
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?
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
alcohol-based hand cleaner is effective on hands that are not visibly soiled with blood and body fluids
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:
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
remove the gloves, and perform hand hygiene before measuring the VS
The nurse will wear a gown during care of an infected wound for any patient in this type of isolation:
1. airborne precautions
2. droplet precautions
3. contact precautions
4. TB precautions
contact precautions
The nurse is preparing to change the tracheostomy ties on a pt. Which precaution would necessitate wearing a mask?
1. airborne precautions
2. droplet precautions
3. contact precautions
4. standard precautions
droplet precautions
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?
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
the flap that opens away from the nurse
The patient asks the nurse how his skin will be sterilized before his surgery. The nurse's best response is:
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."
"It is not possible to sterilize skin, but we will use an antimicrobial solution to eliminate most microorganisms."
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:
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
to drain the wound area by gravity
Which nursing intervention would be appropriate should the pt's abdominal wound eviscerate?
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
apply warm, moist sterile dressings
The nurse prepares to irrigate a pt's wound. The primary reason for performing this procedure is to:
1. remove debris from the wound
2. decrease scar formation
3. improve circulation from the wound
4. decrease irritation from wound drainage
remove debris from the wound
What is the best indicator that a wound has become infected?
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
purulent drainage is coming from the wound area
Which nursing entry is the most complete in its description of a wound?
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
incisional edges approximated without erythema or exudate; two 4x4s applied
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?
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
assess the skin integrity carefully before reapplying each new bandage
Which statement is correct in regard to the use of an abdominal binder?
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
the pt must have adequate ventilatory capacity
The first step in packing a wound is to:
1. assess its size, shape, and depth
2. prepare a sterile field
3. select gauze packing material
4. irrigate the wound
assess its size, shape, and depth
The correct procedure for the wet-to-dry dressing method is to:
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
place moist gauze into the wound and remove it when it is dry
Serious drainage from a wound is described as:
1. fresh bleeding
2. thick and yellow
3. clear, water plasma
4. beige to brown and foul smelling
clear, water plasma
A binder placed around a surgical pt with a new abdominal wound is indicated for:
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
reduction of stress on the abdominal incision
The purpose of a wet-to-dry dressing is:
1. debridement
2. cooling
3. comfort
4. antiinfection
debridement
A surgical wound infection can be reduced by:
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
changing the dressing using sterile technique
When changing a pt's dressing, which nursing action is correct?
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
free the tape by pulling it away from the incision
When emptying the drainage in a Hemovac reservoir, which nursing action is essential for reestablishing the negative pressure within this drainage device?
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
compress the reservoir and close the vent
Which pt is more at risk for wound dehiscence?
1. the pt who smokes
2. the obese pt
3. the pt with a hx of peripheral vascular disease
4. the immunocompromised pt
the obese pt
Which wound drain is classified as providing gravity-assisting drainage?
1. Jackson-Pratt
2. Hemovac
3. Penrose
4. Wound VAC system
Penrose
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:
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
stop the suture removal and contact the physician immediately
When providing care to a pt with a Hemovac drain, the nurse should:
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
record the appearance of the drainage in the nursing progress notes and include the amount in the intake and output calculations
During assessment of a pt following abdominal surgery, the nurse suspects internal hemorrhaging based on which finding?
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
the dressing is saturated with bright red sanguineous drainage, and the pt has an increased urinary output
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?
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
allow as much freedom of movement as possible when applying SRDs
In the situation of previous question, what is an appropriate goal (expected outcome) for the pt requiring a physical restraint?
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
pt will remain free of injury
Documentation related to use of an SRD is required to include:
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
the specific type of SRD used
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:
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
monitor the skin for signs of impairment
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:
1. notify the fire dept
2. disconnect the oxygen supply
3. use any extinguisher on the fire
4. remove the pt from the area
remove the pt from the area
The patient who requires the use of an extremity SRD has an edematous extremity. The most appropriate nursing action is to:
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
remove the SRD and watch the patient more closely
A type C fire extinguisher is required for which of the following types of fire:
1. paper
2. cloth
3. grease
4. electrical
electrical
When assessing a pt's knowledge of the fire safety precautions, which action indicates the need for further fire safety instruction?
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
a heating pad cord is taped when a frayed area is noted
Which factor places a child at greatest risk for specific types of injuries?
1. sex of the child
2. overall health
3. educational level
4. developmental level
developmental level
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?
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
a school bus accident
Vomiting is most likely to be induced if poisoning is related to the ingestion of which substance(s)?
1. lye
2. petroleum products
3. household cleaners
4. salicylates, such as aspirin
salicylates, such as aspirin
A 63yo pt is brought to the emergency dept for treatment of an accidental poisoning. The first step in the treatment is to:
1. induce vomiting
2. assess the pt
3. place the pt in an upright position
4. notify the poison control center
place the pt in an upright position
Which is the greatest safety issue for caregivers of older adults?
1. accidental poisoning
2. electrical shock
3. accidental falls
4. thermal burns
accidental falls
A potential environmental health threat is the possibility of:
1. bioterrorism
2. noise pollution
3. water pollution
4. air pollution
bioterrorism
In the event of a mercury spill, which statement is true?
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
do not vacuum the spill
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:
1. log-rolling
2. using two nurses to lift
3. a hydraulic lift with a Hoyer sling
4. a gurney lift
a hydraulic lift with a Hoyer sling
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:
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
support her while falling and allow her to sit on the floor
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?
1. assess his temperature
2. assess his pulse and respirations
3. perform an oximetry check
4. remove antiembolism stockings
assess his pulse and respirations
The pt accidentally knocks the emesis basin to the floor. When picking up the emesis basin, the nurse will use proper body mechanics to:
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
flex the knees and bend at the waist
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:
1. use the back muscles
2. use the large muscles across the scapula
3. exert less physical effort
4. use the gluteal muscles
exert less physical effort
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:
1. base of support
2. body alignment
3. head and chin tilt
4. gluteal pressure
body alignment
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:
1. dorsal recumbent
2. lithotomy
3. Sims'
4. prone
dorsal recumbent
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:
1. semi-Fowler's
2. dorsal
3. Sims'
4. orthopneic
orthopneic
The nurse explains to the pt that the log-rolling technique will be used to help the pt change position by stating:
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."
"It is important to keep your neck and spin in straight alignment while we help you move onto your side."
The nurse and an assistant are to move a dependent pt from the supine to the lateral position and will:
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
move the pt to the center of the bed first
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:
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
assess the pt's need for pain medication before helping her change position
A principle of good body mechanics includes:
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
maintaining a wide base of support and bending at the knees
A pt becomes faint while sitting on the side of the bed. To prevent injury to the pt, the nurse will:
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
lay pt straight back and support head
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:
1. pain
2. impaired skin integrity
3. altered tissue perfusion
4. risk for activity intolerance
risk for activity intolerance
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?
1. trapeze bar
2. trochanter roll
3. hand rolls
4. footboard
trapeze bar
In which position is the pt lying face down or chest down?
1. supine
2. lateral
3. prone
4. fowler's
prone
A necessary safety precaution when helping a pt to ambulate is to:
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
have pt wear well-fitting rubber-soled shoes or slippers
Active and passive ROM exercises benefit the pt by preventing:
1. contractures
2. arthritis
3. muscle strain
4. atrophy of surrounding tissue
contractures
A footboard can prevent footdrop, also known as:
1. plantar flexion of the foot
2. dorsiflexion of the foot
3. ankle extension
4. ankle hyperextension
plantar flexion of the foot
When using a drawsheet to assist in moving a pt up in bed, ask the pt to:
1. bend knees to assist in moving
2. keep hands at sides
3. raise arms above the bed
4. maintain straight body position
maintain straight body position
Following surgery for a total knee replacement, a pt was given an epidural catheter for fentanyl epidural analgesia. An important nursing intervention is to:
1. administer additional analgesic medications prn
2. change the epidural dressing every shift
3. assess respiratory rate carefully
4. encourage unassisted ambulation
assess respiratory rate carefully
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:
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."
"Pain is what you say it is; I will assist you in whatever way I can."
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:
1. aspirin
2. acetaminophen
3. morphine
4. ibuprofen
morphine
A drug delivery system to control pain via a portable computerized pump with a chamber for a syringe is called:
1. patient-controlled analgesia
2. transcutaneous electric nerve stimulation
3. a venous access device
4. a placebo
patient-controlled analgesia
The gate control theory of pain suggests that:
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
pain impulses are regulated or even blocked by mechanisms located along the CNS
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:
1. deductive
2. speculative
3. objective
4. subjective
subjective
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:
1. precisely localized
2. referred
3. intermittent
4. chronic
referred
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:
1. visual analog
2. categorical
3. functional
4. numerical
numerical
People who have less pain than others from a similar injury have a:
1. higher level of endorphins
2. lower level of endorphins
higher level of endorphins
Research shows nurses treating pain have a tendency to:
1. overtreat
2. undertreat
undertreat
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:
1. epidural analgesia
2. transcutaneous electric nerve stimulation (TENS)
3. NSAIDs
4. patient-controlled analgesia
transcutaneous electric nerve stimulation (TENS)
Unrelieved pain is:
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
dangerous and can lead to many physical and psychological complications
An important nursing responsibility related to pain is to:
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
believe what the pt says about pain
A nurse believes that pts with the same type of tissue injury will have the same amount of pain. This statement reflects:
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
the nurse's lack of knowledge about pain mechanisms and is likely to contribute to poor pain management
Research indicates that the risk of clinically significant opioid-induced respiratory depression is:
1. less than 1%
2. 5%
3. 20%
4. 30%
less than 1%
Which route is most appropriate for treating rapidly escalating severe pain?
1. oral
2. IM
3. IV
4. transdermal
IV
Which opioid is no longer a drug of choice for managing pain because of its toxic complications, such as causing seizures?
1. codeine
2. morphine
3. meperidine
4. fentanyl
meperidine
Which are reasons that the patient-controlled analgesia (PCA) pumps are frequently used for postoperative pain management?
(Select all that apply)
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
PCAs encourage the use of pain analgesic before the patient experiences severe pain
In selecting alternative therapies, acupressure may be most effective with which patient?
1. restless, anxious patient
2. patient with ulcerative colitis
3. pregnant woman
4. psychiatric patient
restless, anxious patient
The nurse's presentation on alternative therapies for a community group states that herbal therapies are:
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
allowed to be packaged as dietary supplements if they are without health claims
A pt asks about different herbal therapies that may promote physical endurance and reduce stress. On which would the nurse provide information?
1. ginseng
2. ginger
3. echinacea
4. chamomile
ginseng
When assessing a pt's use of alternative therapies, the nurse asks:
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?"
"What types of activities or remedies do you use when you do not feel well?"
Which statement is correct regarding complementary and alternative medicine?
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
one third to one half of the US population uses one or more forms of alternative therapy
A benefit that the pt can gain from relaxation therapy is a decrease in:
1. receptivity
2. peripheral skin temperature
3. oxygen consumption
4. alpha brain activity
oxygen consumption
Which factor makes accurate administration of precise dosages of herbs difficult?
1. multiple clinical trials are under way
2. availability in many different forms
3. infrequent usage by consumers
4. excessive standardization by international organizations
availability in many different forms
Which instruction should be included when teaching a pt about safe herbal product usage?
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."
"Inform your primary care provider of all herbal products you use."
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:
1. acupressure
2. magnet therapy
3. acupuncture
4. chiropractic therapy
acupuncture
Patient teaching about herbal therapies should address which statement?
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
inform the primary care provider of any drugs being used, including herbal remedies
Which is a contraindication for the use of reflexology?
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
presence of heart problems, blood pressure problems, epilepsy, or diabetes
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.
1. massage therapy
2. Chinese medicine
3. shamanism
4. breathwork and imagery
breathwork and imagery
What does holistic nursing address and treat?
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
mind, body, and spirit of the pt
One of the principles of complementary and alternative medicine (CAM) therapies is that the individual becomes:
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
actively involved in the treatment
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:
1. should be taken internally
2. may cause cancer
3. can only be used externally
4. is a known antiseptic
is a known antiseptic
Patients with certain medical diagnoses should avoid chiropractic treatment. These diagnoses include:
1. joint sublaxation
2. vertigo
3. osteoporosis
4. hypertension
osteoporosis
Imagery is used to:
1. gain relief for skin diseases
2. control and relieve pain
3. treat cardiac dysrhythmias
4. gain relief from alcohol addiction
control and relieve pain
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:
1. foods high in salt or sodium
2. milk products
3. anything containing barley, such as beer
4. aged cheese and red wine
anything containing barley, such as beer
When preparing for pt care, a student nurse learns that microorganisms are spread by:
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
placing soiled linens on the floor
During the bed bath, the pt is covered with a bath blanket:
1. to prevent skin impairment
2. for cosmetic purposes
3. to prevent the spread of microorganisms
4. to prevent chilling
to prevent chilling
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:
1. an inflammatory ulcer
2. a pressure ulcer
3. a stasis ulcer
4. the inner canthus
a pressure ulcer
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?
1. back and buttocks
2. eyes, ears, and nose
3. upper torso and thighs
4. upper thighs, genitalia, and anal area
upper thighs, genitalia, and anal area
Which patient would be at greatest risk for skin impairment?
1. child on bed rest
2. infant with cool skin temperature
3. young man with diarrhea
4. a 60yo in a body cast
child on bed rest
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:
1. use only water
2. ask the pt her preference
3. use soap in all areas except the eyes
4. use a cleansing cream
ask the pt her preference
When bathing a 12yo pt with a leg cast, the nurse is aware that proper eye care would be:
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
to use a different section of washcloth for each eye
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:
1. 109.4F
2. 110 to 115F
3. 98 to 100F
4. 85-98C
109.4F
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:
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
reduce temperature in febrile pts
An 80yo uncircumcised man is in the first postoperative day after a transurethral prostatectomy. When administering perineal care, the nurse will:
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
retract the foreskin, cleanse the penis, and return the foreskin with a gently forward motion
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:
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
cleanse from the pubis toward the rectum
Which pt is most at risk for complications of the feet?
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
a 60yo person with DM
An 82yo pt is unconscious and requires meticulous oral hygiene. The optimal position for providing oral hygiene to the pt is ______ to prevent choking.
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
side-lying with head facing to the side
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?
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
cleansing the outer ear with the washcloth during the bath
The student nurse has completed her educational instructions on the correct procedures for bedmaking. Which intervention is correct for bedmaking?
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
washing hands thoroughly after handling soiled linen
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?
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
long, smooth strokes along the length of the back
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?
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
brush dentures with a soft toothbrush
The nurse will position the patient in the 30 degree lateral position to prevent pressure ulcers over the:
1. spinous processes
2. ischial tuberosities
3. greater trochanters
4. occipital prominence
greater trochanters
Stage III pressure ulcers are identified as:
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
full-thickness skin loss extending to but not through the fascia
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:
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
the normal process of healing with healthy granulation tissue
In addition to bathing, which intervention is likely to best promote patient comfort?
1. books or tapes
2. back rub
3. snacks
4. postural drainage
back rub
Pts will experience conditions that threaten the integrity of oral mucosa; therefore:
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
more frequent mouth care is needed
The goal of meticulous foot care for pts is to:
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
prevent injury to the toes and feet
When providing hygiene to the older adult, it is important to remember that the older adult's skin is:
1. fragile with decreased elasticity
2. fragile with increased elasticity
3. fragile with increased circulation
4. fragile with increased muscle mass
fragile with decreased elasticity
Which tissues are most vulnerable to pressure?
1. skin and cartilage
2. skin and muscle tissue
3. skin and subcutaneous tissue
4. muscle and subcutaneous tissue
skin and muscle tissue
Which statement about moisture is correct?
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
topical moisture barriers protect the skin from breakdown and impairment
The color of eschar is:
1. pink or red
2. pale, almost white
3. tan, brown, or black
4. yellow, gray, or green
tan, brown, or black
When assessing the skin of a pt with dark skin, it is best to have which source of light?
1. halogen
2. fluorescent
3. soft
4. sunlight
fluorescent
Staging a pressure ulcer is not possible if:
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
skin is intact with a blood-filled blister present that is cool to the touch
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:
1. increased blood to the site
2. provide easy access to device
3. prepare the site
4. prevent needle puncture of the nurse
increased blood to the site
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:
1. pharyngeal suctioning
2. nasotracheal suctioning
3. oropharyngeal suctioning
4. percussion and vibration
nasotracheal suctioning
The physician has ordered a stool specimen for blood that it is not possible to see with the naked eye. This examination is for:
1. profuse bleeding
2. gross blood
3. melena
4. occult blood
occult blood
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:
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
identify the causative organisms
To obtain a 24 hour urine specimen, which instruction should be given to the pt?
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
discard the first voided specimen and then collect the total volume of each voiding for 24 hours
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:
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
aspirating 10mL of urine with a sterile syringe from the tubing port
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:
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
the side of the finger is less responsive to pain than other sites
An important preexamination nursing intervention for the pt undergoing an invasive diagnostic examination is:
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
obtaining the informed consent
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:
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
be NPO after midnight and have a series of enemas
The physician has ordered a urine sample to be collected. The nurse will have to:
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
verify whether this is to be a sterile sample
Before obtaining a blood sample, the nurse will first:
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
verify the pt identification
On evaluation of the pt after a venipuncture, the nurse notes which occurrence as an unexpected outcome?
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
soft lump is noted under the skin at the venipuncture site
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:
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
suggest that the pt use warm water on the finger just before using the lancet
The nurse notes that the pt does not require further teaching regarding home use of stool testing for occult blood when the pt states:
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."
"It is best if I can get two separate samples from the same stool."
The nurse has just completed attaching the leads for an electrocardiogram. The next step is to:
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
obtain the tracing
When obtaining a midstream urine specimen from a female pt, which instructions will be most important to tell the pt?
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
wipe from front to back when cleansing the urethral area
When nursing action is essential before a chest x-ray film is obtained?
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
remove the pt's metal necklace
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:
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
culture and sensitivity of the urine specimen
Which method will determine the correct distance to insert a nasogastric tube?
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
measure from tip of nose to tip of earlobe to end of sternum
After inserting a nasogastric tube, it is possible to be certain it is in the proper place if:
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
gastric contents are aspirated with cone-tipped syringe
A pt diagnosed with throat cancer is 2 days postoperative and has a tracheostomy. Which part of the tracheostomy tube is removed for cleaning?
1. outer cannula
2. inner cannula
3. single lumen tube
4. double lumen tube
inner cannula
What safety precaution must be taken for a pt who has a tracheostomy tube?
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
keep curved hemostat at the bedside
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:
1. overcoming fatigue
2. numbing of mucous membranes
3. replenishing oxygen
4. subsiding of pain
replenishing oxygen
Preoperatively the physician orders "enemas until clear." The maximum number of enemas the nurse can give without further orders is:
1. two
2. three
3. five
4. unlimited
three
The most serious problem that is possible to develop with the use of a condom catheter is:
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
restriction of blood supply to the penis
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?
1. wear gloves
2. wear goggles
3. use povidone-iodine for preparing the skin
4. use sterile tape for dressings over venipuncture site
wear gloves
Ear irrigation is a common procedure implemented to remove cerumen from the external ear canal. When irrigating the ear:
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
proceed in a gentle manner
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?
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
assess patency of the cannula every 2 hours
A more precise oxygen concentration is possible to achieve using a:
1. nasal cannula
2. simple face mask
3. venturi mask system
4. plastic face mask and inflated reservoir bag
venturi mask system
The unit manager orienting a new staff nurse evaluates which technique as appropriate for nasotracheal suctioning?
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
applying intermittent suctioning for 10 seconds during catheter removal
What is a priority for the nurse when teaching a family about home oxygen therapy?
1. pathophysiology of the patient
2. use of the equipment
3. oximetry readings
4. length of time the oxygen is to be used
use of the equipment
what is important in the site selection for a new IV line?
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
using sites away from a dialysis graft
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?
1. intensity of pain
2. warmth of skin surrounding IV site
3. amount of subcutaneous edema
4. skin discoloration resembling bruising
warmth of skin surrounding IV site
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?
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
stop the blood transfusion
Which is the least invasive alternative to urethral catheterization?
1. suprapubic catheterization
2. reinsertion of a Foley catheter
3. catheter irrigation
4. condom catheterization
condom catheterization
What is appropriate for the nurse to incorporate into the teaching plan for a pt with an incontinent urinary diversion?
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
special skin care is a priority
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?
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
inflating the balloon to test it before catheter insertion
A bladder retraining program for a pt in an extended care facility will properly include:
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
putting the pt on a q2h toilet scheduling during the day
When irrigating a colostomy, the nurse will use a cone that fits properly to prevent:
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
leaking of the solution from the stoma
The nurse recognizes which as true concerning ostomies?
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
some pts will have control over when they can evacuate their colon
To secure a condom catheter to the penile shaft appropriately, it is important to apply the device so that the catheter is:
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
snug and secure, but does not cause constriction to blood flow
In order to maintain proper drainage of an indwelling catheter, it is important to:
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
ensure that the collection device is below bladder level
Fecal impactions are best treated by:
1. a clear liquid diet
2. cleansing enemas
3. limiting the pt fluid intake
4. oil-retention enemas
oil-retention enemas
For optimal results, in which position will the nurse place the pt when administering a cleansing enema?
1. supine
2. dorsal recumbent
3. left Sims'
4. prone
left Sims'
Which nursing intervention is the most important in preventing the introduction of microorganisms to the pt when initiating an IV?
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
hand hygiene
When assessing an IV site, indications that phlebitis has occurred in include:
1. paleness and coolness
2. bleeding from the site
3. slowing of the flow of solution
4. pain and erythema
pain and erythema
The ideal needle gauge for a rapid whole blood transfusion is:
1. 14- to 16-gauge
2. 18- to 20-gauge
3. 22- to 24-gauge
4. 26- to 28-gauge
18- to 20-gauge
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?
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
the pt's blood pressure decreases
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?
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
briefly stop the installation
When providing indwelling catheter care, what areas are most important to be cleansed?
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
the area surrounding the urinary meatus
Which pt will be at the greatest risk of complications from heat or cold therapy?
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
a pt who is unconscious following a motor vehicle accident
The Infusion Nurses Society (INS) suggests changing IV tubing on peripheral lines in a facility with an IV-related infection rate of 3% every:
1. 24 hours
2. 48 hours
3. 72 hours
4. 96 hours
24 hours
A 35yo pt is healthy but wishes to lose weight because her BMI is 27. Which suggestions are more appropriate for her?
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
appropriate weight loss is possible with a healthy, reduced calorie diet and incorporating at least 30 minutes of physical activity into each day
A 10yo has an elevated BMI. Which suggestions are most appropriate to help him with his weight management?
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
encourage using the www.mypyramid.gov website to plan a healthy diet, and suggest limiting TV viewing time
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:
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."
"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."
A cancer pt is experiencing anorexia and weight loss. Which suggestions are most likely to help him increase intake and prevent weight loss?
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
suggest he snack often on high kilocalorie foods
A pt with type 2 diabetes obese and has an elevated blood cholesterol. Which goals for nutrition therapy are most appropriate for this pt?
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
encourage her to focus her efforts on achieving healthy blood glucose and lipid levels and to include regular exercise
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?
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
consume small portions of fermented dairy products such as cheese or yogurt
A pt with iron deficiency anemia started taking iron supplements but is also trying to increase iron absorption. What will enhance iron absorption?
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
taking iron supplements with coffee, tea, or red wine
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?
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
it will sometimes increase excretion of vitamin C and possibly lead to loss of iron from the GI tract
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?
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
folic acid may help prevent neural tube defects in the developing fetus
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?
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
they are from plant sources and are liquid at room temperature
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?
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
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
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?
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."
"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."
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?
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.
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
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?
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
stick margarines, shortening, deep fried restaurant foods, and commercially prepared baked goods
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?
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
consuming a high protein diet
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?
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
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
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?
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
the formula rate, strength, or volume is possibly too great
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?
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
try consuming five or six smaller meals each day, and include a source of protein in each meal
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.
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."
"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."
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?
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
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
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?
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
ask the pt which foods he desires assistance with. encourage the pt to take part in his eating as much as possible
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?
1. legumes, whole wheat products, oats
2. nuts and seeds, peanut butter, gelatin
3. olive oil, canola oil, flaxseed oil
4. eggs, meats, milk
eggs, meats, milk
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:
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."
"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."
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?
1. heart attack
2. high blood pressure
3. dehydration
4. alcohol abuse
dehydration
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?
1. sodium (Na+)
2. potassium (K+)
3. chloride (Cl-)
4. calcium (Ca++)
sodium (Na+)
Which regulatory system is the body's first line of defense in keeping the pH within normal limits?
1. buffers in the blood
2. respiratory system
3. renal system
4. blood pressure
buffers in the blood
The most accurate method to use in determining water balance in the body is to:
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
weigh the pt daily at the same time each day
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?
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
baked chicken, green salad, and fresh fruit plate
The major route of excretion of all electrolytes from the body is via the:
1. skin
2. lungs
3. kidneys
4. feces
kidneys
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:
1. diffusion
2. filtration
3. active transport
4. osmosis
osmosis
Tee largest fluid compartment in the body is the:
1. intracellular
2. extracellular
3. interstitial
4. intravascular
intracellular
Diffusion, osmosis, and filtration are all examples of:
1. active transport
2. passive transport
3. ATP energy
4. Krebs cycle
passive transport
The term used to indicate hydrogen ion concentration in the body is:
1. mEq
2. ATP
3. pH
4. mL
pH
The most common cause of hypocalcemia involves a dysfunction of:
1. antidiuretic hormone
2. growth hormone
3. parathyroid hormone
4. thyroid hormone
parathyroid hormone
A pt has a positive Chvostek's sign. The nurse will expect laboratory tests to reveal:
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
total serum calcium of less than 8.9mEq/L
Potassium is responsible for:
1. building muscle mass
2. building bone structure and strength
3. neuromuscular and cardiac function
4. maintaining normal blood glucose levels
neuromuscular and cardiac function
Neuromuscular signs and symptoms of hypokalemia include:
1. confusion and irritability
2. diminished deep tendon reflexes
3. parkinsonian type of tremors
4. carpopedal spasms
diminished deep tendon reflexes
Medications to be given when treating hyperkalemia include:
1. sodium succinate and mannitol
2. mannitol and regular insulin
3. sodium polystyrene sulfonate (Kayexalate)
4. antacids
sodium polystyrene sulfonate (Kayexalate)
Because 1L of fluid equals 2.2 pounds (1kg), a weight change of 2kg (4.4 pounds)will reflect a loss or gain of
2 liters
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:
1. slowing the respiratory rate
2. decreasing the heart rate
3. increasing the depth and rate of respirations
4. lowering the blood pressure
increasing the depth and rate of respirations
Which statements concerning a pt with severe hyperkalemia are correct?
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
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
In acute respiratory acidosis, the renal compensatory mechanisms begin to operate within:
1. 4 to 6 hours
2. 24 hours
3. 2 to 3 days
4. 1 to 2 hours
24 hours
Daily water intake and output (I&O) is approximately how many mL?
1. 1500
2. 3500
3. 6500
4. 2500
2500
It is necessary for the kidneys to secrete a minimum of how many mL/hr of urine to eliminate waste products from the body?
1. 30mL/hr
2. 60mL/hr
3. 20mL/hr
4. 100mL/hr
30mL/hr
The normal pH of blood is approximately _________.
7.35-7.45
Ketoacid accumulation in diabetic ketoacidosis often results in which type of respirations?
1. Cheyne-Stokes respirations
2. Kussmaul's respirations
3. Bradypnea
4. Apnea
Kussmaul's respirations
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?
1. 2mL
2. 0.2mL
3. 0.05mL
4. 0.5mL
2mL
Digoxin (Lanoxin) 0.125mg is ordered. On hand is Lanoxin 0.5mg/mL. How many mL will the nurse give?
1. 3mL
2. 0.25mL
3. 2.5mL
4. 0.025mL
0.25mL
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?
1. 1tsp
2. 2tsp
3. 3tsp
4. 1/2tsp
1tsp
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?
1. 20.6kg
2. 15kg
3. 13.6kg
4. 22kg
13.6kg
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?
1. 100mL/hr
2. 125mL/hr
3. 150mL/hr
4. 175mL/hr
125mL/hr
An IV of 1L of D5 1/2 NS is to run at 150mL/hr. How long will this IV run?
1. 6 hours
2. 6.6 hours
3. 7.5 hours
4. 8 hours
6.6 hours
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?
1. has to infuse slower
2. has to infuse faster
3. is at the correct rate
4. has to be discontinued
has to infuse slower
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?
1. ventrogluteal site
2. deltoid site
3. vastus lateralis site
4. dorsogluteal site
dorsogluteal site
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)
1. it is appropriate
2. it is a little too much
3. it is an extreme overdose
4. it is not enough
it is an extreme overdose
The average dose of a medication is 0.4mg (gr 1/150) for an adult. What is the dosage for a 12yo?
1. 2mg
2. 0.002mg
3. 0.02mg
4. 0.2mg
0.2mg
An adult dose of diazepam (Valium) is 5mg. How many mL is appropriate for a child who weighs 27kg?
1. 2mg
2. 1.5mg
3. 3mg
4. 2.5mg
2mg
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?
1. lasix tablet
2. coreg tablet
3. robitussin cough syrup
4. paxil tablet
robitussin cough syrup
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:
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."
"I am not permitted to transport an unlabeled container."
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:
1. intramuscular
2. intradermal
3. subcutaneous
4. intravenous
intradermal
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?
1. 22 guage
2. 25 gauge
3. 18 gauge
4. 16 gauge
22 gauge
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?
1. 45 degrees
2. 90 degrees
3. 15 degrees only
4. 35 degrees only
90 degrees
The nurse is deciding on the angle used in delivering subcutaneous heparin. The decision will be based on the:
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
amount of subcutaneous tissue of the pt
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:
1. 1 to 1 1/2 inches
2. 3/8 inch
3. 5/8 inch
4. 1/4 inch
1 to 1 1/2 inches
A 6 month old is to be immunized for diphtheria, tetanus, and pertussis. His IM injection will be given in which muscle?
1. deltoid
2. ventrogluteal
3. gluteus maximus
4. vastus lateralis
vastus lateralis
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?
1. 1mL tuberculin syringe
2. 100 units per 1mL syringe
3. 3mL syringe
4. 5mL syringe
1mL tuberculin syringe
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:
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
lower than average adult dosages
When obtaining information about a specific drug, what book is published annually and contains information from drug manufacturers?
1. Nurse's Drug Handbook
2. Drug Facts and Comparisons Guide
3. Physicians' Desk Reference (PDR)
4. Pharmacy Policy Manual
Physician's Desk Reference (PDR)
What is the acceptable time range to administer an 8am medication?
1. 0800 to 1000
2. 0700 to 0900
3. 0800 to 0830
4. 0730 to 0830
0800 to 0830
What is true regarding nursing responsibilities with controlled substances?
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
only statements 1 and 2 are true
Documentation of medication administration is extremely important. What information will the nurse include in the documentation?
(Choose all that apply)
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
all of the above
The first action to take when a medication error takes place is to:
1. call the physician
2. call the supervisor
3. complete an incident report
4. check the pt
check the pt
If a medication is ordered orally, and the pt is NPO (nothing by mouth), which action does the nurse take?
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
consult the nurse in charge
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)
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
1, 2, and 4
When reading a medication label, the nurse should:
(Choose all that apply)
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
1, 2, 3
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?
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
inform the pt that the medication is available to take every 3 to 4 hours as needed for pain
Prescribed medications are prepared and administered during which phase of the nursing process?
1. assessment
2. planning
3. implementation
4. evaluation
implementation
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?
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
hold the medication and inform the physician of a change in the pt's bp
The priority assessment to make of a victim at the scene of a car accident is whether or not:
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
the victim has a patent airway
When caring for a victim who has a head injury and is developing shock, the nurse should:
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
leave the victim in a flat position
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?
1. splint the fractured arm
2. get the woman out of the car
3. give mouth-to-mouth resuscitation
4. stop the bleeding
get the woman out of the car
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?
1. hydrogen peroxide
2. petroleum jelly
3. cool compress
4. saltwater compress
cool compress
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:
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
ensure that the pt has an open airway
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:
1. shock
2. head trauma
3. peripheral vascular injury
4. spinal injury
shock
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:
1. control the bleeding
2. immobilize the neck and spine
3. move him to a warmer area
4. ensure there is an open airway
ensure there is an open airway
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:
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
position him on his back on the ground with feet elevated
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:
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
use 4 inch by 4 inch gauze pads to apply direct pressure
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:
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
obtain pulse oximetry and start oxygen via NC
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:
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
call the poison control center
A new potential environmental health threat is the possibility of:
1. bioterrorism
2. noise pollution
3. water pollution
4. air pollution
bioterrorism
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.
30, 2
The compression rate for one or two rescuer CPR for adults and children is approximately _____ compressions per minute.
100
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:
1. secondary survey
2. high resource intensity
3. triage
4. collaborative care
triage
Shock is best defined as:
1. cardiovascular collapse
2. loss of sympathetic tone
3. inadequate tissue perfusion
4. blood pressure less than 90mmHg systolic
inadequate tissue perfusion
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)?
1. April 13
2. April 27
3. May 20
4. March 27
April 27
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?
1. probable
2. positive
3. presumptive
4. possible
presumptive
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:
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
extends her leg and dorsiflexes her foot during the cramp
The pt asks the nurse how she will know when she first feels the baby move. The best explanation is that the movement:
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
is flutterlike and is called quickening
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?
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
no alcohol
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?
1. urine frequency
2. severe headaches
3. backache
4. heartburn
severe headaches
During the third trimester, pts often complain of various discomforts. Which discomfort would not be expected at this time?
1. dyspnea
2. insomnia
3. ankle edema
4. dysuria
dysuria
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?
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
fetal heart rate increases in connection with fetal movement
Constipation is a frequent complaint as a pregnancy progresses. Which measure would be best to recommend to relieve constipation?
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
drink 6 to 8 glasses of water daily
At one of her prenatal visits, the pt is scheduled for a sonogram. Sonography cannot be used to assess:
1. number of fetuses
2. gestational age of fetus
3. Down syndrome
4. congenital anomalies
Down syndrome
Which symptom would be considered a first trimester warning sign and should be reported immediately to the health care provider?
1. nausea with occasional vomiting
2. fatigue
3. urinary frequency
4. vaginal bleeding
vaginal bleeding
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:
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."
"You may find that you need to modify your exercising to walking later in your pregnancy, around the 7th month."
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:
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."
"Come to the office right away."
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?
1. 4-1-1-1-3
2. 4-1-2-0-3
3. 3-0-3-0-3
4. 3-1-2-0-3
4-1-2-0-3
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:
1. a positive pregnancy test
2. fetal movement palpated by the primary caregiver
3. Braxton Hicks contractions
4. nausea and vomiting
fetal movement palpated by the primary caregiver
___________ woman who is pregnant
gravida
_________ woman who is pregnant for the first time