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Answer A 73-year-old patient who sustained a right hip fracture in a fall requests pain medication from the nurse. Based on his injury, which type of pain is this patient most likely experiencing? 3) Deep somatic Rationale: Which pain management task can the nurse safely delegate to nursing assistive personnel? 1) Asking about pain during vital signs 2) Evaluating the effectiveness of pain medication 3) Developing a plan of care involving nonpharmacologic interventions 4) Administering over-the-counter pain medications
Rationale: Which factor in the patient's past medical history dictates that the nurse exercise caution when administering acetaminophen (Tylenol)? 1) Hepatitis B 1) Hepatitis B Rationale: Which action should the nurse take before administering morphine 4.0 mg intravenously to a patient complaining of incisional pain? 1) Assess the patient's incision. 2) Clarify the order with the prescriber. 3) Assess the patient's respiratory status. 4) Monitor the patient's heart rate.
Rationale: Which action should the nurse take when preparing patient-controlled analgesia for a postoperative patient? 1) Caution the patient to limit the number of times he presses the dosing button. 2) Ask another nurse to double-check the setup before patient use. 3) Instruct the patient to administer a dose only when experiencing pain. 4) Provide clear, simple instructions for dosing if the patient is cognitively impaired.2) Ask another nurse to double-check the setup before patient use. Rationale: The nurse administers codeine sulfate 30 mg orally to a patient who underwent craniotomy 3 days ago for a brain tumor. How soon after administration should the nurse reassess the patient's pain? 1) Immediately 2) In 10 minutes 3) In 15 minutes 4) In 60 minutes4) In 60 minutes Rationale: Which nonsteroidal anti-inflammatory drug might be administered to inhibit platelet aggregation in a patient at risk for thrombophlebitis? 1) Ibuprofen (Motrin) 3) Aspirin (Ecotrin) Rationale: A client who is receiving epidural analgesia complains of nausea and loss of motor function in his legs. The nurse obtains his blood pressure and notes a drop in his blood pressure from the previous reading. Which complication is the patient most likely experiencing? 1) Infection at the catheter insertion site 2) Side effect of the epidural analgesic 3) Epidural catheter migration 4) Spinal cord damage
Rationale: Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply): 1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing 2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening 3) Heart rate was 76 before eating and is 60 after eating 4) Respiratory rate was 14 when standing and is 22 after walking1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing Rationale: The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has: 1) Crackles 2) Rhonchi 3) Stridor 4) Wheezes
Rationale: The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the: 1) Pulse deficit 2) Blood pressure 3) Apical pulse 4) Pulse pressure
Rationale: Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is: 1) 118/68 when standing and 110/72 when lying down 2) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing 3) 126/72 lying down and 133/80 when sitting, and reports shortness of breath 4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy
Rationale: A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client? 1) Axillary with an electronic thermometer 2) Oral with a glass thermometer 3) Rectal with an electronic thermometer 4) Tympanic with an infrared thermometer
Rationale: Which of the following clients would have the most difficulty maintaining thermoregulation? 1) Young child playing soccer during the summer 2) Middle-aged adult snow skiing 3) Young adult playing golf on a hot day 4) Older adult raking leaves on a cold day
Rationale: Which of the following clients should have an apical pulse taken? A client who is: 1) Febrile and has a radial pulse of 100 bpm 2) A runner who has a radial pulse of 62 bpm 3) An infant with no history of cardiac defect 4) An elderly adult who is taking antianxiety medication
Rationale: Which situation requires intrapersonal communication? 1) Staff meetings 2) Positive self-talk 3) Shift report 4) Wound care committee meeting
Rationale: The nurse suspects that a patient is being physically abused at home. What is the best environment in which to discuss the possibility of abusive events? 1) The patient's shared semiprivate room 2) The hallway outside the patient's room 3) An empty corner at the nurse's station 4) A conference room at the end of the hall
Rationale: A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: 1) Describe how to operate the bed and call for the nurse. 2) Discuss communication patterns and roles within the family. 3) Openly express his concerns about the hospitalization. 4) State expectations related to discharge.
Rationale: A local church organizes a group for people who are having difficulty coping with the death of a loved one. Which type of group has been organized? 1) Work-related social support group 2) Therapy group 3) Task group 4) Community committee
Rationale: A mother comes to the emergency department after receiving a phone call informing her that her son was involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my son?" Which response by the nurse is best? 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." 2) "Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him." 3) "Everything will be okay; please take a seat and I'll check on him for you." 4) "Your son is strong and has youth on his side; I'm sure he'll be fine."
Rationale: During a presentation at a nursing staff meeting, the unit manager speaks very slowly with a monotone. She uses medical and technical terminology to convey her message. Dressed in business attire, the manager stands erect and smiles occasionally while speaking. Which elements of her approach are likely to cause the staff to lose interest in what she has to say? Select all answers that apply. 1) Slow speech 2) Monotone 3) Occasional smile 4) Formal dress
Rationale: Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply. 1) Orthostatic hypotension 2) Appendectomy 3) Dizziness 4) Hyperthyroidism
Rationale: The nurse is teaching a child and family about firearm safety. The nurse should instruct the child to take which step first if he sees a gun at a friend's house? 1) Leave the area. 2) Do not touch the gun. 3) Stop where he is. 4) Tell an adult.
Rationale: A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1) Apply a vest restraint. 2) Move the patient to a quieter room. 3) Ask another nurse to care for the patient. 4) Provide comfort measures.
Rationale: While teaching a health promotion group of adults, the nurse notices one person who is clutching his throat with both hands. What should the nurse do first? 1) Call 9-1-1. 2) Encourage the person to cough vigorously. 3) Ask, "Are you choking?" 4) Give five back blows.
Rationale: What should parents do to promote child safety in the home? 1) Attach the baby's pacifier to a ribbon so that it does not fall on the floor. 2) Give a 2-year-old whole grapes instead of popcorn for a snack. 3) Store firearms unloaded and out of sight in a location too high for the child to reach. 4) Install window guards; never leave a window wide open.
What is the leading cause of unintentional death for the entire U.S. population? 1) Motor vehicle accidents 2) Poisoning 3) Choking 4) Falls
Rationale: Which change in hygiene practices may be necessary as the patient ages? 1) Brushing teeth twice a day 2) Bathing every other day 3) Decreasing moisturizer use 4) Increasing soap use
Rationale: A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers. 1) Male nursing assistant 2) Male licensed practical nurse 3) Female graduate nurse 4) Female registered nurse
Rationale: A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity?
Rationale: The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? 1) Maceration 2) Abrasion 3) Excoriation 4) Pressure ulcer
Rationale: The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? 1) Bathe the patient's entire body using 8 to 10 washcloths. 2) Assist the patient to a chair and provide bathing supplies. 3) Saturate a towel and blanket in a plastic bag, and then bathe the patient. 4) Assist the patient to the bathtub and provide a bath chair.
Rationale: For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? 1) Cover the mattress with a sheepskin. 2) Keep the linens wrinkle free. 3) Separate the skin folds with towels. 4) Apply petrolatum barrier creams.
Rationale: A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1) Fever 2) Intact skin 3) Inflammation 4) Lethargy
Rationale: A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? 1) A clean gown and gloves must be worn when in contact with the client. 2) Everyone who enters the room must wear a N-95 respirator mask. 3) All linen and trash must be marked as contaminated and send to biohazard waste. 4) Place the client in a room with a client with an upper respiratory infection.
Rationale: A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One 1) admitted with unstable diabetes mellitus. 2) who underwent surgical repair of a perforated bowel. 3) with a stage 3 sacral pressure ulcer. 4) admitted with a urinary tract infection.
Rationale: Which action demonstrates a break in sterile technique? 1) Remaining 1 foot away from nonsterile areas 2) Placing sterile items on the sterile field 3) Avoiding the border of the sterile drape 4) Reaching 1 foot over the sterile field
Rationale: A mother who breastfeeds her child passes on which antibody through breast milk? 1) IgA 2) IgE 3) IgG 4) IgM
Rationale: What is the rationale for hand washing? Hand washing is expected to remove: 1) transient flora from the skin. 2) resident flora from the skin. 3) all microorganisms from the skin. 4) media for bacterial growth.
Rationale: Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 30 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration
Rationale: The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: 1) Separates the health record according to discipline 2) Organizes documentation around the patient's problems 3) Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation
Rationale: When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO
Rationale: The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: 1) Are comprehensive charting forms that integrate assessments and nursing actions 2) Contain only graphic information, such as I&O, vital signs, and medication administration 3) Are used to record routine aspects of care; they do not contain assessment data 4) Contain vital data collected upon admission, which can be compared with newly collected data
Rationale: At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.
Rationale: The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours.
Rationale: In the United States, the first programs for training nurses were affiliated with: 1) The military 2) General hospitals 3) Civil service 4) Religious orders
Rationale: Which of the following is/are an example(s) of a health restoration activity? Select all that apply. 1) Administering an antibiotic every day 2) Teaching the importance of hand washing 3) Assessing a client's surgical incision 4) Advising a woman to get an annual mammogram after age 50 years
Rationale: Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? 1) Established standards of care 2) Professional organizations 3) Practice supported by scientific research 4) Activities determined by a scope of practice
Rationale: The charge nurse on the medical surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? 1) Team nursing 2) Case method nursing 3) Functional nursing 4) Primary nursing
Rationale: A patient who suffered a stroke has difficulty swallowing. Which healthcare team member should be consulted to assess the patient's risk for aspiration? 1) Respiratory therapist 2) Occupational therapist 3) Dentist 4) Speech therapist
Rationale: Which of the following is/are an example(s) of theoretical knowledge as defined in this chapter? Select all that apply. 1) Antibiotics are ineffective in treating viral infections. 2) When you take a patient's blood pressure, the patient's arm should be at heart level. 3) In Maslow's framework, physical needs are most basic. 4) When drawing medication out of a vial, inject air into the vial first.
Rationale: Critical thinking and the nursing process have which of the following in common? Both: 1) Are important to use in nursing practice 2) Use an ordered series of steps 3) Are patient-specific processes 4) Were developed specifically for nursing1) Are important to use in nursing practice Rationale: In which step of the nursing process does the nurse analyze data and identify client problems? 1) Assessment 2) Diagnosis 3) Planning outcomes 4) Evaluation
Rationale: In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem?
Rationale: What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions 2) Identify the most effective interventions for a patient 3) Communicate more efficiently with colleagues, patients, and families 4) Learn and remember new procedures and techniques
Rationale: Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis 1) E, B, A, D, C 2) A, B, C, D, E 3) A, E, C, D, B 4) D, A, B, E, C
Rationale: How are critical thinking skills and critical thinking attitudes similar? Both are: 1) Influences on the nurse's problem solving and decision making 2) Like feelings rather than cognitive activities 3) Cognitive activities rather than feelings 4) Applicable in all aspects of a person's life1) Influences on the nurse's problem solving and decision making Rationale: The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process
Rationale: Which organization's standards require that all patients be assessed specifically for pain? 1) American Nurses Association (ANA) 2) State nurse practice acts 3) National Council of State Boards of Nursing (NCSBN) 4) The Joint Commission
Rationale: Which of the following is an example of data that should be validated? 1) The urinalysis report indicates there are white blood cells in the urine. 2) The client states she feels feverish; you measure the oral temperature at 98°F. 3) The client has clear breath sounds; you count a respiratory rate of 18. 4) The chest x-ray report indicates the client has pneumonia in the right lower lobe.
Rationale: Which of the following is an example of appropriate behavior when conducting a client interview? 1) Recording all the information on the agency-approved form during the interview 2) Asking the client, "Why did you think it was necessary to seek health care at this time?" 3) Using precise medical terminology when asking the client questions 4) Sitting, facing the client in a chair at the client's bedside, using active listening4) Sitting, facing the client in a chair at the client's bedside, using active listening Rationale: The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns
Rationale: The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1) Used a vague generality 2) Did not use the patient's exact words 3) Used a "waffle" word (e.g., appears) 4) Recorded an inference rather than a cue1) Used a vague generality Rationale: A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1) Ongoing assessment 2) Comprehensive physical assessment 3) Focused physical assessment 4) Psychosocial assessment3) Focused physical assessment Rationale: The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? 1) Sitting upright 2) Lying flat on the back with knees flexed 3) Lying flat on the back with arms and legs fully extended 4) Side-lying with the knees flexed1) Sitting upright Rationale: For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion 1) D, B, A, C 2) C, A, D, B 3) B, C, D, A 4) A, B, C, D
Rationale: The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? 1) Sims' 2) Supine 3) Dorsal recumbent 4) Semi-Fowler's
Rationale: How should the nurse modify the examination for a 7-year-old child? 1) Ask the parents to leave the room before the examination. 2) Demonstrate equipment before using it. 3) Allow the child to help with the examination. 4) Perform invasive procedures (e.g., otoscopic) last.
Rationale: The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1) Dorsal recumbent 2) Semi-Fowler's 3) Lithotomy 4) Sims'
Rationale: The nurse should use the diaphragm of the stethoscope to auscultate which of the following? 1) Heart murmurs 2) Jugular venous hums 3) Bowel sounds 4) Carotid bruits
Rationale: The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: 1) Obese 2) Overweight 3) Average 4) Underweight
Rationale: What will the nurse instruct nursing assistive personnel NAP to do when measuring an adult patient's radial pulse?What will the nurse instruct nursing assistive personal (NAP) to do when measuring an adult patient's radial pulse? Place the patient in the lateral (side-lying) position before measuring the pulse. Apply gloves with each patient before measuring the pulse.
Which instruction would the nurse give to nursing assistive personnel NAP that is exclusive of tympanic temperature assessment?Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to tympanic temperature assessment? Leave the probe in place until the reading is complete.
What instruction should the nurse give NAP regarding the appropriate technique when measuring the adult patient's apical pulse?What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient's apical pulse? Document the patient's pulse rate and rhythm. Place the patient in the right lateral position before measuring the apical pulse.
Which measurement can the nurse delegate to nursing assistive personnel?Rationale: The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client's skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.
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