Fundamentals

Question 1

A significant number of reported facility accidents are related to falls. The nurse is accountable for implementation of essential actions to reduce the risk associated with falls. Identify 6 contributing factors that increase the risk for falls.

Answer 1

• Older age.
• Impaired mobility.
• Cognitive and/or sensory impairment
• Bowel and bladder dysfunction.
• Side effects of medications.
• History of falls.

Question 2

What is the proper BSL protocol?

Answer 2

CAB:

• Circulation
• Airway
• Breathing

Question 3

For an adult, what is the compression-to-ventilation ratio?

Answer 3

For an adult, the normal compression-to-ventilation ratio is 30:2.

Question 4

How should you perform chest compressions?

Answer 4

When performing chest compressions, push hard and fast, and avoid interrupted compressions.

Question 5

You suspect a client has a neck injury while performing CPR, what maneuver should be done?

Answer 5

If a neck injury is suspected, the jaw thrust maneuver is used to open the victim’s airways.

Question 6

Foreign body airways obstructions and blind finger sweeps:

Answer 6

Blind finger sweeps in the mouth of a victim with a foreign body airways obstruction (FBAO) should not be performed because of the risk of pushing the object further into the airway.

Question 7

What is the proper maneuver to remove a foreign body out of an infant?

Answer 7

In an infant, deliver five back slaps and then five chest thrusts to remove the foreign body from the airway.

Question 8

The victim of a FBAO is pregnant, what position should you place them in so that you can clear the airway?

Answer 8

If the victim of an FBAO is pregnant, and it is necessary to place the client supine, remember to place a wedge, such as a pillow or rolled blanket, under the right abdominal flank and hip to displace the uterus to the left side of the abdomen. This prevents hypotension.

Question 9

The nurse walks into a client’s room and find the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?

Answer 9

• Start chest compressions.

The next nursing action would be to start chest compressions (CAB). CC are used to keep blood moving throughout the body and to the vital areas. After 2 minutes, rescuer opens the airway.

Question 10

The nurse witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse determines the need to open the airway. The nurse opens the airway in this victim by using with method?

Answer 10

• Jaw thrust maneuver.

If a neck injury if suspected, the jaw thrust maneuver is used to open the airway.

Question 11

What is the correct guideline for adult cardiopulmonary resuscitation for a health care provider?

Answer 11

• Each recuse breath should be given over 1 second and should produce a visible chest rise.

In adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed.

Question 12

The nurse attempts to relieve an airway obstruction in a 3-year-old conscious client. Where should the nurse’s hands be positioned to deliver the thrusts?

Answer 12

• Umbilicus and the xiphoid process.

To perform abdominal thrusts on a child, the rescuer stands behind the victim and places the arms directly under the victim’s axillae and around the victim. The rescuer places the thumb side of one fist against the victim’s abdomen in the midline, slightly above the umbilicus and well below the tip of the xiphoid process.

Question 13

The nurse is performing rescue breathing on a 7-year-old child. The nurse delivers one breathe per how many seconds?

Answer 13

• 6-8

In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered.

Question 14

The nurse is performing CPR on an infant. When performing chest compressions, the nurse compresses at least how many times?

Answer 14

• 100 times per minute.

In an infant, the rate of chest compression is at least 100 times per minute.

Question 15

The nurse is teaching CPR to nursing students. The nurse asks a student to describe why blind finger sweeps are avoided in infants. The nurse determines that the student understands this reason is he states?

Answer 15

• The object may be forced back farther into the throat.

Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object farther down into the airway.

Question 16

The nurse witnesses the collapse of a victim in her neighborhood and suspects cardiac arrest. Which action should the nurse take first?

Answer 16

• Activate the emergency response system.

If a collapse is witnessed and the nurse suspects cardiac arrest, the nurse should first activate the emergency response system. Next, the nurse should obtain a AED, followed by initiation of CPR, beginning with chest compressions.

Question 17

The nursing instructor asks a nursings student to describe the procedure for performing abdominal thrusts on an unconscious pregnant woman at 32 weeks’ gestation. The student describes this procedure correctly if he states, what action?

Answer 17

• Place a rolled blanket under the right abdominal flank and hip area.

If an unconscious woman in an advanced gestational stage f pregnancy has a foreign body airway obstruction, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side on the abdomen. This prevents supine hypotension that can occur if the gravid uterus rests on the vena cava. The rescuer then attempts ventilations.

Question 18

The nurse is performing CPR on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inches?

Answer 18

• 2 inches.

When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant it is 1 1/2 inches.

Question 19

The nurse is caring for a combative client. The HCP prescribes restraints. What is an appropriate action?

Answer 19

• Remove each restraint one at a time every 2 hours.

This should be done to allow the client to perform range-of-motion exercises and the nurse to perform neurological checks.

Question 20

A nurse is caring for a client with hypokalemia. What food should the nurse recommend?

Answer 20

• Avocados.

Avocados are an excellent source of potassium.

Question 21

The nurse is caring postoperatively for a client who just received a colostomy. What finding should the nurse report to the provider?

Answer 21

• Stoma appears purple in color.

The stoma should appear red and moist. The provider should be notified if the stoma appears dark in color, which is an indication of poor circulation.

Question 22

The nurse is providing instructions for an older adult client who has a prescription for an electric heating pad to his lumbosacral area. The nurse determines teaching has been effective if the client states?

Answer 22

• I will remove the heating pad in 30 minutes.

The client should apply the heating pad periodically and for no more than 30 to 45 minutes at a time to prevent reflex vasoconstriction. Continuous heat application can result in tissue damage.

Question 23

A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which intervention is appropriate?

Answer 23

• Ask the family if there are any special rituals that they would like to follow at this time.

The nurse should ask the family if there are any special rituals because culture can influence rituals people follow when death occurs.

Question 24

A nurse is reviewing a client’s fluid and electrolyte status. Which should be reported to the provider?

Answer 24

• Potassium level of 5.4 mEq/L

The value is above the expected reference range and the nurse should report this finding.

Question 25

A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. What action should the nurse take first?

Answer 25

• Discontinue the infusion.

A red line extending outward from the insertion site indicates the client is at greatest risk to the client is further injury to the vein; therefore the first action the nurse should take is to discontinue the infusion.

Question 26

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning?

Answer 26

• During the admission process.

Discharge planning should begin as soon as the client is undergoing admission. The nurse should begin to assess the client’s needs and plan for care during and after hospitalization.

Question 27

A nurse is caring for a client who is postop and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client’s vital signs every 15 minutes and call him back in 1 hr. From a legal perspective, what should the nurse do?

Answer 27

• Notify the nursing manager.

The greatest risk to the client is not receiving timely intervention for this deterioration i physiological status; therefor, the next action the nurse should take is to activate the chain of command to ensure the necessary care.

Question 28

A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk from primary hypertension?

Answer 28

• A client who has an elevated LDL.

The client who has an elevated LDL is at risk from primary hypertension.

Question 29

A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. What value should the nurse report?

Answer 29

• SaO2 86%.

This value may indicate hypoxia and therefore the nurse should report this finding.

Question 30

A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused treatment due to religious beliefs. What action should the nurse take next?

Answer 30

• Examine personal values about the issue.

The nurse should examine personal values about the issue in order to provider unbiased care.

Question 31

A nurse is caring for a client who has an indwelling urinary catheter. What assessment finding indicates that the catheter should be irrigated?

Answer 31

• Bladder scan reveals 525 mL of urine.

A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore the nurse should irrigate the catheter to resolve a blockage. This finding may indicate a blockage of the catheter and would require irrigation.

Question 32

A nurse is caring for a client and performing blood glucose monitoring. What is an appropriate nursing intervention?

Answer 32

• Wipe away the first drop of blood from the client’s finger.

The first drop of blood is typically more serous and contains fewer red blood cells.

Question 33

A nurse is caring for a cline who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking?

Answer 33

• “When I get out of a chair, I’ll hold both crutches on the side next to my weak leg”.

When getting out of a chair, a client should hold both crutches on the unaffected side.

Question 34

A nurse is caring for a client who has recently started using a hearing air worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive device?

Answer 34

• “I will be sure to remove my hearing aid before taking a shower”.

The client should remove any hearing device before showering because exposure to water can damage the hearing aid.

Question 35

A nurse has just inserted an NG tube for a client. Which of the following assessment findings indicates that the tube is properly positioned?

Answer 35

• An x-ray shows the end of the tube above the pylorus.

An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

Question 36

A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. What is an appropriate nursing intervention?

Answer 36

• Have a second nurse witness the disposal of remaining medication.

The nurse should have a second nurse witness the disposal of any unused controlled substances to ensure client safety.

Question 37

A nurse finds a client on the floor upon entering the client’s room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?

Answer 37

• Client found lying on floor.

Documentation must contain descriptive, objective information about what the nurse actually observes, without any opinions or judgment about motive or cause.

Question 38

A nurse is planning to insert a peripheral IV catheter in an older adult client. What action should the nurse plan to take?

Answer 38

• Position the client’s arm in the dependent position.

The nurse should instruct the client to place his arm in the dependent position, because the veins will distend due to gravity.

Question 39

A nurse is preparing to transfer a client who has right sided weakness from the bed to a chair. Which of the following actions should the nurse take to assist the client? (Put the steps in order).

Answer 39

• Ask the client if he can bear weight.
• Position the chair on the left side of the bed.
• Have the client sit and dangle his feet at the bedside.
• Use the stand and pivot technique to move the client to the chair.

The first action the nurse should take using the nursing process is to assess the client; therefore the nurse should first assess the client to determine is he can bear weight and assist with the transfer. Next the nurse should position the chair on the side of the bed closest to the client’s stronger side for easy access; Next the nurse should have the client sit and dangle his feet at the bedside to allow the client to adjust to sitting up and prevent dizziness when transferring; Last, the nurse should use the stand and pivot technique to move the client to the chair.

Question 40

A nurse is teaching a client about self-administering NPH insulin (Humulin N). Which of the following actions by the client indicates a need for further teaching?

Answer 40

• The client inserts the needle at a 30-degree-angle.

The client should insert the needle at 45-90 degree angle depending on the depth of the adipose tissue.

Question 41

Following administration of levothyroxine (Synthroid) 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication?

Answer 41

• Levothyroxine 125 mcg given at 0800. Provider notified.

The nurse should notify the provider of a variance in the provider’s prescription.

Question 42

A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP?

Answer 42

• Assist the client with a partial bed bath.
• Measure the client’s BP after the nurse administers an antihypertensive medication.
• Use a communication board to ask what the client wants for lunch.

Question 43

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

Answer 43

• Clean sutures along with the incision site.

The greatest risk to this client is injury from infection; therefore, the first action the nurse should take is to clean the incision to minimize the risk of infection.

Question 44

A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?

Answer 44

• A nursing student consults a former classmate to assist with her documentation.

Only health care professionals directly caring for a client have access to medical information; therefore, this is a violation of HIPAA guidelines.

Question 45

A nurse is planning care for a group of clients who have communicable diseases. What is an appropriate nursing action to include in the plan of care?

Answer 45

• Place the client who has tuberculosis in a room with negative-pressure airflow.

The nurse should place a client who has TB in a negative-pressure room to reduce the risk of infection transmission.

Question 46

A nurse contacts the facility’s interpreter to explain a therapeutic procedure for a client who does not speak English. What guidelines should the nurse follow when working with the interpreter?

Answer 46

• Explain the purpose of the communication to the interpreter.

The nurse should have a brief meeting with the interpreter prior to approaching the client, so that the nurse can clarify expectations of the session.

Question 47

A nurse is providing discharge instructions to a client who will be using a walking. What statement made by the client indicates a need for further instruction?

Answer 47

• “I will replace the old throw rug in the kitchen with a new one”.

The use of throw rugs increases the client’s risk for falls, as it creates a tripping a slipping hazard.

Question 48

A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. After confirming the fire, what action should the nurse take next?

Answer 48

• Evacuate the client.

According to the RACE mnemonic, the first action in response to a fire is to rescue the client, moving to a safe area.

Question 49

A nurse is planning care to promote improved self-feeding for a client who has visual impairment. What intervention should the nurse include in the plan of care?

Answer 49

• Use a clock pattern to describe food on the plate to the client.
• Use of a clock pattern to describe the location of food on the plate allows for greater independence during meals for the client with visual impairment.

Question 50

A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following?

Answer 50

• “I want you to tell me about measures available to keep me comfortable”.

The client has accepted that his diagnosis is terminal and is focusing on the goals of palliative care, which are comfort and symptom control.

Question 51

A nurse is caring for a client who is receiving medication intramuscularly. The should should recognize that this route..

Answer 51

• “increases infection rates”.

Because the IM route breaks skin integrity, the risk for infection is increased.

Question 52

A nurse is preparing to administer oral medications to a client who has dysphagia. What action is appropriate by the nurse?

Answer 52

• Offer each medication one at a time.

The nurse should administer the medications one at a time in order to verify that the client swallows each medication. This also reduces the risk is aspiration.

Question 53

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about self-administration. What action should the nurse take first?

Answer 53

• Determine the client’s learning style.

Using the nursing process, the first action the nurse should take is to assess the client’s learning style.

Question 54

A nurse is teaching a client and his family how to care for the client’s tracheostomy at home. What instruction is appropriate for the client and family?

Answer 54

• Use tracheostomy covers when outdoors.

Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne particles.

Question 55

A nurse is caring for a client who asks about the purpose of advanced directives. What is an appropriate response by the nurse?

Answer 55

• “It indicates the form of treatment a client is willing to accept in the event of a serious illness”.

Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness.

Question 56

A nurse is assessing a client who reports increased pain following physical therapy. What question should the nurse ask to assess the quality of the client’s pain?

Answer 56

• “Is your pain sharp or dull”?

Asking the client whether the pain is sharp or dull is an appropriate way to determine the quality of the pain.

Question 57

A client demonstrates anger when the nurse does not respond within 5 minutes of ringing for the nurse. What is an appropriate response?

Answer 57

• “It must be frustrating. I have a few minutes now”.

This response is therapeutic because the nurse is acknowledging the client’s feelings, and offering self.

Question 58

A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. What intervention should be initiated?

Answer 58

• Notify security for placement of the necklace.

Security can provide a safe, documented place to store the client’s valuables.

Question 59

What is the responsibility of a nurse who is caring for a client receiving a PCA?

Answer 59

• Instruct the family to refrain from pushing the button for the client while she is asleep.

The nurse should instruct family members to not activate the button for the client while she sleeps. Even though PCA pumps minimize the risk of overdose, toxic effects could still result if the client receives more medication than she needs to control her pain.

Question 60

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands the preoperative teaching regarding pain control has been effective when the client states what?

Answer 60

• “It may help me to listen to music while I’m lying in bed”.

Listening to music is an effective nonpharmacological intervention for the management of mild pain.

Question 61

A nurse is developing a plan of care for an African-American child who is preschool and experiencing pain. What is the best way for the nurse to assess the child’s pain?

Answer 61

Show the child the Oucher Pain Scale.

Obtaining the child’s report of pain is the best way for the nurse to assess pain. The Oucher Pain Scale is age appropriate and is available in different ethnic versions.

Question 62

A nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. What should the nurse include in the teaching?

Answer 62

• Protein intake is often inadequate in older adults.

Protein intake is often less than recommended in many older adults due to the lack of financial resources and dental problems.

Question 63

A nurse is monitoring an older adult client who is receiving IV fluid therapy. What assessment finding should the nurse recognize as adverse effects of excess fluid therapy?

Answer 63

• Edema
• Crackles in the lungs
• Elevated blood pressure
• Jugular venous distention

Question 64

To prevent foot drop in a client who has decreased mobility, the nurse should..

Answer 64

• Place the client’s feet against a foot board perpendicular to the mattress.

The nurse should place a foot board perpendicular to the mattress and parallel to and touching the soles of the client’s feet. This will maintain the feet in a dorsiflexion and prevent foot drop.

Question 65

A nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this child?

Answer 65

• Use role plate and imitation when explaining.

Preschoolers learn by role play and imitation.

Question 66

A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, “All I have had since midnight is water and some juice.” What action is appropriate?

Answer 66

• Reschedule this lab test for the next morning.

The nurse will need to reschedule this lab test because in oder to ensure accuracy of a fasting blood sugar, the client should fast for 8 to 12 hours before the sample is drawn.

Question 67

The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. What action by the newly licensed nurse should cause the nurse to intervene?

Answer 67

• The newly licensed nurse places the cap of the sterile saline bottle on the sterile field.

The newly licensed nurse should place the cap with the sterile side up on a clean surface because the other edges are unsterile and will contaminate the sterile field.

Question 68

A nurse is preparing to perform NG suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate?

Answer 68

• Performing suctioning while removing the catheter.

The nurse should apply intermittent suction as she rotates the catheter and withdraws if from the airway.

Question 69

A nurse is caring for a preschooler who has heart disease. The provider prescribes digoxin (Lanoxin) at the maximum adult dose. Which action should the nurse take?

Answer 69

• Call the provider to discuss concerns regarding the dosage for the child.

Contacting the provider to discuss the dosage concerns is the appropriate action for the nurse to take to prevent injury to the child.

Question 70

A nurse is checking a client’s blood pressure to assess for orthostatic hypotension. What action should the nurse take?

Answer 70

• Obtain blood pressure 2 minutes after assisting the client to a sitting position.

The nurse should obtain the blood pressure with the client in the first the supine, then the siting and finally the standing positions. The nurse should wait 1 to 3 minutes after each position change.

Question 71

A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which piece of information is most essential to provide?

Answer 71

• Breath sounds.

When using the airway, breathing, circulation approach to client care the nurse determines the priority information to provide are the client’s breath sounds.

Question 72

A nurse is performing a spiritual assessment on a client newly admitted to to the unit. The nurse recognizes that the purpose of performing a spiritual assessment is to..

Answer 72

• Identify the client’s religious and spiritual beliefs, affiliations, and practices.

The purpose of a spiritual assessment is to help the nurse make appropriate referrals and incorporate the client’s practices and resources into the plan of care.

Question 73

A nurse receives report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hours. What action should the nurse take first?

Answer 73

• Check the IV tubing for obstruction.

The first action the nurse should take using the nursing process is to assess the client. By checking the IV tubing for obstruction, the nurse may be able to facilitate flow of fluid through the tubing. This insures the client receives the 0.9% sodium chloride at the prescribed rate.

Question 74

A nurse is admitting a new client. What action should the nurse take while performing medication reconciliation?

Answer 74

• Compare the client’s home medications with the providers prescription.

The nurse should compare the client’s home medications with the provider’s prescriptions when performing medication reconciliation.

Question 75

A nurse is preparing to care for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and gloves, the nurse will need which equipment in order to provide care?

Answer 75

• Face shield.

The nurse should choose personal protective equipment to prevent contamination from spraying blood or bodily fluids, when caring for a client who has MRSA in the lungs the nurse should wear a face shield.

Question 76

Which of the following is an appropriate nursing intervention when caring for an 83 year old patient as death nears?

Answer 76

-Hold the pt’s hand and state, “You’re not alone.”

Holding the hand of a dying pt and stating “You’re not alone” communicates concern and caring even if the pt is unable to respond. An actively dying person may not be able to interact, and telling the pt that he or she is going to die soon may increase their sense of anxiety.

Question 77

Which task could a staff nurse delegate to a certified nursing assistant?

Answer 77

-Feeding a stroke pt who has minimal dysphagia

The majority of state boards have addressed the issue of delegation and have developed rules that may offer specific guidelines regarding who can do what. The scope of practice for each level of acre provider usually includes a description of the tasks that may be performed at that level.

Question 78

To evaluate thoroughly an older adults pt’s memory, it is helpful to use reminiscence strategies because they

Answer 78

-Stimulate memory chains through associations

Reminiscence strategies can be used to stimulate memory chains by attempting to recall patterns of association that will improve the pt’s recollection.

Question 79

Conscious sedation is being considered for a pt undergoing a cervical dilation and endometrial biopsy in the health care provider’s office. The pt asks the nurse, “What is this conscious sedation?” The nurse’s response is based on the knowledge that conscious sedation

Answer 79

-Enables the pt to respond to commands and accept painful procedures

Conscious sedation is a moderate sedation that allows the pt to manage his or her own airway and respond to commands and yet the pt can emotionally and physically accept painful procedures

Question 80

If the family of a dying pt is highly emotional and critical of the nursing care which of the following is appropriate?

Answer 80

-Listen to concerns and provide reassurance

The family of a dying pt often responds emotionally due to stress and frustration. Active listening and reassurance can help reduce this.

Question 81

The lesions exhibited by a pt who has herpes simplex should be documented as

Answer 81

-Vesicles

Inflammatory and immune responses cause sequential and symptomatic production of areas of inflammation, causing the movement of histamines and fluid to the surface of the skin creating fluid filled vesicles.

Question 82

How can energy based therapies be described or defined?

Answer 82

-The balance and return of a person’s energy field to its optimal flow to facilitate healing.

A disruption in the flow of energy can result in symptoms of physical or psychologic illness. Balancing and returning the optimal flow energy facilitates healing.

Question 83

Which of the following pt’s is at highest risk of developing dehydration?

Answer 83

-A 78 year old pt with dementia

Older pts are at risk for dehydration bc of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink

Question 84

A nurse motivating a pt in a smoking cessation program should suggest

Answer 84

-Attempting to rid the area of tobacco odor

Question 85

A nurse has just given a narcotic for pain relief and must now leave the unit. To whom should the nurse delegate the task of evaluating the pt’s response to the pain medication?

Answer 85

-An RN

Assessment and management of pain belongs only to the RN’s scope of practice

Question 86

A 93 year old pt is likely to demonstrate hopelessness by

Answer 86

-Failing to follow medical recommendations

Hopeless individuals tend to be passive and uninterested in seeking care of following through with recommendations.

Question 87

A pt on initial assessment reports, “cough for 3 days and its getting worst.” The nurse says, “Tell me more about your cough.” The pt says, “I wish I could, but that is why I’m here. You tell me what’s wrong!” Which of these responses would be most appropriate for enhancing communication?

Answer 87

-“After 3 days, you’re tired of coughing. Have you had a fever?”

The nurse validated the pt’s information, relayed empathy, and sought further knowledge.

Question 88

When a pt complains of nausea after the first dose of morphine for pain the nurse should:

Answer 88

-Instruct the pt that with continued use, the nausea lessens

Opioids can cause nausea and vomiting bc of action on the brainstem centers. This s/e decreases with repeated use, but until then the tx for nausea should be instituted.

Question 89

A hospice nurse is caring for the family of a pt who has just died. Which interventions should the nurse implement in caring for the family

Answer 89

• Allow the family time with the body in private
• Used periods of silence of conversion

The nurse should allow the family time alone with the body to allow for grieving and closure and use periods of silence during the conversation. The nurse does not have to talk but can emotionally support the family simply by being present

Question 90

When unit staffing includes UAP which of following is a characteristic?

Answer 90

-Licensed personnel are accountable for the tasks delegated to the UAP

Nurses remain accountable for pt outcomes whether or not the specific tasks are performed nurses or nurse extenders.

Question 91

Which of the following may be left in place when a pt is sent to the operating room?

Answer 91

-Hearing aid

If a pt is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place

Question 92

A 75 year old pt who has vision and hearing problems has a history of striking out at caregivers. Which of the following is the most appropriate nursing intervention?

Answer 92

-Get the pts attn and consent before starting care

Individuals with limited sensory ability may strike out bc of fear or confusion. Taking time to make contact with the individual before starting care should reduce problems.

Question 93

If the edges of a pt’s appendectomy incision are approximated and no drainage is noted, a nurse should document that the incision appears to be healing by

Answer 93

-Primary intention

Primary intention is the use of suture or other wound closures to approximate the edges of an incision or a clean laceration

Question 94

Which of the following may indicate pain in a 76 year old pt with communication impairments

Answer 94

• Decreased appetite
• Tearing of the eyes
• Increased social isolation

Question 95

An 82 year old man tells a nurse that he is having difficulty hearing and that he has “too much ear wax.” Bc of the pts age the nurse should most appropriately ask

Answer 95

-“Did you ever experience impacted ear wax?”

Obstruction of the ear is most often caused by impacted cerumen. Older adults are more susceptible to cerumen impaction bc hair in the ear becomes coarser with age and traps the wax. Impacted cerumen can cause hearing losses in pts of all ages.

Question 96

A nurse should obtain an air mattress for a pt at risk for impaired skin integrity bc it will

Answer 96

-Distribute body weight over a larger area

Air mattresses are used to reduce pressure points by distributing weight over a larger area. Air mattresses do not reduce friction and pulling nor keep the skin cool and dry. Air mattresses do not encourage movement

Question 97

Many complementary and alternative therapies share which of the following concepts?

Answer 97

-Pts are capable of decision making and should be part of the health care team.

The emphasis of alternative and complementary therapies is that the pt is viewed as a whole being capable of decision making and an integral part of the health care team.

Question 98

When providing care to a dying pt, a nurse should remember that the following is longest lasting sense?

Answer 98

-Hearing

A dying pt can hear even when he or she is unable to respond.

Question 99

Wet to dry dressings for mechanical debridement of a would should

Answer 99

-Be only moist, not wet, when applied

Wet to dry dressing used for mechanical debridement of wounds should be moist, not wet. The dressing is positioned in the wound and held in place by an outer dressing or gauze wrap. Dressings should be removed when partially dried (4-6 h)

Question 100

Which of the following best describes therapeutic touch?

Answer 100

-Movement of the hands over the body to assess energy

The therapeutic touch practitioner uses hands to assess, modulate, and transfer energy to or from the pt to restore energy balance. The pt’s body is not physically touched

Question 101

In the operating room, a pt tells the nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye. What should the nurse do first?

Answer 101

-Ask the pt his name

Ensuring proper identification of a pt is a responsibility of all members of the surgical team. The priority is with the nurse identifying the pt and the other pt’s const form before the physicians are notified.

Question 102

Which of the following is an appropriate task for a nurse to delegate to a nursing assistant?

Answer 102

-Toileting a pt on a bladder training regimen

Basic nursing interventions are within scope of practice of a nursing assistant

Question 103

Which of the following addressed the type and extent of care a pt wishes?

Answer 103

-Advance directives

AD need to be considered when planning care. AD give instructions as to a person’s wishes for care.

Question 104

What would be the most effective way for a nurse to validate “informed consent?”

Answer 104

-Ask the pt what he or she understands regarding the procedure

Informed consent in the health care setting is a process whereby a pt is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done.

Question 105

Which of the following is most likely to be effective in meeting a pt’s teaching/learning needs preoperatively?

Answer 105

-Teaching the pt and family

A nurse should determine learning needs preoperatively and teach both the pt and the family before surgery.

Question 106

A homehealth nurse is performing an initial assessment on an elderly pt. which physiologic changes should the nurse anticipate as being “normal” for an elderly pt?

Answer 106

• Decreased saliva production
• Delayed wound healing
• Loss of visual acuity

Question 107

While inspecting a 69 year old pt, if a nurse notes that the left upper eyelid droops, covering more of the iris than the right eyelid, this should be recorded as

Answer 107

-Ptosis on the left eye

Ptosis is when the eyelid droops and covers a larger portion of the iris. This condition results from nerve damage or a lid muscle disorder.

Question 108

Drug administration would be considered palliative in which of the following situations?

Answer 108

-Pain management for a pt with terminal cancer

Palliate means to alleviate with curing. Palliation therapy is typically usied for pts with end stage disease or illness to make pts as comfortable as possible

Question 109

The nurse suspects the possibility of sepsis in the burn pt based on changes in

Answer 109

-Vital signs

Early signs of sepsis include an elevated temperature, increased pulse and respiratory rate, accompanied by decreased BP and later decreased urine output and perhaps paralytic ileus.

Question 110

Standard precautions applies to what type of pts?

Answer 110

-To all pts receiving care

Standard precautions were implemented to provide safety for caregivers and pts regardless of infectious status.

Question 111

A nurse is caring for a surgical pt in the preoperative area. The nurse obtains the pts informed consent for the surgical procedure. Which statements are true regarding informed consent?

Answer 111

• Informed consent must be signed while the pt is free from mind altering medications
• Informed consent must be witnessed