Exam 1 Mod 1-6 Flashcards
1
Q
Nurses use _______ and _______ for care prioritization.
A
Maslow’s Hierarchy and ABCs (Airway, Breathing, Circulation
2
Q
Prioritize maintaining skin integrity and preventing ________.
A
pressure ulcers
3
Q
Root cause analysis and _____ prevent future errors in healthcare settings.
A
incident reporting
4
Q
Assess patient’s hygiene needs, physical limitations, and _______ or _______.
A
cultural or personal preferences
5
Q
Uphold _____, _____, _____, and _____ in patient care.
A
autonomy, beneficence, nonmaleficence, and justice
6
Q
Nurses apply _______, infection control measures, and medication safety checks to ensure patient safety.
A
fall prevention strategies
7
Q
Choose appropriate interventions like _____, _____, and _____.
A
bathing, oral care, and perineal care
8
Q
Maintain patient _____, _____, and _____ during hygiene care.
A
dignity, privacy, and comfort
9
Q
The nursing process includes the steps of _____, _____, _____, _____, and _____ for problem-solving.
A
Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE)
10
Q
Clinical decision-making in nursing should utilize _____-_____ _____ to improve patient outcomes.
A
Evidence-Based Practice (EBP)
11
Q
Prolonged immobility in older adults can lead to complications such as _____, _____, and _____.
A
venous thromboembolism (VTE), pneumonia, and constipation
12
Q
Pharmacologic interventions for managing chronic pain in older adults include administering analgesics like _____ and _____ based on assessment.
A
NSAIDs and opioids
13
Q
Non-pharmacologic methods for managing chronic pain in older adults may involve _____, _____, and _____.
A
heat therapy, massage, and relaxation techniques
14
Q
Implement fall prevention strategies using _____, ______, and ______.
A
bed alarms, non-slip footwear, and assistive devices
15
Q
Older adults may show atypical symptoms such as _____ during infections.
A
confusion
16
Q
Older adults face increased risks of _____, _____, and _____.
A
falls, fractures, and pressure ulcers
17
Q
Educating patients on the correct usage of assistive devices is important to _____ and _____.
A
prevent injury and promote independence
18
Q
Nurses must manage multiple chronic illnesses and reduce the risks associated with _____ in older adults.
A
polypharmacy
19
Q
Regular repositioning is necessary to prevent _____ and enhance _____.
A
pressure ulcers; circulation
20
Q
Common assistive devices for patients with impaired mobility include _____, _____, _____, and _____.
A
{{c1::canes, walkers, wheelchairs, and gait belts}}
21
Q
Regular pain assessment using appropriate pain scales, such as the _____, is essential in caring for older adults with chronic pain.
A
Numeric Rating Scale
22
Q
Care planning for older adults should address geriatric syndromes like _____, _____, and _____.
A
fall risks, delirium, and incontinence
23
Q
Encourage active and passive _____ for patients with immobility in the acute care setting.
A
range-of-motion exercises
24
Q
Hydration is encouraged to _____ in patients with respiratory issues.
A
thin secretions and promote effective airway clearance
25
_____ is crucial for education and support in long-term oxygen therapy.
Family involvement
26
Nurses regularly assess older adults with chronic respiratory conditions for signs of _____ or _____.
respiratory distress or exacerbation
27
Medication dosages may need adjustment in older adults to avoid _____.
toxicity
28
Nursing interventions for patients with respiratory issues in the acute care setting include administering oxygen at prescribed levels using devices like _____ and _____.
nasal cannulas and masks
29
Aging leads to decreased lung elasticity, increasing the risk of _____.
pneumonia
30
Airway clearance techniques for respiratory issues include _____, _____, and _____.
{{c1::incentive spirometry, chest physiotherapy, and suctioning}}
31
Nurses manage medications for older adults with chronic respiratory conditions by administering _____ and _____ as prescribed.
bronchodilators and steroids
32
Nurses educate patients with chronic respiratory conditions on _____ and _____.
{{c1::energy conservation and breathing techniques}}
33
Older adults are more prone to _____, necessitating close monitoring.
hypoxia
34
The care plan for older adult patients with impaired oxygenation includes assessing _____, vital signs, and signs of hypoxia.
respiratory function
35
Interventions for impaired oxygenation involve administering oxygen, encouraging _____, and positioning patients upright.
deep breathing exercises
36
Administering SQ medications should be done at a _____ or _____ angle, depending on patient body type.
45° or 90°
37
Confirm IV line _____ before administration.
patency
38
Accurately calculate dosages based on patient weight, age, or body surface area then _____.
Double-check critical medication calculations with another nurse.
39
Confirm the patient's ability to _____ and assess for risk of _____ before administering PO medications.
swallow; aspiration
40
Provide _____ for complex medication regimens.
clear, written information
41
Use the _____ to assess patient understanding of medication instructions.
{c1::teach-back method}}
42
Rotate injection sites to avoid _____.
lipodystrophy
43
Verify NG or PEG tube placement before administering medications to ensure safe administration. T/F
T
44
Double-check orders for high-risk medications such as _____ and insulin.
anticoagulants
45
To prevent clogging, flush the tube _____ and _____ medication administration.
before and after
46
Calculate and adjust _____ appropriately.
IV drip rates
47
Ensure medication orders include patient name, medication, dosage, route, frequency, and _____.
signature
48
Administer IV medications _____ to prevent reactions.
{{c1::slowly}}
49
Avoid crushing _____ or _____ pills.
extended-release or enteric-coated
50
Monitor for signs of _____ or _____.
infiltration or phlebitis
51
For SQ injections, use _____, typically _____.
25–27 gauge needles; ⅜–⅝ inch
52
Double-check orders for high-risk medications such as anticoagulants and _____.
insulin
53
Common causes of impaired urinary elimination include neurological disorders such as _____ and spinal cord injuries.
multiple sclerosis
54
Medications like _____ and anticholinergics can cause impaired urinary elimination.
diuretics
55
In men, _____ is a common cause of impaired urinary elimination.
prostate enlargement
56
Medications affecting bladder function, including _____ and antihistamines, are risk factors for impaired urinary elimination.
sedatives
57
Urinary retention in Impaired Urinary Elimination is marked by _____, _____, or _____.
difficulty starting urination, a weak stream, or feeling of incomplete bladder emptying
58
Impaired Urinary Elimination can include urinary incontinence characterized by _____.
involuntary leakage of urine
59
For patients with impaired urinary elimination, providing education on _____ can help manage incontinence.
pelvic floor exercises
60
Nursing care for impaired urinary elimination involves assessing urinary patterns and symptoms, promoting fluid intake, and _____.
monitoring output
61
UTIs in the context of Impaired Urinary Elimination present with _____, _____, _____, and _____.
frequency, urgency, dysuria, and hematuria
62
Risk factors for impaired urinary elimination in older populations include age-related changes like decreased _____ and weakened pelvic muscles.
bladder capacity
63
Cognitive impairments such as _____ are risk factors for impaired urinary elimination in vulnerable populations.
dementia
64
Obstructions such as _____ and tumors can lead to impaired urinary elimination.
kidney stones
65
Chronic diseases like _____ and stroke are risk factors for impaired urinary elimination in older adults.
diabetes
66
To manage alkalosis, administer appropriate fluids and electrolytes, such as _____ or _____.
potassium or chloride
67
Work with respiratory therapists for ventilatory support in managing _____.
acid-base imbalances
68
Collaborate with healthcare teams to optimize _____ and _____ for acid-base imbalances.
medication management and treatment plans
69
Infants and children are at higher risk for fluid and electrolyte imbalances due to their higher _____.
metabolic rates
70
Key electrolytes like bicarbonate, chloride, and sodium play critical roles in maintaining _____.
acid-base balance
71
Infants and children have an increased metabolic rate leading to rapid changes in _____.
acid-base balance
72
_____ acts as a buffer to neutralize excess acids.
Bicarbonate
73
Patients with mental health issues may neglect fluid intake, increasing the risk of _____ and _____.
fluid and electrolyte imbalances
74
Chronic illnesses such as _____ and _____ increase the risk of fluid and electrolyte imbalances.
heart failure and renal disease
75
Assessment of acid-base imbalances includes monitoring vital signs, particularly _____ and _____.
respiratory rate and pattern
76
Comorbidities such as chronic lung disease and ______ are age-related risk factors for acid-base imbalances.
diabetes
77
Alkalosis signs include hyperventilation, muscle twitching, and _____.
tachycardia
78
Symptoms of alkalosis include lightheadedness, nausea, and tingling in _____.
extremities
79
Metabolic acidosis shows _____, _____, _____, and _____.
rapid breathing, confusion, fatigue, and nausea
80
Environmental factors like _____, excessive exercise, or illness can increase the risk of fluid and electrolyte imbalances.
hot weather
81
Acidosis signs include respiratory distress, drowsiness, confusion, and decreased _____.
blood pressure
82
The body's response to acid-base imbalances often involves adjustments in renal function for _____ and _____.
bicarbonate and electrolyte excretion
83
Dehydration may lead to ______.
metabolic acidosis
84
Respiratory acidosis presents with _____, _____, _____, and _____, _____.
confusion, headache, lethargy, and rapid, shallow breathing
85
Medications like _____ affecting bicarbonate levels are age-related risk factors for acid-base imbalances.
diuretics
86
Fluid excess imbalances include hypervolemia (high blood volume) and _____.
hyponatremia (low sodium)
87
Ensure fall precautions for patients experiencing _____ or _____ due to acid-base imbalances.
weakness or confusion
88
Teach patients about the importance of adhering to _____ to manage acid-base imbalances effectively.
treatment plans
89
Understanding the relationship between acid-base and fluid-electrolyte imbalances is essential for effective patient assessment and intervention in conditions like kidney disease, heart failure, or _____.
severe dehydration
90
Fluid deficit imbalances include hypovolemia (low blood volume) and _____.
hypernatremia (high sodium)
91
Understanding the relationship between acid-base and fluid-electrolyte imbalances is essential for effective patient assessment and intervention in conditions like kidney disease, _____, or severe dehydration.
heart failure
92
The body's response to acid-base imbalances often involves adjustments in respiratory rate for _____.
CO2 regulation
93
Metabolic alkalosis involves _____, _____, and _____.
muscle twitching, irritability, decreased respiratory rate, and weakness
94
Improving _____ is a method to treat the underlying cause of acidosis.
ventilation
95
Critical thinking barrier: Bias
Bias occurs when the thinker focuses on evidence that confirms a preconceived thought and ignores the facts that counter that preconceived thought
96
Critical thinking barrier: Erroneous Assumption
Assuming the presented information is correct without validating or confirming is an example of erroneous assumption.
97
Critical thinking barrier: Illogical Thinking
Illogical thinking occurs when a nurse jumps to conclusions or is not clearly thinking through the presented information.
98
Critical thinking barrier: Close-mindedness
Being resistant to change, including (in nursing) a new standard of care
99
Intellectual standard: Depth
The nurse completely understands the complexities of the issue.
100
Intellectual standard: Accuracy
The nurse’s perspective has been confirmed as factual.
101
Intellectual standard: Clarity
Others understand the nurse’s point of view.
102
Intellectual standard: Significance
The nurse focuses on the most important aspects of the situation.
103
SBAR communication: Situation
The situation element identifies the patient’s name, age, allergies, and diagnosis.
104
SBAR communication: Background
The background element provides the new nurse with the necessary information that explains why the patient is admitted and any pertinent information that may affect the patient long-term, such as risks for self-harm, suicide, or violence.
105
SBAR communication: Assessment
The assessment element provides the nurse with information about what happened in the care of the patient, such as vital signs, laboratory test values, and interventions used.
106
SBAR communication: Recommendation
Recommendation is the informing of staff about which tasks need to be continued or followed up on.
107
Delegating to unlicensed personnel
Work that does not require a license for legal or liability reasons can be delegated to an unlicensed team member. You need a license (of some kind) to assess/analyze data, but not to collect it (such as vital signs), for example.
108
Primary Prevention
true prevention. Its goal is to reduce the incidence of disease. Many primary prevention programs are supported by the government (e.g., federally funded immunization programs). Primary prevention includes health education programs, nutritional programs, and physical fitness activities. It includes all health promotion efforts and wellness education activities that focus on maintaining or improving the general health of individuals, families, and communities
109
Secondary Prevention
focuses on preventing the spread of disease, illness, or infection once it occurs. Activities are directed at diagnosis and prompt intervention, thereby reducing severity and enabling the patient to return to a normal level of health as early as possible
110
Tertiary Prevention
occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration
111
What is the relationship between illness and aging?
Acute illnesses and injuries increase risk for chronic health conditions as we age. Our immune system weakens as we age. Disease is not expected or automatic for older adults and illnesses are not unique to older adults.
112
What are the changes in the cardiovascular system related to aging?
Orthostatic hypotension is common and lower extremities are colder (especially during the night). Blood pressure changes are not normal or expected solely due to aging.
113
Risks that are higher as we age
Injury, pneumonia, osteoporosis, COPD
114
Maslow's Hierarchy of Needs:
Physiological, Safety, Love and belonging, Esteem, Self-Actualization
115
Maslow's Hierarchy of Needs: Physiologica
The most basic needs, such as food, water, air, shelter, sleep, and clothing
116
Maslow's Hierarchy of Needs: Safety
The need for a safe and secure environment, including financial security, personal security, and protection from harm
117
Maslow's Hierarchy of Needs: Love and belonging
The need to feel a sense of acceptance and belonging, including friendships, family, and intimacy
118
Maslow's Hierarchy of Needs: Esteem
The need for self-esteem and respect, including the desire for knowledge, competence, and independence
119
Maslow's Hierarchy of Needs: Self-Actualization
The need to reach one's full potential, including realizing one's unique talents and abilities
120
Delirium
Delirium is a transient, generally reversible and treatable cause of cerebral dysfunction.
121
Vascular dementia
Vascular dementia results from brain injury due to impaired blood flow to the brain. It is the second most common form of dementia.
122
Alzheimer’s disease
Alzheimer’s disease is the most common form of dementia, which affects 38% of people over age 85. It is caused by beta-amyloid plaques forming in the brain.
123
Lewy body dementia
Lewy Body Dementia. Lewy body dementia occurs when tiny deposits of a protein (alpha-synuclein) appear in nerve cells in the brain.
124
Frontotemporal dementia
Frontotemporal dementia, also called frontotemporal degeneration disease or frontotemporal neurocognitive disorder, encompasses several types of dementia involving the progressive degeneration of the brain's frontal and temporal lobes.
125
Brain functioning changes with age
Older adulthood includes individuals who are older than 65 years of age and is associated with a decline in short-term memory. Long term recall is not usually affected. Older adults may need accommodations (such as larger print) but the drive to learn and ability to learn are not diminished naturally by the aging process itself (without disease).
126
Older adults and sexuality
Older adults, regardless of health status, desire to share passion and affection. Sexual activity doesn’t stop just because of age, so continued STD prevention is important. The ability to have sex can be affected by disease, illness, or injury.
127
Movement devices: trapeze bar
The patient can grasp the bar to pull his or her own weight when repositioning.
128
Movement devices: mechanical lift
A mechanical lift allows nurses to transfer patients from one location to another (bed to bed for example) by lifting them using hydraulics
129
Movement devices: transfer board
A transfer board allows nurses to slide patients from bed to bed
130
Movement devices: friction-reducing sheet
A friction-reducing sheet allows nurses to reposition patients but would not be of any assistance to the patient when repositioning.
131
Positions: Fowlers
Upright
132
Positions: Sim’s
Sim’s position is lying on the left side with the right knee pulled slighter higher than in the side-lying position.
133
Positions: Dorsal recumbent
Dorsal recumbent is lying supine with knees bent.
134
The Nursing Process (in order)
Assessment, Diagnosis (problems), Outcomes (goals), Interventions (taking action), Evaluation
135
Ventilation
the process of moving gases into and out of the lungs, with air flowing into the lungs during inhalation (inspiration) and out of the lungs during exhalation (expiration).
136
Perfusion
relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs
137
Diffusion
is responsible for moving the respiratory gases from one area to another by concentration gradients.
138
Hypoxia
is inadequate tissue oxygenation at the cellular level. It results from a deficiency in oxygen delivery or oxygen use at the cellular level. It is a life-threatening condition. Untreated, it has the potential to produce fatal cardiac dysrhythmias
139
Hyperventilation
is a state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Severe anxiety, infection, drugs, or an acid-base imbalance induces hyperventilation
140
Hypoventilation
occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or to eliminate sufficient carbon dioxide. As alveolar ventilation decreases, the body retains carbon dioxide. For example, atelectasis, a collapse of the alveoli, prevents normal exchange of oxygen and carbon dioxide. As more alveoli collapse, less of the lung is ventilated, and hypoventilation occurs.
141
Prevention strategies: Obesity
Increasing physical activity, plus reducing intake of foods high in fat and foods and drinks high in sugars, can prevent unhealthy weight gain.
142
Prevention strategies: Diabetes Mellitus II
Increasing physical activity and maintaining a healthy weight play critical roles in the prevention and treatment of diabetes mellitus.
143
Prevention strategies: Cardiovascular disease
Reduced intake of saturated and trans fats; sufficient amounts of (omega-3 and omega-6) polyunsaturated fats, fruits, and vegetables; reduced salt intake; physical activity; and controlling weight can reduce the risk of cardiovascular disease.
144
Prevention strategies: Cancer
Maintaining a healthy weight will reduce the risk for cancers of the esophagus, colorectum, breast, endometrium, and kidney. Limiting alcohol intake will reduce the risk for cancers of the mouth, throat, esophagus, liver, and breast. Ensuring an adequate intake of fruits and vegetables should further reduce the risk for oral cavity, esophagus, stomach, and colorectal cancers.
145
Prevention strategies: Osteoporosis and bone fractures
An adequate intake of calcium (500 mg/day or more) and vitamin D in populations with high osteoporosis rates helps to reduce fracture risk. Sun exposure and physical activity to strengthen bones and muscles also help to reduce the risk.
146
Prevention strategies: Dental disease
Limiting the frequency and amount of sugar consumption and increasing the use of fluoride can prevent tooth decay.
147
Chronic care model
The model provides a framework to guide health care delivery for patients living with chronic illnesses. This model considers the complex nature of factors that affect the care delivery needs of persons with a chronic illness: community resources and policies, self-management, support, health systems organization, delivery, design, decision support, and clinical information systems.
148
Rights of Safe Medication Administration
Patient, Medication, Dose, Route, Time… then documentation. (know examples of what doing each of these right/wrong looks like). The main five are in the order (Give Susie Jones Xanax 2mg PO daily… then document it)
149
The “do not crush/cut” meds
Enteric coated and extended release tablets, and any capsules. (note, in practice there are some capsules that can be “dumped out” and mixed with specific food, but it would require a physician order to do that and the RIGHT food to protect the stomach the way the gel coating would have)
150
Body’s natural pH
7.35 - 7.45
151
Body’s natural sodium level
135 to 145 mEq/L
152
Body’s natural potassium level
3.5 to 5.0 mEq/L
153
What are the types of fluid deficit?
Hypovolemia and hypernatremia.
154
What are common signs of fluid overload?
Edema, hypertension, jugular venous distension, crackles in lungs.
155
Name two key electrolytes that influence acid-base balance.
Bicarbonate (HCO₃⁻) and chloride (Cl⁻).
156
What is a common cause of metabolic acidosis?
Diabetic ketoacidosis or renal failure.
157
What are the symptoms of hyperkalemia?
Muscle weakness, fatigue, palpitations, ECG changes (peaked T waves).
158
How does dehydration affect the body's acid-base balance?
It may lead to metabolic acidosis due to decreased fluid volume.
159
What is the nursing priority when assessing an older adult for fluid imbalance?
Monitor for changes in cognitive function and hydration status.
160
How should a nurse respond to a patient with signs of respiratory acidosis?
Assess respiratory rate and provide ventilatory support as needed.
161
What teaching point is essential for a patient with chronic kidney disease regarding fluid intake?
Limit fluid intake to prevent overload and manage electrolyte imbalances.
162
Describe the signs of hypocalcemia.
Numbness, tingling, muscle spasms, Chvostek’s and Trousseau’s signs.
163
What is an important nursing intervention for patients at risk for falls due to dizziness?
Implement fall precautions and monitor vital signs closely.
164
What are the signs of metabolic alkalosis?
Muscle twitching, irritability, decreased respiratory rate, weakness.
165
How does the body compensate for respiratory acidosis?
Increased respiratory rate to eliminate CO₂.
166
What electrolyte imbalance can result from excessive vomiting?
Hypochloremic metabolic alkalosis due to loss of chloride.
167
What nursing action is critical for a patient receiving IV potassium?
Ensure the infusion is running slowly and monitor cardiac rhythm.
168
What is the priority nursing intervention for a patient with dehydration?
Encourage oral fluid intake if alert; administer IV fluids as prescribed.
169
What are the symptoms of hyponatremia?
Confusion, seizures, muscle cramps, fatigue.
170
What laboratory value indicates metabolic alkalosis?
Increased bicarbonate (HCO₃⁻) levels.
171
What assessment finding suggests fluid overload?
Elevated blood pressure, jugular venous distension, edema.
172
What should a patient with hypernatremia be monitored for?
Neurological status changes.
173
What education should be provided about hydration?
Monitor urine color to assess hydration; increase fluid intake during hot weather.
174
Urinary Incontinence
An involuntary leakage of urine, which can be classified into types such as stress, urge, and overflow incontinence.
175
Urinary Retention
The inability to completely empty the bladder, often characterized by a weak urine stream, straining to urinate, or a sensation of incomplete bladder emptying.
176
Urinary Tract Infection (UTI)
A bacterial infection affecting any part of the urinary system, presenting symptoms such as frequency, urgency, dysuria, and sometimes hematuria.
177
Neurogenic Bladder
A condition caused by nerve damage that affects bladder control, leading to issues like urinary retention or incontinence.
178
Pelvic Floor Exercises
Exercises aimed at strengthening the pelvic floor muscles, beneficial for patients experiencing urinary incontinence.
179
Antimuscarinics
Medications prescribed to manage symptoms of overactive bladder, reducing urgency and frequency of urination.
180
Risk Factors for Impaired Urinary Elimination
Includes age-related changes, cognitive impairments, chronic diseases, and medications affecting bladder function.
181
Straight Catheterization
A procedure where a catheter is inserted into the bladder to drain urine, often necessary for patients with neurogenic bladder.
182
Signs of UTI
Symptoms indicating a urinary tract infection, including frequent urination, burning sensation during urination, and cloudy or strong-smelling urine.
183
Bladder Training
A behavioral technique used to help patients regain control over urination by gradually increasing the time between voids.
184
Nursing Assessment and Interventions (Impaired Oxygenation)
Assessment involves evaluating respiratory rate, rhythm, and effort, as well as oxygen saturation levels and lung sounds. Interventions include administering oxygen therapy, positioning the patient for optimal breathing, monitoring vital signs, and providing education on breathing exercises.
185
Nursing Assessment and Interventions (Fluid, Electrolyte, and Acid-Base Imbalances)
Assessment includes monitoring vital signs, fluid intake/output, and laboratory values for electrolytes and pH balance. Interventions involve educating patients on dietary modifications, administering IV fluids or electrolyte replacements, and implementing safety measures to prevent falls due to dizziness or confusion.
186
Nursing Assessment and Interventions (Impaired Urinary Elimination)
Assessment focuses on urinary patterns, frequency, and signs of retention or incontinence. Interventions include implementing bladder training programs, educating on pelvic floor exercises, promoting fluid intake, and monitoring for signs of urinary tract infections.
187
A patient recovering from a myocardial infarction is participating in a cardiac rehabilitation
program to improve their health and prevent future heart issues. This is an example of which
level of prevention?
A. Primary
B. Secondary
C. Tertiary
C (Tertiary) - Correct. The patient is in cardiac rehabilitation, which is aimed at
managing an existing condition
188
During a community health assessment, a nurse conducts a home visit with a single father and
his two children. The nurse reviews their food choices and encourages outdoor playtime for
physical activity. Which level of need is the nurse primarily addressing according to Maslow's
Hierarchy of Needs?
A. Physiological
B. Safety and Security
C. Love and Belonging
A (Physiological) - Correct. The nurse addresses basic needs like nutrition and physical
activity.
189
While transferring a patient’s care from the emergency department to the nursing floor, the nurse
uses the SBAR communication tool. When the nurse states, "The patient has a history of diabetes
and is currently experiencing high blood sugar levels," which SBAR element is being addressed?
A. Background
B. Assessment
C. Recommendation
A (Background) - Correct. The statement provides relevant patient history.
190
Which patient should receive the highest priority for morning care?
A. A patient with a high fever awaiting lab results.
B. A patient experiencing frequent incontinence.
C. A patient who just returned from surgery and is drowsy.
D. A patient complaining of severe pain (9/10) who hasn’t slept.
D - Correct. A patient in severe pain (9/10) requires immediate attention
191
A male nurse is providing personal care to a female patient. Which statement by the nurse best
reflects sensitivity to the patient’s comfort?
A. "I'll make sure this is done quickly."
B. "If you feel uncomfortable at any point, please let me know."
C. "You can handle this part of your care yourself."
D. "I’m just doing my job; it will be over soon."
B - Correct. This statement shows sensitivity to the patient's comfort.
192
The nurse delegates the task of bathing an alert older adult patient to an assistive personnel (AP).
Which activity is appropriate for the AP to perform?
A. Assessing skin integrity for pressure injuries.
B. Providing range-of-motion exercises.
C. Administering medications.
D. Assisting with the patient’s hygiene needs.
D - Correct. Assisting with hygiene needs is appropriate for unlicensed personnel.
193
Which of the following is a common symptom of burnout among healthcare providers?
A. Improved sleep quality
B. Increased empathy towards patients
C. Feeling detached from work
D. Greater interest in professional development
C - Correct. Feeling detached is a common symptom of burnout.
194
Which statement best describes the relationship between chronic illness and aging in older
adults?
A. Aging inevitably leads to chronic illness.
B. Chronic conditions are more prevalent but not exclusively linked to aging.
C. Older adults have a stronger immune response to diseases.
D. Chronic illness is a rare occurrence in older adults
B - Correct. Chronic conditions are prevalent in older adults but not exclusively due to
aging
195
For a patient who had hip surgery and requires assistance repositioning in bed, which device
would be most beneficial?
A. Bed rails
B. Mechanical lift
C. Transfer board
D. Trapeze bar
D - Correct. A trapeze bar would assist with repositioning
196
Which chronic respiratory condition is particularly prevalent among older adults due to age-
related changes?
A. Asthma
B. Lung cancer
C. Chronic obstructive pulmonary disease (COPD)
D. Pulmonary fibrosis
C - Correct. COPD is common among older adults.
197
Which statement reflects a common misconception about sexual health in older adults?
A. Older adults can still engage in satisfying sexual activity.
B. Safe sex practices remain important regardless of age.
C. Sexual health discussions are unnecessary for older adults.
D. Older adults may face physical challenges affecting their sexual health.
C - Correct. This statement reflects a misconception.
198
A patient with chronic obstructive pulmonary disease (COPD) expresses a need for further
education when they state:
A. "I will check my oxygen levels daily."
B. "I should limit my fluid intake when I have a cold."
C. "I’ll join a support group for smoking cessation."
D. "Pursed-lip breathing can help manage my shortness of breath."
B - Correct. The statement indicates a need for education on fluid management.
199
The nurse is caring for a patient diagnosed with pneumonia who is having difficulty clearing
secretions. What is the nurse's first action?
A. Administer a bronchodilator.
B. Encourage the use of an incentive spirometer.
C. Elevate the head of the bed.
D. Notify the physician.
C - Correct. Elevating the head of the bed aids in breathing.
200
When assessing a patient with a chronic illness, which question encourages the patient to
elaborate on their experience?
A. "Do you follow your treatment plan?"
B. "How does your illness affect your daily activities?"
C. "Are you experiencing any pain?"
D. "Do your family members support you?"
B - Correct. This question encourages elaboration on the patient's experience.
201
A nurse is providing care to a patient from a cultural background that traditionally emphasizes herbal remedies for health issues rather than conventional medicine. During the assessment, the patient expresses skepticism about the prescribed medication and prefers to use their herbal treatments. Which of the following actions should the nurse take to provide culturally competent care?
A. Collaborate with the patient to explore how both the prescribed medication and their herbal remedies can be integrated into their care plan.
B. Ask the patient to follow the prescribed treatment plan without discussing their preferences.
C. Assume that all patients from this cultural background prefer herbal remedies and provide educational materials only on those treatments.
D. Explain that the prescribed medication is necessary and discourage the use of herbal remedies.
A - Correct. Collaboration respects the patient's preferences.
202
A patient with chronic obstructive pulmonary disease (COPD) is experiencing increased anxiety
and reports feeling lightheaded and short of breath. The nurse observes that the patient is
breathing rapidly and deeply. Which of the following interventions should the nurse implement
to address these symptoms?
A. Position the patient in a supine position, lowering the head of the bed.
B. Teach the patient to use pursed-lip breathing techniques.
C. Encourage the patient to take deep, rapid breaths.
D. Administer oxygen therapy at a high flow rate.
B - Correct. Pursed-lip breathing can help reduce anxiety and improve oxygenation.
203
Which statement provides an example of considerations for older adults related to sexuality?
A. Individuals experiencing weakness or paralysis are not able to experience sexual pleasure.
B. Safe sex practices are not important after menopause.
C. Sexuality should be discussed during visits with the healthcare team to promote physical and
psychosocial health.
D. People participate in sexual activity primarily for the purpose of reproduction.
C - Correct. Sexual health should be part of health discussions.
204
A nurse is preparing to administer a prescribed medication to a patient. Which action is essential
to ensure the right patient is receiving the medication?
A. Asking the patient to state their name and checking the medication label.
B. Checking the medication label against the MAR only.
C. Reviewing the patient's medical history before administering the medication.
D. Administering the medication quickly to stay on schedule.
A - Correct. This action confirms patient identity
205
During medication administration, the nurse realizes that a prescribed medication is not available
in the pharmacy. What should the nurse do first?
A. Substitute a different medication that the patient is familiar with.
B. Call the pharmacy to find out when the medication will be available.
C. Inform the healthcare provider to change the medication order.
D. Delay the administration until the medication arrives.
C - Correct. Informing the healthcare provider is the priority.
206
A patient is prescribed a narcotic pain medication that is due to be administered. Which step is
critical for ensuring the right dose is given?
A. Measuring the medication using any available cup.
B. Calculating the dose based on the patient’s weight.
C. Using a standard measuring device to prepare the dose.
D. Splitting the tablet to achieve the desired dose.
C - Correct. A standard measuring device ensures accurate dosing.
207
A nurse has just administered a medication and is now preparing to document the administration.
Which action should the nurse take?
A. Document the medication administration on the MAR after the next patient assessment.
B. Write down the medication name and dose at the end of the shift.
C. Immediately document the medication name, dose, route, time, and patient’s response.
D. Wait until the patient requests a PRN medication before documenting.
C - Correct. Immediate documentation is essential for accountability.
208
A patient presents with signs of dehydration, including dry mucous membranes and decreased
skin turgor. What is the priority nursing intervention?
A. Encourage oral fluid intake if the patient is alert.
B. Administer IV fluids as prescribed.
C. Weigh the patient daily to monitor fluid loss.
D. Teach the patient about dietary modifications for hydration.
B - Correct. Administering IV fluids is the priority intervention
209
During a routine assessment, the nurse checks the patient's arterial blood gas results. Which pH
value indicates normal acid-base balance?
A. 7.25
B. 7.35 - 7.45
C. 7.50
D. 7.60
B - Correct. Normal pH is between 7.35 - 7.45
210
A patient with hypokalemia is at risk for serious complications. Which intervention should the
nurse prioritize?
A. Administer potassium supplements as prescribed.
B. Monitor daily weights for fluid status.
C. Increase the patient’s dietary sodium intake.
D. Encourage the patient to engage in light exercise.
A - Correct. Administering potassium supplements is crucial for hypokalemia.
211
A patient is experiencing fluid overload. What is the most appropriate nursing intervention?
A. Administer a diuretic as prescribed.
B. Increase IV fluid rate to help with hydration.
C. Restrict dietary sodium only.
D. Encourage high fluid intake to dilute electrolytes
A - Correct. Administering a diuretic helps manage fluid overload.
212
When developing a care plan for a patient at risk for dehydration, which nursing diagnosis is
most appropriate?
A. Impaired skin integrity.
B. Risk for electrolyte imbalance.
C. Ineffective breathing pattern.
D. Acute pain.
B - Correct. Risk for electrolyte imbalance is appropriate for dehydration.
213
A nurse is assessing a patient with fluid overload. Which finding would most likely be present?
A. Increased urine output.
B. Decreased blood pressure.
C. Elevated blood pressure.
D. Dry, cracked lips.
C - Correct. Elevated blood pressure is typical in fluid overload.
214
In metabolic alkalosis, which laboratory value is most likely elevated?
A. Decreased bicarbonate (HCO₃⁻) levels.
B. Increased blood pH.
C. Decreased potassium (K⁺) levels.
D. Increased carbon dioxide (CO₂) levels.
B - Correct. Increased blood pH indicates metabolic alkalosis.
215
A patient with hypernatremia is admitted to the hospital. What is the nurse's priority action?
A. Administer sodium chloride IV.
B. Increase fluid intake and monitor sodium levels.
C. Initiate a low-sodium diet immediately.
D. Assess the patient’s neurological status frequently.
D - Correct. Monitoring neurological status is a priority in hypernatremia
216
When teaching a patient about hydration, which statement by the patient indicates a need for
further teaching?
A. "Drinking water is not always enough; you may need electrolytes as well."
B. "I can wait until I feel thirsty to drink fluids."
C. "I should monitor my urine color to assess hydration."
D. "I need to increase my fluid intake during hot weather."
B - Correct. Waiting until thirsty indicates a need for further teaching
217
A patient presents with difficulty starting urination and a weak stream. Which condition is the
patient most likely experiencing?
A. Urinary incontinence
B. Urinary retention
C. Urinary tract infection
D. Neurogenic bladder
B - Correct. The symptoms suggest urinary retention
218
During a routine assessment, the nurse notes the patient has hematuria. Which action should the
nurse take next?
A. Document the finding and continue the assessment.
B. Ask the patient about recent physical activity.
C. Notify the healthcare provider immediately.
D. Instruct the patient to increase fluid intake.
C - Correct. Notifying the healthcare provider is the next step for hematuria
219
Which of the following is a common cause of urinary incontinence in older adults?
A. Increased bladder capacity
B. Neurological disorders
C. Use of diuretics
D. Prostate enlargement
B - Correct. Neurological disorders can lead to incontinence in older adults.
220
A nurse is educating a patient on how to perform Kegel exercises. What is the primary purpose
of these exercises?
A. To improve bladder capacity
B. To strengthen pelvic floor muscles
C. To increase urine output
D. To prevent urinary tract infections
B - Correct. Kegel exercises strengthen pelvic floor muscles.
221
A patient is scheduled for a urinary catheter insertion. Which of the following steps should the
nurse prioritize during the procedure?
A. Cleaning the periurethral area with soap and water
B. Asking the patient to bear down while inserting the catheter
C. Maintaining a sterile field throughout the procedure
D. Inflating the balloon before confirming urine return
C - Correct. Maintaining a sterile field is crucial during catheter insertion
222
Which assessment finding in an older adult may indicate a urinary tract infection (UTI)?
A. Increased urine output
B. Decreased thirst response
C. Sudden onset of confusion
D. Low blood pressure
C - Correct. Sudden confusion can indicate a UTI in older adults.
223
A patient is experiencing overflow incontinence. Which statement should the nurse include in the
teaching plan?
A. "You will need to restrict your fluid intake."
B. "You may need to use intermittent catheterization."
C. "Bladder training will help eliminate your symptoms."
D. "Surgery is the only option for your condition."
B - Correct. Intermittent catheterization may be necessary for overflow incontinence.
224
What is the priority nursing intervention for a patient with a spinal cord injury who is at risk for
urinary retention?
A. Increase the patient’s fluid intake
B. Schedule regular catheterizations
C. Monitor for signs of a UTI
D. Educate the patient on bladder training techniques
B - Correct. Regular catheterizations help manage urinary retention
225
Which statement about urinary elimination in older adults is accurate?
A. Bladder capacity increases with age.
B. Incontinence is a normal part of aging.
C. Increased fluid intake is unnecessary for older adults.
D. Cognitive impairment can affect urinary elimination.
D - Correct. Cognitive impairment can affect urinary elimination.
226
When caring for an elderly patient with chronic urinary incontinence, which holistic approach
should the nurse prioritize to ensure patient-centered care?
A. Implementing a strict fluid restriction to manage incontinence
B. Educating the patient about pelvic floor exercises and cultural considerations regarding
bladder health
C. Focusing solely on catheterization to manage urinary elimination
D. Encouraging the patient to verbalize any concerns about their condition and involving them in
the care plan
D - Correct. Encouraging patient concerns promotes patient-centered care.
227
Age-related factors for fluid and electrolyte imbalances include decreased _____ and reduced _____.
kidney function; thirst response
228
Interventions for fluid and electrolyte imbalances include _____, _____, _____, and _____.
fluid management with IV fluids, medication administration, patient education, and ensuring patient safety
229
In managing alkalosis, it is important to treat _____.
underlying causes
230
Age-related risk factors for acid-base imbalances include decreased _____.
respiratory function
231
Alkalosis is a condition where blood pH is above _____.
7.45
232
Older adults have fragile health status, reduced physiological reserve, and _____, making them vulnerable to acid-base imbalances.
polypharmacy
233
To manage acidosis, one intervention is to administer _____.
bicarbonate
234
Older adults are more susceptible to fluid and electrolyte imbalances due to _____ and _____.
fragile skin and comorbidities
235
Teach patients about the importance of recognizing _____ to manage acid-base imbalances effectively.
symptoms
236
Symptoms of acidosis include headache, weakness, nausea, and _____.
vomiting
237
Understanding the relationship between acid-base and fluid-electrolyte imbalances is essential for effective patient assessment and intervention in conditions like _____, heart failure, or severe dehydration.
kidney disease
238
Assessment of fluid and electrolyte imbalances involves monitoring _____, _____, _____, and _____.
vital signs, daily weights, intake and output records, and laboratory values
239
Medications like _____ and _____ can contribute to fluid and electrolyte imbalances.
diuretics and laxatives
240
Checking arterial blood gases for _____, _____, and _____ is crucial in assessing acid-base imbalances.
pH, CO2, and HCO3 levels
241
Changes in fluid volume, such as dehydration or overhydration, can affect the concentration of electrolytes, influencing _____.
acid-base status
242
Respiratory alkalosis includes _____. _____, _____, and _____.
lightheadedness, palpitations, tingling in fingers, and muscle cramps
243
Acidosis is a condition where blood pH is below 7.35.
7.35
