Patient Care and Nursing Practices: A Comprehensive Guide, Exams of Nursing

Download Patient Care and Nursing Practices: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! RNSG 1513 Foundations of Nursing Exam 2 Questions, Answers and Rationales. A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient. - Correct Answer D) Enter only objective and factual information about the patient. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record. A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation. - Correct Answer B) Gives a newly ordered medication before entering the order in the patient's medical record. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur. As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A. The patient has a defiant attitude and is demanding his test results. B. The patient appears to be upset with his nurse because he wants his test results immediately. C. The patient is demanding and complains frequently about his doctor. D. The patient stated that he felt frustrated by the lack of information he received regarding his tests. - Correct Answer D. The patient stated that he felt frustrated by the lack of information he received regarding his tests. This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern. You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater control over your personal health care information. D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care. - Correct Answer C. HIPAA provides you with greater control over your personal health care information. HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record. During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients. You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A. Documented medication given by another nursing student. B. Included the date and time of all entries in the chart. C. Stood with his back against the wall while documenting on the computer. D. Signed all documentation electronically. - Correct Answer A. Documented medication given by another nursing student. Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed. A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time necessary for health care providers to write orders." C. "Health care providers can write orders from any computer that has Internet access." D. "CPOE reduces the time nurses use to communicate with health care providers." - Correct Answer A. "CPOE reduces transcription errors." CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly. You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A. The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B. You need to use words the patients can understand when writing the directions. C. The form needs to be given to patients in a sealed envelope to protect their health information. D. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home. - Correct Answer B. You need to use words the patients can understand when writing the directions. Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability. A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry - Correct Answer Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user. While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A. The nurses forgot to document on the pulmonary system. B. The nurses were charting by exception. C. The computer is not working correctly. D. The physician does not have authorization to view the nursing assessment. - Correct Answer The nurses were charting by exception. Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits. What is an appropriate way for a nurse to dispose of printed patient information? A. Rip several times and place in a standard trash can B. Place in the patient's paper-based chart C. Place in a secure canister marked for shredding D. Burn the documents - Correct Answer Place in a secure canister marked for shredding Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times. A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A. Alcoholism and hypertension B. Obesity and diabetes C. Stress-related illnesses D. Cardiopulmonary disease and lung cancer - Correct Answer D. Cardiopulmonary disease and lung cancer Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer. A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A. Increased breathlessness but increased activity tolerance B. Decreased breathlessness and decreased activity tolerance C. Increased activity tolerance and decreased breathlessness D. Decreased activity tolerance and increased breathlessness - Correct Answer D. Decreased activity tolerance and increased breathlessness When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain. A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? "I'll make sure that I rest between activities so I don't get so short of breath." "I'll rest for 30 minutes before I eat my meal." "If I have trouble breathing at night, I'll use two to three pillows to prop up." "If I get short of breath, I'll turn up my oxygen level to 6 L/min." - Correct Answer "If I get short of breath, I'll turn up my oxygen level to 6 L/min." Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe. The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? Raise the head of the bed to 45 degrees. Take his oxygen saturation with a pulse oximeter. Take his blood pressure and respiratory rate. Notify the health care provider of his shortness of breath. - Correct Answer Raise the head of the bed to 45 degrees. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation. The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) SpO2 levels Amount of sputum production Change in respiratory rate and pattern Pain in lower calf area - Correct Answer Change in respiratory rate and pattern SpO2 levels Amount of sputum production Pain in the lower calf area indicates vascular, not respiratory, status Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? "Suctioning the patient requires sterile technique." "I'll apply suction while rotating and withdrawing the suction catheter." "I'll suction the mouth after I suction the endotracheal tube." "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." - Correct Answer "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed. Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? Record the amount and continue to monitor drainage Notify the health care provider Strip the chest tube starting at the chest Increase the suction by 10 mm Hg - Correct Answer Record the amount and continue to monitor drainage Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color. Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? Postural drainage Chest percussion Incentive spirometer Suctioning - Correct Answer Incentive spirometer An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production. The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? Nasal cannula Venturi mask Simple face mask without inflated reservoir bag Plastic face mask with inflated reservoir bag - Correct Answer A nasal cannula delivers precise, high-flow rates of oxygen. During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with: Food allergy. Irritable bowel. Lactose intolerance. Increased peristalsis. - Correct Answer Lactose intolerance. This patient possibly lacks the enzyme needed to digest milk sugar lactase and therefore is potentially lactose intolerant. When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): If patient reports rectal bleeding. When there is a family history of polyps. As part of a routine examination for colon cancer. If a palpable mass is detected on digital examination. - Correct Answer As part of a routine examination for colon cancer. This is used as a diagnostic screening tool for colon cancer as recommended by the American Cancer Society. Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.) Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to: Ask the patient to void. Wash the patient's perineum. Secure a sterile, specimen container. Plan to collect the first specimen of the day. - Correct Answer Ask the patient to void. Emptying the urinary bladder before collecting the stool sample prevents contamination of the specimen. The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? Describe your bowel movements. How often do you have a bowel movement? When was the last time you moved your bowels? Correct Do you routinely use stool softeners, laxatives, or enemas? - Correct Answer When was the last time you moved your bowels? Lack of a bowel movement is a sign of a bowel obstruction and is a medical emergency. The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? Malnutrition Dehydration Skin breakdown Incontinence - Correct Answer Dehydration Diarrhea interferes with absorption time of digestive juices. With frequent loose, watery stools, dehydration becomes a major problem in the older adult. The nurse recognizes which patient needs to use a fracture pan for a bowel movement? The patient who is obese The patient experiencing confusion The patient on bed rest A patient recovering from hip surgery - Correct Answer A patient recovering from hip surgery A fracture pan is used for a patient with back or lower-extremity health issues. Because a fracture pan is shallow in comparison to a regular bedpan, the fracture pan prevents disturbing the patient's body alignment. Number the steps to irrigating a NG tube in order: 1. Slowly aspirate the syringe 2. Reconnect the NG tube to suction 3. Clamp and disconnect the NG tube 4. Perform hand hygiene and apply clean gloves. 5. Insert tip of syringe into NG tube and slowly inject 30mL saline. - Correct Answer 4. Perform hand hygiene and apply clean gloves. 3. Clamp and disconnect the NG tube 5. Insert tip of syringe into NG tube and slowly inject 30mL saline. 1. Slowly aspirate the syringe 2. Reconnect the NG tube to suction List the correct order in which to apply an ostomy pouch: 1.Remove the used pouch and skin barrier. 2. Perform hand hygiene and apply clean gloves 3. Assess the stoma for color, swelling, healing. 4. Gently cleanse the peristomal skin with warm tap water. 5. Apply non-allergenic tape around the pectin skin barrier. 6. Cut an opening on the pouch 0.15cm-0.3cm larger than the stoma. 7. Press the adhesive backing of the pouch smoothly against the skin. - Correct Answer 2. Perform hand hygiene and apply clean gloves 1.Remove the used pouch and skin barrier. 4. Gently cleanse the peristomal skin with warm tap water. 3. Assess the stoma for color, swelling, healing. 6. Cut an opening on the pouch 0.15cm-0.3cm larger than the stoma. 7. Press the adhesive backing of the pouch smoothly against the skin. 5. Apply non-allergenic tape around the pectin skin barrier. Diuresis - Correct Answer Increase rate of formation and excretion of urine. Hematuria - Correct Answer Abnormal presence of blood in the urine. Micturition - Correct Answer Urination; act of passing or expelling urine voluntarily through urethra. Nocturia - Correct Answer Urination at night; can be symptom of renal disease or may occur in persons who drink excessively before bedtime. Renal Calculi - Correct Answer Calcium stones in the renal pelvis. Residual Urine - Correct Answer Volume of urine remaining in the bladder after normal voiding; the bladder normally is almost completely empty after micturition. Urinary Incontinence - Correct Answer Inability to control urine Urinary Retention - Correct Answer Retention of urine in the bladder; condition frequently caused by a temporary loss of muscle function. A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: Cystitis. Hematuria. Pyelonephritis. Dysuria. - Correct Answer Cystitis Urine is cloudy in cystitis because of bacterial and white cells. A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? Suggest he stand at the bedside Stay with the patient Give him the urinal to use in bed Tell him that, if he doesn't urinate, he will be catheterized - Correct Answer Suggest he stand at the bedside A man voids more easily in the standing position. bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output? _______ - Correct Answer 1320 mL Correct Responses: "The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output., 1320 mL, 1320 mL, The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output." The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: 1400. 1600 1700. 2300. - Correct Answer 1700. The patient may experience urinary retention after removal of the catheter. If 4 hours after Foley removal have elapsed without voiding, it may be necessary to reinsert the Foley. The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? Encourage fluid intake Administer pain medication Catheterize the patient Turn on the bathroom faucet as he tries to void - Correct Answer Turn on the bathroom faucet as he tries to void The sound of running water helps many patients to void through the power of suggestion. The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) Note any allergies. Monitor intake and output. Provide for perineal hygiene. Assess vital signs. Encourage fluids after the procedure. - Correct Answer Note any allergies. Encourage fluids after the procedure. The dye used in the procedure is iodine based. Assessing for history of any allergies can predict allergy to the dye used. Fluid intake dilutes and flushes the dye from the patient. The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: Use the double-voiding technique. Perform Kegel exercises. Use Credé's method. Keep a voiding diary. - Correct Answer Use Credé's method. With this method pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter. The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: "I will perform my Kegel exercises every day." "I joined weight watchers." "I drink two glasses of wine with dinner." "I have tried urinating every 3 hours." - Correct Answer "I drink two glasses of wine with dinner." Alcohol is a bladder irritant. It increases urine production and causes uncontrolled bladder contractions. The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to: Irrigate the Foley. Check for kinks in the tubing. Notify the health care provider. Assess the patient's intake. - Correct Answer Check for kinks in the tubing. Kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing. Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? I need to stop eating red meat. I will increase the servings of fruit juice to four a day. I will make sure that I eat a balanced diet and exercise regularly. I will not eat so many dark green vegetables and eat more yellow vegetables. - Correct Answer I will make sure that I eat a balanced diet and exercise regularly. Obesity is an epidemic in the United States. Proposed contributing factors are sedentary lifestyle and poor meal choices. Healthy eating and participation in exercise or other activities of healthy living promote good health. The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? Fat Protein Vitamin Carbohydrate - Correct Answer Protein Proteins provide a source of energy (4 kcal/g), and they are essential for synthesis (building) of body tissue in growth, maintenance, and repair. Collagen, hormones, enzymes, immune cells, deoxyribonucleic acid (DNA), and ribonucleic acid (RNA) are all made of protein. The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) Sit the patient upright in a chair. Give liquids at the end of the meal. Place food in the strong side of the mouth. Provide thin foods to make it easier to swallow. Feed the patient slowly, allowing time to chew and swallow. Encourage patient to lie down to rest for 30 minutes after eating. - Correct Answer Sit the patient upright in a chair. Place food in the strong side of the mouth. successive measurements; and (3) routinely evaluate the patient for aspiration and use nursing measures to reduce the risk of aspiration if GRV is between 250 and 500 mL. The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A 55-year-old obese man recently diagnosed with diabetes mellitus A recently widowed 76-year-old woman recovering from a mild stroke A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery A 46-year-old man recovering at home following coronary artery bypass surgery - Correct Answer A recently widowed 76-year-old woman recovering from a mild stroke Older adults who are homebound and have a chronic illness have additional nutritional risks. Frequently this group lives alone with few or no social or financial resources to assist in obtaining or preparing nutritionally sound meals. This contributes to a risk for food insecurity caused by low income and poverty. In addition, the mild stroke might cause dysphagia. Which statement made by a patient of a 2-month-old infant requires further education? I'll continue to use formula for the baby until he is a least a year old. I'll make sure that I purchase iron-fortified formula. I'll start feeding the baby cereal at 4 months. I'm going to alternate formula with whole milk starting next month. - Correct Answer I'm going to alternate formula with whole milk starting next month. Infants should not have regular cow's milk during the first year of life. It causes gastrointestinal bleeding, is too concentrated for the infant's kidneys to manage, increases the risk of milk product allergies, and is a poor source of iron and vitamins C and E. Breast milk or formula provides sufficient nutrition for the first 4 to 6 months of life. The development of fine- motor skills of the hand and fingers parallels the infant's interest in food and self-feeding. Iron-fortified cereals are typically the first semisolid food to be introduced. For infants 4 to 11 months, cereals are the most important nonmilk source of protein. The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) Avoid grapefruit and grapefruit juice, which impair drug absorption. Increase the amount of carbohydrates for energy. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Limit fluids to decrease the risk of edema. - Correct Answer Avoid grapefruit and grapefruit juice, which impair drug absorption. Take a multivitamin that includes vitamin D for bone health. Cheese and eggs are good sources of protein. Caution older adults to avoid grapefruit and grapefruit juice because these impair absorption of many drugs. Thirst sensation diminishes, leading to inadequate fluid intake or dehydration; thus older adults should be encouraged to ingest adequate fluids. Some older adults avoid meats because of cost or because they are difficult to chew. Cream soups and meat-based vegetable soups are nutrient-dense sources of protein. Cheese, eggs, and peanut butter are also useful high-protein alternatives. Milk continues to be an important food for older women and men who need adequate calcium to protect against osteoporosis (a decrease of bone mass density). Screening and treatment are necessary for both older men and women. Vitamin D supplements are important for improving strength and balance, strengthening bone health, and preventing bone fractures. The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: Fastens the tube to the gown with tape. Places the patient supine while giving a bath. Performs oral care for the patient. Elevates the head of the bed 45 degrees. - Correct Answer Places the patient supine while giving a bath. Patients receiving enteral feedings should have the head of the bed elevated a minimum of 30 degrees, preferably 45 degrees, unless medically contraindicated. Laying the patient supine increases the risk of aspiration of the feeding and should be avoided. This needs to be addressed to maintain patient safety. The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention. - Correct Answer TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. The TPN formula is a combination of crystalline amino acids, hypertonic dextrose, electrolytes, vitamins, and trace elements. Administration of concentrated glucose is accompanied by increases in endogenous insulin production, which causes cations (potassium, magnesium, and phosphorus) to move intracellularly. Blood glucose levels should be monitored every 6 hours to assess for hyperglycemia. Maintaining blood glucose within acceptable limits helps prevent complications from the TPN. The catheter of the pt. receiving PN becomes occluded. Place the steps of caring for the occluded catheter in the order in which the nurse would perform them. 1. Attempt to aspirate the clot 2. Temporarily stop the infusion 3. Flush the line with saline or heparin 4. Use a thrombolytic agent if ordered or per protocol. - Correct Answer 2. Temporarily stop the infusion 3. Flush the line with saline or heparin 1. Attempt to aspirate the clot 4. Use a thrombolytic agent if ordered or per protocol. The nurse is checking the feeding tube placement. Place the steps in the proper sequence. Fluid that has K+ and HCO3- in it Coffee or tea, whichever they prefer - Correct Answer Fluid that has sodium (salt) in it Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced. You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? 56-year-old with acute kidney renal failure 40-year-old with appendicitis 28-year-old who has acute pancreatitis 65-year-old with hypertension and asthma - Correct Answer 28-year-old who has acute pancreatitis People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids. Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.) Measuring oral intake and urine output Preparing intravenous (IV) tubing for routine change Reporting an IV container that is low in Changing an IV fluid container - Correct Answer Measuring oral intake and urine output Reporting an IV container that is low in The registered nurse cannot delegate working with IV tubing or changing an IV infusion to NAP Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.) Edema and pain Streak formation Pain and erythema Pallor and coolness Numbness and pain - Correct Answer Edema and pain Pallor and coolness Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area. Which of the following defi ning characteristics is consistent with fluid volume deficit? A 1-lb (0.5 kg) weight loss, pale yellow urine Engorged neck veins when upright, bradycardia Dry mucous membranes, thready pulse, tachycardia Bounding radial pulse, fl at neck veins when supine - Correct Answer Dry mucous membranes, thready pulse, tachycardia The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow urine rather than pale yellow, which is normal. Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? Auscultate dependent portions of lungs Check color of urine Assess muscle strength Check skin turgor over sternum or shin - Correct Answer Auscultate dependent portions of lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults. While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? Notify a health care provider Insert an indwelling catheter Alert the blood bank Stop the transfusion - Correct Answer Stop the transfusion Development of chills, tachycardia, and flushing during a blood transfusion is an indication of an acute hemolytic reaction. You stop the transfusion immediately so no more of the incompatible blood reaches the patient. The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? Flat neck veins Tachycardia Hypotension Oliguria - Correct Answer Oliguria Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia. Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing? Notify her health care provider that she is hyperventilating Provide frequent oral care to keep her mucous membranes moist Ask her to breathe slower and help her to calm down and relax Assess her for pain and request an order for a sedative - Correct Answer Provide frequent oral care to keep her mucous membranes moist Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. Rapid breathing can make oral mucous membranes dry and cracked. Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? 700 mL 900 mL 1000 mL Spirituality offers a sense of connectedness, intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power). In a caring relationship the patient and nurse come to know one another so both move toward a healing relationship. Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors? Increasing the working hours of the staff Increasing salary benefits of the staff Creating a setting that allows flexibility and autonomy for staff Encouraging increased input concerning nursing functions from physicians - Correct Answer Creating a setting that allows flexibility and autonomy for staff These factors all affect nursing satisfaction. When nurses' job satisfaction is high, they have a greater connectedness with their patients and believe that caring practices are part of the nursing culture. When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of: Instilling hope and faith. Forming a human-altruistic value system. Cultural caring. Being with. - Correct Answer Instilling hope and faith. Instilling hope and faith helps to increase an individual's capacity to get through an event or transition and face the future with meaning. An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: Making health care decisions for patients. Having family members provide a patient's total personal hygiene. Injecting the nurse's perceptions about the level of care provided. Asking permission before performing a procedure on a patient. - Correct Answer Asking permission before performing a procedure on a patient. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members. A nurse demonstrates caring by helping family members: Become active participants in care. Provide activities of daily living (ADLs). Remove themselves from personal care. Make health care decisions for the patient. - Correct Answer Become active participants in care. Caring for the family takes into consideration the context of the patient's illness and the stress it imposes on all members. Listening is not only "taking in" what a patient says; it also includes: Incorporating the views of the physician. Correcting any errors in the patient's understanding. Injecting the nurse's personal views and statements. Interpreting and understanding what the patient means. - Correct Answer Interpreting and understanding what the patient means. Listening is powerful. It conveys the nurse's full attention and interest. A true caring presence involves listening. Listen to what is important to another person and the meaning of a situation to that person. A nurse is caring for an older adult who needs to enter an assisted-living facility following discharge from the hospital. Which of the following is an example of listening that displays caring? The nurse encourages the patient to talk about his concerns while reviewing the computer screen in the room. The nurse sits at the patient's bedside, listens as he relays his fear of never seeing his home again, and then asks if he wants anything to eat. The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. The nurse listens to the patient talk about his fears of not returning home and then tells him to think positively. - Correct Answer The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story. Attentive listening lets the nurse hear the patient's story and then correctly summarize it. It does not occur when the nurse is distracted by equipment or other personnel. The importance of listening is not to distract the patient or solve the problem, but rather to hear what the patient has to say and understand what the situation means to him. Presence involves a person-to-person encounter that: Enables patients to care for self. Provides personal care to a patient. Conveys a closeness and a sense of caring. Describes being in close contact with a patient. - Correct Answer Conveys a closeness and a sense of caring. Providing presence is a person-to-person encounter conveying closeness and a sense of caring. It involves "being there" and "being with." "Being there" is not only a physical presence but also includes communication and understanding. Presence is an interpersonal process that is characterized by sensitivity, holism, intimacy, vulnerability, and adaptation to unique circumstances. A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully insert the Foley catheter. This is an example of what type of touch? Caring touch Protective touch Task-oriented touch Interpersonal touch - Correct Answer Task-oriented touch Nurses use task-orientated touch when performing a task or procedure. An expert nurse learns that any procedure is more effective when administered carefully and in consideration of any patient concern. A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? Caring touch Protective touch Task-oriented touch A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) Difficulty paying his bills Seeing his pastor as a means of support Family practice of not routinely seeing a health care provider Stress from the divorce and the loss of a job - Correct Answer Stress from the divorce and the loss of a job Family practice of not routinely seeing a health care provider Difficulty paying his bills External factors impacting health practices include family beliefs and economic impact. How patients’ families use health care services generally affects their health practices. Their perceptions of the serious nature of diseases and their history of preventive care behaviors (or lack of them) influence how patients will think about health. Economic variables may affect a patient’s level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system. The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? Physiological Safety and security Love and belonging Self-actualization - Correct Answer Safety and security The teaching addresses the need for safety and security. The throw rugs, low lighting, and low stool are hazards that can cause falls in the elderly. Preventing falls is a priority safety issue for older adults. When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? Holistic Health belief Transtheoretical Health promotion - Correct Answer Holistic The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care. When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? Health belief Illness behavior Health promotion Illness prevention - Correct Answer Illness behavior The nurse is using a holistic model of care that considers emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care. A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model? Perceived threat of the disease Likelihood of taking preventive health action Analysis of perceived benefits of preventive action Perceived susceptibility to the disease. - Correct Answer Perceived susceptibility to the disease. The health belief model addresses the relationship between a person's beliefs and behaviors. It provides a way of understanding and predicting how patients will behave in relation to their health and how they will comply with health care therapies. In the perceived susceptibility to the disease phase, the patient recognizes the familial link to the disease. A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take? Care for the boy as she would any other patient Ask the manager to talk with the father and keep him out of the unit Have another nurse care for the boy because maybe that nurse will do better with the father Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community - Correct Answer Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community The nurse needs to understand how the Greek culture impacts the father's health beliefs and communication with health care providers. Cultural variables must be incorporated into the child's plan of care. Cultural background influences beliefs, values, and customs. It influences the approach to the health care system, personal health practices, and the nurse-patient relationship. Cultural background may also influence an individual's beliefs about causes of illness and remedies or practices to restore health. If nurses are not aware of their own and other cultural patterns of behavior and language, they may not be able to recognize and understand a patient's behavior and beliefs and may have difficulty interacting with the patient. The patient attends cardiac rehabilitation sessions weekly. - Correct Answer A home health care nurse visits a patient's home to change a wound dressing. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. The home health nurse changing the wound dressing is an activity that is focused on preventing complications. Much of the nursing care related to secondary prevention is delivered in homes, hospitals, or skilled nursing facilities. The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-year-old female patient admitted with heart failure. The patient is obese. The nurse should intervene if what is observed? The UAP waits 2 minutes after position changes to take orthostatic pressures. The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second. The UAP takes the blood pressure with the patient's arm at the level of the heart. The UAP takes a forearm blood pressure because the largest cuff will not fit the patient's upper arm. - Correct Answer The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second. The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient. A 44-year-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After the nurse teaches him about the medication, which statement by the patient indicates his correct understanding? "If I take this medication, I will not need to follow a special diet." "It is normal to have some swelling in my face while taking this medication." "I will need to eat foods such as bananas and potatoes that are high in potassium." "If I develop a dry cough while taking this medication, I should notify my doctor." - Correct Answer "If I develop a dry cough while taking this medication, I should notify my doctor." Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet. A 67-year-old woman with a history of coronary artery disease and prior myocardial infarction is admitted to the emergency department with a blood pressure of 234/148 mm Hg and started on IV nitroprusside (Nitropress). What should the nurse determine as an appropriate goal for the first hour of treatment? Mean arterial pressure lower than 70 mm Hg Mean arterial pressure no more than 120 mm Hg Mean arterial pressure no lower than 133 mm Hg Mean arterial pressure between 70 and 110 mm Hg - Correct Answer Mean arterial pressure no lower than 133 mm Hg The initial treatment goal is to decrease mean arterial pressure by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours. Lowering the blood pressure too much may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. Additional gradual reductions toward a normal blood pressure should be implemented over the next 24 to 48 hours if the patient is clinically stable. The nurse admits a 73-year-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine (Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone) - Correct Answer Bumetanide (Bumex) Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities. The nurse teaches a 28-year-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which statement by the patient requires an intervention by the nurse? "I will avoid adding salt to my food during or after cooking." "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications." - Correct Answer "I can lower my blood pressure by switching to smokeless tobacco." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (such as the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure- lowering medication. The home care nurse visits a 73-year-old Hispanic woman with chronic heart failure. Which clinical manifestations, if assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? Fatigue, orthopnea, and dependent edema Severe dyspnea and blood-streaked, frothy sputum Temperature is 100.4o F and pulse is 102 beats/minute Respirations 26 breaths/minute despite oxygen by nasal cannula - Correct Answer Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate > 30 breaths per minute, orthopnea, wheezing, and coughing with the production of frothy, blood- tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol. A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? Patient complains of chest pain with strenuous activity. Patient says muscle leg pain occurs with continued exercise. Patient has numbness and tingling of all his toes and both feet. Patient states the feet become red if he puts them in a dependent position. - Correct Answer Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor. A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure - Correct Answer Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status. A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time (APTT) - Correct Answer Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin, but that is not the expected effect. A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? Low-fat diet High-protein diet Calorie-restricted diet High-carbohydrate diet - Correct Answer High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered. Which of the following signs or symptoms in an opioid-naïve patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? Oxygen saturation of 95% Difficulty arousing the patient Respiratory rate of 10 breaths/min Pain intensity rating of 5 on a scale of 0 to 10 - Correct Answer Difficulty arousing the patient Opioid-naive patients may develop a rare adverse effect of respiratory depression, and sedation always occurs before respiratory depression. A health care provider writes the following order for an opioidnaive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: Calls the health care provider, and questions the order Applies the patch the third postoperative day Applies the patch as soon as the patient reports pain Places the patch as close to the hip dressing as possible - Correct Answer Calls the health care provider, and questions the order Fentanyl is 100 times more potent than morphine and not recommended for acute postoperative pain. A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? Stool softener Stimulant laxative H 2 receptor blocker Proton pump inhibitor - Correct Answer Stimulant laxative Patients usually become tolerant to the side effects of opioids, with the exception of constipation. Routinely administer stimulant laxatives, not simple stool softeners, to prevent and treat constipation. A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? The drug The time interval The dose The route - Correct Answer The time interval A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: Call the patient's health care provider. Administer pain medication as ordered. Check the patient's vital signs. Assess the characteristics of the pain. - Correct Answer Assess the characteristics of the pain. It is necessary to monitor pain on a regular basis along with other vital signs. It is important for the nurse to understand that pain assessment is not simply a number. The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. The patient's report of pain is the best method for assessing the pain. The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. The nurse is the most experienced at assessing pain. - Correct Answer The patient's report of pain is the best method for assessing the pain. A patient's self-report of pain is the single most reliable indicator of the existence and intensity of pain. When using ice massage for pain relief, which of the following are correct? (Select all that apply.) Apply ice using firm pressure over skin. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. Apply ice until numbness occurs and discontinue application. Apply ice for no longer than 10 minutes. - Correct Answer Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. Apply ice using firm pressure over skin. Cold therapies are particularly effective for pain relief. Ice massage involves applying a frozen cup of ice firmly over the skin. When numbness occurs, remove the ice for usually 5 to 10 minutes. When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? TENS works by causing distraction. TENS therapy does not require a health care provider's order. TENS requires an electrical source for use. TENS electrodes are applied near or directly on the site of pain. - Correct Answer TENS electrodes are applied near or directly on the site of pain. TENS involves stimulation of the skin with a mild electrical current passed through external electrodes. The therapy requires a health care provider order. The TENS unit consists of a battery-powered transmitter, lead wires, and electrodes. Place the electrodes directly over or near the site of pain. While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends: Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. Using acetaminophen for refractory pain. Limiting the use of opioids because of the likelihood of side effects. Avoiding total sedation, regardless of how severe the pain is. - Correct Answer Transitioning use of adjuvants with nonsteroidal antiinfl ammatory drugs (NSAIDs) to opioids. The WHO analgesic ladder transitions from the use of nonopioids (NSAIDS) with or without adjuvants to opioids with or without adjuvants. Acetaminophen is recommended for lesser levels of pain. Side effects related to the use of opioids may be unavoidable but are treatable. Treatment for severe pain may result in some level of sedation. A postoperative patient is currently asleep. Therefore the nurse knows that: The sedative administered may have helped him sleep, but assessment of pain is still needed. The intravenous (IV) pain medication is effectively relieving his pain. Pain assessment is not necessary. The patient can be switched - Correct Answer The sedative administered may have helped him sleep, but assessment of pain is still needed. Sedatives, antianxiety agents, and muscle relaxants have no analgesic effect; however, they can cause drowsiness and impaired coordination, judgment, and mental alertness and contribute to respiratory depression. It is important to avoid attributing these adverse effects solely to the opioid. You need to conduct a thorough reassessment. The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? Call a pharmacist to interpret the order Call the physician to have the order clarified Consult the unit manager to help interpret the order Ask the unit secretary to interpret the physician's handwriting - Correct Answer Call the physician to have the order clarified You must have the right documentation and clarify all orders with the prescriber before administering medications. The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? 2 mL 5 mL 16 mL 30 mL - Correct Answer 30 mL 1 tablespoon = 15 mL; 2 tablespoons = 30 mL. A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? Outward Back Upward and back Upward and outward - Correct Answer Upward and outward Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age. A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? ½ tablet 1 tablet 1 ½ tablets The order from the prescriber needs to indicate the route of administration. A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse: Continues to let the IV run. Applies a warm compress to the infiltrated site. Stops the administration of the medication and follows agency policy. Should not worry about this because vesicant filtration is not a problem. - Correct Answer Stops the administration of the medication and follows agency policy. When an IV medication infiltrates, stop giving the medication and follow agency policy. If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: Sepsis. Phlebitis. Infiltration. Fluid overload. - Correct Answer Phlebitis. Redness, warmth, and tenderness at the IV site are signs of phlebitis. After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: Follow ISMP guidelines for safe medication abbreviations. Explain to the physician that the order needs to be given to a registered nurse. Write down the order on the patient's order sheet and read it back to the physician. Ensure that the six rights of medication administration are followed when giving the medication. - Correct Answer Explain to the physician that the order needs to be given to a registered nurse. Nursing students cannot take orders. A nurse accidentally gives a patient a medication at the wrong time. The nurse's first priority is to: Complete an occurrence report. Notify the health care provider. Inform the charge nurse of the error. Assess the patient for adverse effects. - Correct Answer Assess the patient for adverse effects. Patient safety and assessing the patient are priorities when a medication error occurs. When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? Restrict all caffeine. Restrict sodium intake. Increase protein intake. Use calcium supplements. - Correct Answer Restrict sodium intake. The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP. In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? BUN of 15 mg/dL Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Correct Serum potassium of 3.5 mEq/L - Correct Answer Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits. When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast - Correct Answer Roasted duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet. The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide (Hydrodiuril) daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? Weight loss of 2 lb Blood pressure 128/86 Absence of ankle edema Output of 600 mL per 8 hours - Correct Answer Blood pressure 128/86 Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure. In reviewing medication instructions with a patient being discharged on antihypertensive medications, which statement would be most appropriate for the nurse to make when discussing guanethidine (Ismelin)? "A fast heart rate is a side effect to watch for while taking guanethidine." "Stop the drug and notify your doctor if you experience any nausea or vomiting." "Because this drug may affect the lungs in large doses, it may also help your breathing." "Make position changes slowly, especially when rising from lying down to a standing position." - Correct Answer "Make position changes slowly, especially when rising from lying down to a standing position." Guanethidine is a peripheral-acting α-adrenergic antagonist and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. Support stockings may also be helpful. Tachycardia or lung effects are not evident with guanethidine. When assessing the patient for orthostatic hypotension, after taking the blood pressure (BP) and pulse (P) in the supine position, what should the nurse do next? Repeat BP and P in this position. Take BP and P with patient sitting. Record the BP and P measurements. Take BP and P with patient standing. - Correct Answer Take BP and P with patient sitting. When assessing for orthostatic changes in BP after measuring BP in the supine position, the patient is placed in a sitting position and BP is measured within 1 to 2 minutes and then repositioned to the standing position with BP measured again, within 1 to 2 minutes. The results are then recorded with a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing indicating orthostatic hypotension. Today she has gone to the ED, and her blood pressure has risen to 200/140. What is the priority assessment for the nurse to make? Is the patient pregnant? Does the patient need to urinate? Does the patient have a headache or confusion? Is the patient taking antiseizure medications as prescribed? - Correct Answer Does the patient have a headache or confusion? The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency. The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions. - Correct Answer Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues. The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? Muscle aches Constipation Pounding headache Anorexia and nausea - Correct Answer Anorexia and nausea Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. The nurse would become concerned and notify the health care provider if the patient exhibited any of these symptoms. The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? Withhold the daily dose until the following day. Withhold the dose and report the potassium level. Give the digoxin with a salty snack, such as crackers. Give the digoxin with extra fluids to dilute the sodium level - Correct Answer Withhold the dose and report the potassium level. The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range. What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? Urine output Lung sounds Blood pressure Respiratory rate - Correct Answer Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide. A patient admitted with heart failure appears very anxious and complains of shortness of breath. Which nursing actions would be appropriate to alleviate this patient's anxiety (select all that apply)? Administer ordered morphine sulfate. Position patient in a semi-Fowler's position. Position patient on left side with head of bed flat. Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient. - Correct Answer Instruct patient on the use of relaxation techniques. Use a calm, reassuring approach while talking to patient. Position patient in a semi-Fowler's position. Administer ordered morphine sulfate. Morphine sulfate reduces anxiety and may assist in reducing dyspnea. The patient should be positioned in semi-Fowler's position to improve ventilation that will reduce anxiety. Relaxation techniques and a calm reassuring approach will also serve to reduce anxiety. A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? Taper the patient off his current medications. Continue education for the patient and his family. Pursue experimental therapies or surgical options. no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained. After having an MI, the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108/minute. What should the nurse suspect is happening? ADHF Chronic HF Left-sided HF Right-sided HF - Correct Answer Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure. Beyond the first year after a heart transplant, the nurse knows that what is a major cause of death? Infection Acute rejection Immunosuppression Cardiac vasculopathy - Correct Answer Cardiac vasculopathy Beyond the first year after a heart transplant, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are the major causes of death. During the first year after transplant, infection and acute rejection are the major causes of death. Immunosuppressive therapy will be used for posttransplant management to prevent rejection and increases the patient's risk of an infection. The patient with chronic heart failure is being discharged from the hospital. What information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to ADHF? Take medications as prescribed. Use oxygen when feeling short of breath. Only ask the physician's office questions. Encourage most activity in the morning when rested. - Correct Answer Take medications as prescribed. The goal for the patient with chronic HF is to avoid exacerbations and hospitalization. Taking the medications as prescribed along with nondrug therapies such as alternating activity with rest will help the patient meet this goal. If the patient needs to use oxygen at home, it will probably be used all the time or with activity to prevent respiratory acidosis. Many HF patients are monitored by a care manager or in a transitional program to assess the patient for medication effectiveness and monitor for patient deterioration and encourage the patient. This nurse manager can be asked questions or can contact the health care provider if there is evidence of worsening HF. A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? Buttock, upper outer quadrant Abdomen, anterior-lateral aspect Back of the arm, 2 inches away from a mole Anterolateral thigh, with no scar tissue nearby - Correct Answer Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles. The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? Remove the air bubble in the prefilled syringe. Aspirate before injection to prevent IV administration. Rub the injection site after administration to enhance absorption. Pinch the skin between the thumb and forefinger before inserting the needle - Correct Answer Pinch the skin between the thumb and forefinger before inserting the needle The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection. The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? Vitamin K Cobalamin Heparin sodium Protamine sulfate - Correct Answer Vitamin K Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin). The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? Decreased cardiac output Increased blood pressure Cerebral or pulmonary emboli Excessive bleeding from incision or IV sites - Correct Answer Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium. The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? 1.0 1.8 2.7 Sit the patient at a 30-degree angle before administration. - Correct Answer Leave the air bubble in the prefilled syringe. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue. What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings - Correct Answer Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position. A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? "Try to keep your stockings on 24 hours a day, as much as possible." "While you're still lying in bed in the morning, put on your stockings." "Dangle your feet at your bedside for 5 minutes before putting on your stockings." "Your stockings will be most effective if you can remove them for a few minutes several times a day." - Correct Answer "While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness. Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Remove the patient's IV catheter. Apply an ice pack to the affected area. Decrease the IV rate to 20 to 30 mL/hr. Administer prophylactic anticoagulants. - Correct Answer Remove the patient's IV catheter. The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic. A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? Gender Smoking Ethnicity Co-morbidities - Correct Answer Smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD. A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? Keep the patient on bed rest. Assist the patient with walking several times. Have the patient sit in the chair several times. Place the patient on her side with knees flexed. - Correct Answer Assist the patient with walking several times. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines. A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Crampiness Referred pain - Correct Answer Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred. A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? Buerger's disease Venous thrombosis Acute arterial ischemia Raynaud's phenomenon - Correct Answer Buerger's disease Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose. A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? Ramipril (Altace) Cilostazol (Pletal) Simvastatin (Zocor) Clopidogrel (Plavix) Warfarin (Coumadin) Aspirin (acetylsalicylic acid) - Correct Answer Aspirin (acetylsalicylic acid) Simvastatin (Zocor) Ramipril (Altace) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients. What would the nurse do if he or she were not able to insert a nasogastric tube in either of a patient's nares? Ask another nurse to attempt the insertion. Document the attempts in the patient's medical record. Notify the physician that the attempts were unsuccessful. Allow the patient to rest for 30 minutes before resuming the process. - Correct Answer Notify the physician that the attempts were unsuccessful. The nurse would notify the physician because he or she will need to attempt to insert the tube or determine another treatment option. Attempting to insert a tube again may harm the patient. Although documentation is necessary, it does not address the patient's need for a nasogastric tube. Delaying an attempt at inserting the nasogastric tube makes success no more likely and risks harming the patient. What would the nurse do if he or she encountered resistance when inserting a nasogastric tube? Ask the patient to cough. Withdraw the tube to the nasopharynx. Encourage the patient to swallow. Instruct the patient to hyperextend the neck. - Correct Answer Withdraw the tube to the nasopharynx. If the patient starts to cough, experiences a drop in oxygen saturation, or shows other signs of respiratory distress, withdraw the tube into the posterior nasopharynx until normal breathing resumes. Do not force the tube or push it against resistance. If the tube meets resistance, swallowing will not help to advance it. If the tube meets resistance, hyperextending the neck will not help to advance it. Coughing will not help remove the source of resistance; rather, it is an indication that the tube is misplaced. Which patient does not have a medical condition that contraindicates placement of a nasogastric tube? A 28-year-old patient who fractured a femur after heavy drinking A 73-year-old patient who is on anticoagulation therapy. A 54-year-old patient who broke a cheekbone in a fall A 67-year-old patient with a history of unexplained nosebleeds - Correct Answer A 28-year-old patient who fractured a femur after heavy drinking Neither the patient's broken femur nor the patient's alcohol consumption would contraindicate placement of a nasogastric tube. What might the nurse do to reduce the patient's discomfort before inserting a nasogastric tube? Examine each naris for patency and skin breakdown. Place the patient in the high-Fowler's position. Anesthetize the throat. Have the patient take a few sips of water. - Correct Answer Examine each naris for patency and skin breakdown. Examining each naris for patency and signs of skin breakdown will help the nurse determine which naris will accommodate a nasogastric tube with less discomfort. Although the high-Fowler's position is recommended for insertion of a nasogastric tube, the position itself will not reduce discomfort. Anesthetizing the throat would hinder the patient's ability to swallow safely during insertion of the nasogastric tube. Sipping water will not reduce the patient's discomfort. Which intervention might the nurse delegate to nursing assistive personnel (NAP) when inserting a nasogastric tube? Positioning the patient in a high-Fowler's position Assessing the patient's abdomen for bowel sounds Determining any history of unexplained nosebleeds Educating the patient about the need for the intervention - Correct Answer Place the patient in the high-Fowler's position. Positioning the patient is within NAP scope of practice. NAP are not permitted to assess bowel sounds. It is not within NAP scope of practice to determine any portion of the patient's medical history. Patient education may not be delegated to NAP. Why does the nurse elevate the head of the bed to 30 degrees for a patient receiving an intermittent tube feeding? Elevating the head of the bed reduces the risk for aspiration. Proper elevation of the head of the bed promotes the patient's digestion. Acid reflux is reduced when the head of the bed is elevated at least 30 degrees. Nutrients are absorbed more efficiently when the head of the bed is elevated. - Correct Answer Elevating the head of the bed reduces the risk for aspiration. Digestion is not affected when the head of the bed is elevated. Reducing acid reflux is not the reason for elevating the head of the bed. Nutrient absorption is unaffected by elevating the head of the bed. What is the proper response to the nurse's observation that the patient's closed-system enteral feeding has 150 mL of formula remaining and that the infusion order rate is for 50 mL/hr? Recalculate the present drip factor for accuracy. Terminate the fluid, and prepare to hang a new bag of formula. Plan to check the feeding for completion within the next 3 hours. The nasogastric tube may be removed only with a health care provider's order. What patient care might the nurse delegate to nursing assistive personnel (NAP) when a patient's nasogastric tube is removed? Assessing the patient for abdominal distention Providing the patient with mouth care Documenting tube removal Checking for bowel sounds - Correct Answer Providing the patient with mouth care The skill of mouth care may be delegated to NAP. Why does the nurse kink the nasogastric tube before removing it from a patient? To suppress the cough reflex To keep any fluid from flowing out To hinder the gag reflex To prevent transmission of microorganisms - Correct Answer To keep any fluid from flowing out Kinking the tube keeps any residual fluid in the tube from flowing out. Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? To provide the correct amount of oxygen to the patient To ensure the therapeutic effects of oxygen therapy To prevent any adverse reaction to the prescribed oxygen therapy To minimize the risk of combustion during oxygen delivery - Correct Answer To provide the correct amount of oxygen to the patient The role of the flow regulator is to deliver the amount of oxygen indicated on the regulator. What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? Advising the patient to call for assistance before getting out of bed Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed Observing the six rights of medication administration Monitoring the patient for signs of hypoxia - Correct Answer Observing the six rights of medication administration Oxygen is considered a medication and must be administered following the six rights of medication administration. What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? Regularly measure and trend the patient's pulse oximetry (SpO2) values. Evaluate venous blood levels every morning. Monitor the patient's arterial blood gas (ABG) levels hourly. Assess the patient for compliance with the prescribed therapy. - Correct Answer Regularly measure and trend the patient's pulse oximetry (SpO2) values. Measuring and analyzing the patient's pulse oximetry values will provide objective information about the patient's response to oxygen therapy. What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? Encourage oral fluids. Restrict fluids. Ensure that humidification is present. Measure blood pressure every hour. - Correct Answer Ensure that humidification is present. If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier. What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? Arterial blood gas (ABG) levels Oxygen flow meter setting Respiratory rate Temperature - Correct Answer Oxygen flow meter setting When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? Frequently applying moisturizing lotion to facial areas that come into contact with the cannula Removing the cannula every 2 hours for no longer than 10 minutes Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift Instructing the patient to inform staff of any problems with facial dryness or cracking - Correct Answer Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown. When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? Frequently asking the patient how he or she is breathing Ensuring that the oxygen tubing is pulled tight, with little or no slack Securing the oxygen tubing to the patient's clothing to prevent tugging Assessing for proper placement of the mask on the patient's face - Correct Answer Assessing for proper placement of the mask on the patient's face Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen prescribed. When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? Looping the oxygen tubing around the side rail of the bed Assessing breath sounds every shift Securing the tubing snugly to the patient's gown Assessing that the reservoir bag stays inflated - Correct Answer Assessing that the reservoir bag stays inflated A mask that fits properly will deliver the prescribed amount of oxygen. When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? Testing the closing capacity of the mask's valves Routinely monitoring the seal over the patient's mouth and nose Ensuring that a mist is always present Regularly verifying that the mask is positioned loosely - Correct Answer Ensuring that a mist is always present Apply sterile gloves. Place the patient in a semi-Fowler's or sitting position. Remove the nasal cannula. Flush the suction catheter with 200 mL of warm tap water. - Correct Answer Place the patient in a semi-Fowler's or sitting position. A semi-Fowler's or sitting position would facilitate this intervention. After oropharyngeal suctioning, what does the nurse do with the supplies? Place the Yankauer catheter in a clean, dry area. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle. Place dirty gloves in the biohazard receptacle in the patient's room. - Correct Answer Place the Yankauer catheter in a clean, dry area. Placing the Yankauer catheter in a clean, dry area will protect it until it is needed again. When preparing to suction a patient's oral cavity, why would the nurse first suction a small amount of water through the catheter? To moisten the exterior of the plastic catheter To ensure that the catheter's suction is functioning properly To minimize friction as the catheter moves within the oral cavity To avoid startling the patient with the sound created by the suction - Correct Answer To ensure that the catheter's suction is functioning properly A small amount of water is suctioned through the catheter to ensure that the suction equipment is working properly. What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask? Complete the suctioning process in 20 seconds or less. Keep the oxygen mask near the patient's face during the suctioning procedure. Encourage the patient to take several deep breaths before suctioning begins. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning. - Correct Answer Keep the oxygen mask near the patient's face during the suctioning procedure. Keeping the oxygen mask near the patient's face during the intervention ensures that oxygen therapy will not be interrupted. Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning? Comparing presuctioning and postsuctioning respiratory assessment data Confirming that the patient's pulse oximetry value is >90% Asking the patient to report any symptoms of dyspnea Assessing the patient's skin for signs of cyanosis - Correct Answer Comparing presuctioning and postsuctioning respiratory assessment data Comparing presuctioning and postsuctioning assessment data allows the nurse to compare the patient's postintervention respiratory status against his or her baseline to see if it has improved. Which action is part of the preparation for nasotracheal suctioning? Place the patient in a supine position. Preoxygenate the patient with 100% oxygen. Suction 100 mL of warm tap water to flush the suction catheter. Place water-soluble lubricant onto the open sterile catheter package. - Correct Answer Place water-soluble lubricant onto the open sterile catheter package. Lubricant facilitates the insertion of the catheter. Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? Patient complains of discomfort during the procedure Patient has a severe bout of nonproductive coughing and complains of sore throat After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% Patient's pulse rate increases by 10 beats/min - Correct Answer After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 beats/min to 80 beats/min. What is the best course of action? Encourage the patient to take several deep breaths. Interrupt suction to the catheter for at least 10 seconds. Discontinue suctioning by removing the suction catheter. Assess the patient's pulse oximetry reading to see if oxygenation is adequate. - Correct Answer Discontinue suctioning by removing the suction catheter. A drop in pulse of 20 beats/min or more necessitates discontinuation of suctioning and removal of the catheter. As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? Complete the catheter insertion in 5 seconds or less. Remove the catheter. Encourage the patient to take several deep breaths to minimize the nausea. Stop advancing the catheter, and allow the patient to rest for several minutes. - Correct Answer Remove the catheter. Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed. How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? Asking the patient about symptoms of respiratory difficulty Comparing respiratory assessment data from before and after the suctioning procedure. Confirming that the patient's pulse oximetry value is >90% Auscultating the patient's chest after suctioning - Correct Answer Comparing respiratory assessment data from before and after the suctioning procedure. Comparing presuctioning and postsuctioning assessment data will provide the best measure of the procedure's efficacy. The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter. When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Remove the cotton balls from the kit for later use. Advance the catheter 10 to 12 inches or until urine flows. Lubricate the first 5 to 7 inches of the catheter. Hold the penis at a 45-degree angle during insertion. - Correct Answer Lubricate the first 5 to 7 inches of the catheter. The first 5 to 7 inches of the catheter is lubricated to ease insertion. The penis is to be held at a 90-degree angle, not a 45-degree angle. The catheter should be inserted 7 to 9 inches or until urine flows, not 10 to 12 inches. The cotton balls will be used for cleansing. Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? The collection bag has been placed on the side rail of the bed. The excess catheter tubing has been coiled beside the patient's inner thigh. The collection bag has been placed on the bed. The collection bag is held above the level of the bladder while ambulating the patient. - Correct Answer The excess catheter tubing has been coiled beside the patient's inner thigh. The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow. Which action will the nurse implement to reduce the risk of catheter- associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Frequently pull on the drainage system tubing. Use the largest-size catheter possible. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus. - Correct Answer Clean the urinary meatus daily. To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary. While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Rinse off the supplies that were contaminated with urine. Cleanse the patient's urinary meatus. Replace all contaminated supplies, and begin the process again. Change the patient's bed linens. - Correct Answer Replace all contaminated supplies, and begin the process again. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again. Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? Sterile technique protects the patient from microorganisms in the urine. Sterile technique protects the nurse from microorganisms in the urine. Sterile technique reduces the amount of pain caused by the procedure. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. - Correct Answer Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment. Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Placing the specimen in a biohazard bag Having someone take the specimen to the lab immediately Cleaning the outside surface of the container Ensuring that a stock of sterile urine collection kits is available - Correct Answer Having someone take the specimen to the lab immediately Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection. Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" "See if the catheter is causing the patient any problems and if he is having any pain." "Please get two sterile urine collection containers from the utility room." "Let me know if the urine contains blood or sediment, or appears cloudy." - Correct Answer "Let me know if the urine contains blood or sediment, or appears cloudy." This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse. Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Firmly securing the lid of the urine specimen container Using a sterile urine specimen container Using a sterile syringe to access the sampling portd. Placing the urine specimen container in the refrigerator until the laboratory comes to get it - Correct Answer Firmly securing the lid of the urine specimen container Securing the specimen container lid is one way to minimize the risk for infection to the staff. When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Checking the patency of the indwelling catheter tubing Placing the urinary collection bag below the level of the bladder Clamping the catheter tubing for 15 minutes before collection