NCLEX practice questions Interventions Nursing Prep

NCLEX practice questions Interventions Nursing Prep Question 1: (see full question) When performing an abdominal assessment,the nurse uses a different order of techniques than with other systems. Which ofthe following ...

NCLEX practice questions Interventions Nursing Prep Question 1: (see full question) When performing an abdominal assessment,the nurse uses a different order of techniques than with other systems. Which ofthe following represents this order You selected: Correct Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This isthe preferred approach because palpation and percussion before auscultation may alterthe sounds heard. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 ________________________________________ Question 2: (see full question) The nurse in post-anesthesia recovery (PAR) is caring for a 27-year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain,the client continues to report abdominal discomfort and requests more morphine. Which action bythe nurse is best? You selected: Correct Explanation: Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment bythe nurse to rule out peritonitis or internal bleeding by observingthe abdomen for distention and rigidity. Administration of more morphine could maskthe cause ofthe abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat tothe abdomen would increase blood flow tothe area and potentially increase pain or internal bleeding. Positioningthe client in a knees-flexed position may relievethe discomfort, but an assessment is needed before any intervention is implemented. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 ________________________________________ Question 3: (see full question) The nurse will obtainthe greatest amount of information aboutthe thyroid gland by using which technique of assessment? You selected: Correct Explanation: The thyroid gland is assessed by palpation, although it is not normally palpable in some patients. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648. Chapter 25: Health Assessment - Page 647 ________________________________________ Question 4: (see full question) The nurse is asking admission interview questions andthe client has explainedthe reason for seeking care. Which ofthe following isthe most appropriate way to documentthe response? You selected: Client describes shortness of breath and increased sputum production. Incorrect Correct response: Explanation: The client's reason for seeking care should always be stated inthe client's own words. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628 ________________________________________ Question 5: (see full question) The nurse inthe emergency department observes a client experiencing a generalized tonic–clonic seizure. What isthe priority intervention forthe nurse to take? You selected: Correct Explanation: Risk for aspiration is a concern during a seizure becausethe client will have copious oral secretions that will need to be suctioned and allowed to drain out ofthe mouth.the nurse should assessthe client's airway and maintain it by placingthe client in a side-lying position, which will allowthe oral secretions to drain from his mouth and not accumulate in his throat and compromisethe airway. It is contraindicated to place anything inthe mouth of a person who is actively convulsing. Reorientingthe client and documentingthe seizure are important actions afterthe postictal phase, but client safety isthe priority intervention during a seizure. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 ________________________________________ Question 6: (see full question) The nurse is caring for a client who just informed her that he noticed some blood inthe toilet after a bowel movement.the nurse assessesthe client's anal area and notes a deep linear separation inthe skin that extends intothe dermis.the nurse recognizes that this skin lesion is characteristic of which ofthe following? You selected: Erosion Incorrect Correct response: Explanation: A fissure is characterized as a deep linear separation inthe skin that extends intothe dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) onthe skin. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4. Chapter 25: Health Assessment - Page 641 ________________________________________ Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 654, Box 25-5. Chapter 25: Health Assessment - Page 654 Question 7: (see full question) The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In countingthe apical pulse,the nurse recognizes which characteristic about heart sounds? You selected: Correct Explanation: Each lub (the first heart sound) representsthe closure ofthe mitral and tricuspid valves during systole, andthe dub (the second heart sound) representsthe closure ofthe aortic and pulmonic valves during diastole. Togetherthe lub-dub sounds are counted as one beat.the two sounds occur within 1 second or less of each other, depending onthe heart rate. (less) Question 8: (see full question) Which assessment measure wouldthe nurse use to assessthe location, shape, size, and density of a tumor? You selected: Correct Explanation: Percussion isthe act of striking one object against another to produce sound.the fingertips are used to tapthe body over body tissues to produce vibrations and sound waves.the location, shape, size, and density of organs or tumors are assessed with this method. Observation is visually looking at an object.the characteristics that can be determined about a tumor by palpation include shape, size, consistency, surface, mobility, tenderness, and pulsatile. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 635 ________________________________________ Question 9: (see full question) The nurse is palpatingthe skin of a 30-year old patient and documents that when picked up in a fold,the skin fold slowly returns to normal. What would bethe next action ofthe nurse based on this finding? You selected: Correct Explanation: Turgor isthe fullness or elasticity ofthe skin.the patient should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. Whenthe patient is dehydrated,the skin’s elasticity is decreased, andthe skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease, nor cystic fibrosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 639 ________________________________________ Question 10: (see full question) The nurse is using a bed scale to weigh a patient, andthe patient becomes agitated asthe sling rises inthe air. What would bethe priority nursing intervention in this situation? You selected: Enlistthe help of another nurse to holdthe patient steady duringthe procedure. Incorrect Correct response: Explanation: The nurse should stop liftingthe patient and reassure him or her. Ifthe patient continues to be agitated,the nurse lowersthe patient back tothe bed, and reevaluatesthe necessity of obtaining weight at that exact time. Continuing to liftthe patient may result in injury tothe patient. An order for sedation would only be requested if it was absolutely necessary to obtainthe patient’s weight at this time. Another nurse holdingthe patient steady does not addressthe patient’s agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 674 ________________________________________ Question 11: (see full question) To obtain subjective data about a newly admitted client's sleep pattern,the nurse You selected: Correct Explanation: The assessment of sleep and rest focuses onthe client's normal sleep patterns, alterations fromthe normal pattern, and satisfaction with quality of rest and sleep. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 ________________________________________ Question 12: (see full question) A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What isthe term for this type of assessment? You selected: Correct Explanation: A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 626. Chapter 25: Health Assessment - Page 626 ________________________________________ Question 13: (see full question) A 57-year-old male client is admitted tothe medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique wouldthe nurse perform last? You selected: Correct Explanation: The sequence of techniques used to assessthe abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659. Chapter 25: Health Assessment - Page 659 ________________________________________ Question 14: (see full question) You are assessing a patient's thorax and lungs. Which ofthe following findings would indicatethe need for further assessment? You selected: Correct Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 ________________________________________ Question 15: (see full question) A nurse assesses a patient for blood pressure. Which ofthe following techniques would be used for this assessment? You selected: Inspection Incorrect Correct response: Explanation: Auscultation isthe act of listening with a stethoscope to sounds produced withinthe body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection isthe process of performing deliberate, purposeful observations in a systematic manner. It usesthe senses of smell, hearing, and sight.the hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assessthe location, shape, and size of organs, andthe density of other underlying structures or tissues. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 632. Chapter 25: Health Assessment - Page 632 ________________________________________ Question 16: (see full question) The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which ofthe following actions, if observed, would requirethe charge nurse to intervene? You selected: Correct Explanation: Palpation of both arteries at once can obstruct blood flow tothe brain. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 655. Chapter 25: Health Assessment - Page 655 ________________________________________ Question 17: (see full question) The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration.the nurse bringsthe client his breakfast tray and notes thatthe client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? You selected: Correct Explanation: Ear wax (cerumen) becomes drier inthe elderly and can blockthe ear canal and cause decreased hearing. Askingthe client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating withthe hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking tothe elderly who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic forthe elderly. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646. Chapter 25: Health Assessment - Page 646 ________________________________________ Question 18: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 19: (see full question) A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior tothe client's scheduled surgery.the nurse would document an unexpected finding if unable to palpate a client's ... You selected: Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up.the liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 ________________________________________ Question 20: (see full question) Upon auscultation of a client's lung fields,the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors;the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing againstthe chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Question 18: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 19: (see full question) A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior tothe client's scheduled surgery.the nurse would document an unexpected finding if unable to palpate a client's ... You selected: Correct Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up.the liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655. Chapter 25: Health Assessment - Page 652 ________________________________________ Question 20: (see full question) Upon auscultation of a client's lung fields,the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? You selected: Correct Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors;the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing againstthe chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652. Chapter 25: Health Assessment - Page 652 Answer Key Question 1: (see full question) The nurse is caring for a client after a stroke that leftthe client's right side weaker thanthe left.the nurse coordinatesthe plan of care withthe physical therapist.the nurse's interventions reflect which one of nursing's four broad goals? You selected: Correct Explanation: The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. Inthe example,the nurse is coordinating care withthe other disciplines in an attempt regain some ofthe strength inthe client's right side. This is an example of restoring a client's health.the nurse is not preventingthe stroke or promoting health prior tothe stroke or facilitating coping withthe stroke. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 10. Chapter 1: Introduction to Nursing - Page 10 ________________________________________ Question 2: (see full question) A man age 61 years is distraught because he has just learned that his most recent computed tomography (CT) scan shows that his colon cancer has metastasized to his lungs. Which ofthe following nursing aims shouldthe nurse prioritize inthe immediate care of this patient? You selected: Correct Explanation: This patient's care inthe coming weeks or months will likely encompass all ofthe four foundational roles ofthe nurse. However, becausethe patient has just recently received bad news and is emotionally distraught, helpingthe patient cope is an appropriate priority in his immediate care. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 13. Chapter 1: Introduction to Nursing - Page 13 ________________________________________ Question 3: (see full question) The nurse working with an LPN understands which ofthe following about LPNs? You selected: They may work independently. Incorrect Correct response: Explanation: Schools for practical nursing programs are located in varied settings. Most programs are 1 year in length. Upon completion ofthe program, graduates can takethe National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work underthe direction of a physician or RN to give direct care to clients, focusing on meeting healthcare needs in hospitals, nursing homes, and home health agencies. (less) Question 4: (see full question) A group of nursing students has attended a presentation aboutthe National Student Nurses' Association (NSNA). Which statement bythe group indicates that they have understoodthe information presented? You selected: The organization provides programs of current professional interest. Correct Explanation: The National Student Nurses' Association provides programs of current professional interest. It is not run by a group of registered nurses, but by nursing students themselves. It is student-funded, not funded bythe national government.the Commission on Collegiate Nursing Education, notthe National Student Nurses' Association, contributes tothe improvement of public health. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 17. Chapter 1: Introduction to Nursing - Page 17 ________________________________________ Question 5: (see full question) Which nursing actions demonstratethe aim of nursing to facilitate coping? (Select all that apply.) You selected: Correct Explanation: Coping is another important broad aim of nursing. Nurses facilitate client and family coping with altered function, life crisis, and death. Examples of coping would be teaching a client andthe client’s family about how to live with diabetes. Another example would be assisting a client andthe client’s family to prepare for death. A third example would be providing counseling forthe family of a teenager with an eating disorder. Changing bandages, starting an IV, or teaching a class on an expected healthcare issue or need would not be examples ofthe aim of facilitating coping with disability or death. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 13. Chapter 1: Introduction to Nursing - Page 13 ________________________________________ Question 6: (see full question) What was one barrier tothe development ofthe nursing profession inthe United States afterthe Civil War? You selected: Correct Explanation: A lack of educational standards was one barrier tothe development ofthe nursing profession afterthe Civil War. Other barriers included a male dominance of health care andthe pervading belief that women were dependent on men.the location of nursing schools, a lack of influence from nursing leaders, and independent nursing orders were not barriers tothe development ofthe nursing profession afterthe Civil War. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 7: (see full question) In what time period did nursing care as we now know it begin? You selected: Correct Explanation: Fromthe middle ofthe 18th century tothe 19th century, social reforms changedthe roles of nurses and of women in general. It was during this time that nursing as we now know it began, based onthe beliefs of Florence Nightingale. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 8: (see full question) Duringthe Reformation, what factor influencedthe decline of nursing? You selected: Correct Explanation: Women were viewed as subordinate to men and were expected to remain at home caring for children; this decreasedthe number of qualified women practicing nursing. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 9: (see full question) Which ofthe following nursing interventions would bethe most appropriate for a new mother that callsthe nursery for help with breastfeeding? You selected: Correct Explanation: It isthe role ofthe nurse to encourage health promotion by providing information and referrals; therefore,the nurse should referthe mother for a home care visit, as this will enablethe mother to receive all ofthe breast feeing help that is needed. Emailing a link for breastfeeding provides information, but notthe support that is needed if a mother is having difficulty with breastfeeding. Suggesting bottle feeding and/or going tothe emergency room is inappropriate. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 10: (see full question) A nurse is providing care for patients in a long-term care facility. Based onthe definitions of nursing inthe textbook, what should bethe central focus of this care? You selected: The nurse asthe caregiver Incorrect Correct response: Explanation: The client receivingthe care is alwaysthe central focus ofthe nursing care provided.the central focus is notthe nurse,the nursing actions, or nursing as a profession. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 5. Chapter 1: Introduction to Nursing - Page 5 ________________________________________ Question 11: (see full question) The nurse is evaluating client health. Which ofthe following clients shouldthe nurse determine to be exhibitingthe most signs of health? You selected: Correct Explanation: As defined bythe World Health Organization, one’s health includes physical, social, and mental components and is not merelythe absence of disease or infirmity. Health is often a subjective state—a person may be medically diagnosed with an illness, but still consider himself or herself healthy.the client with an amputee is performing activities of daily living, thereby demonstrating healthy behaviors. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 12: (see full question) The nurse utilizingthe nursing process includes which ofthe following steps? Select all that apply. You selected: Correct Explanation: less Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 19. ________________________________________ Question 13: (see full question) Duringthe course of any given day of work inthe acute care setting,the nurse may need to perform which ofthe following roles? Select all that apply. You selected: Correct Explanation: The roles and functions ofthe nurse are many and include: caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are notthe roles ofthe nurse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 ________________________________________ Question 14: (see full question) Florence Nightingale introducedthe concept of apprenticeship for nurses. Which ofthe following statements is an example of this? You selected: Correct Explanation: Florence Nightingale's concept of apprenticeship involved training student nurses in a hospital setting. Completing clinical hours is an example of this.the other choices do not reflect this concept. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 7. Chapter 1: Introduction to Nursing - Page 7 ________________________________________ Question 15: (see full question) The nurse caring for a client with a new diagnosis of cancer allowsthe client to verbalize fears relating to how to tellthe children.the nurse's intervention reflects which aspect of nursing? You selected: Correct Explanation: less Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 5. ________________________________________ Question 16: (see full question) The registered nurse is teaching a community health class about illness prevention. Which ofthe following statements reflects understanding of this concept? You selected: Correct Explanation: Enrolling in a smoking cessation class is an example of illness prevention. It will prevent conditions such as asthma and COPD. A hospice evaluation is for someone who is terminally ill, hypertension is already a disease entity, and an ambulance for injury does not denote illness prevention. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 12. Chapter 1: Introduction to Nursing - Page 12 ________________________________________ Question 17: (see full question) A registered nurse wishes to work as a nurse researcher. Which ofthe following is true regarding nurse researchers? You selected: Correct Explanation: Nurse researchers are responsible forthe continued development and refinement of nursing. They usually have advanced education in addition to a baccalaureate degree in nursing. Nurse administrators, not nurse researchers, serve as liaisons between staff members and directors of nursing. Nurse researchers tend to work in large teaching hospitals, research centers, and academic institutions, not community health centers and long-term care units. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 16. Chapter 1: Introduction to Nursing - Page 16 ________________________________________ Question 18: (see full question) The nurse is conducting a community education class onthe 2011 Institute of Medicine Report onthe role of nursing in transforming healthcare. Which ofthe following statements shouldthe nurse include? You selected: • Nurses should follow physicians' lead for changingthe healthcare system. •the infrastructure for data collection related to nursing is in place. Incorrect Correct response: Explanation: In 2011,the Institute of Medicine (IOM) released four key messages underlying their recommendations for transformingthe nursing profession. These include that nurses should practice tothe full extent of their education and training. Therefore,the nurse should include that nurse practitioners be allowed to practice independently and to practice atthe full extent of their training.the IOM also recommended that nurses achieve higher levels of education and training through an improved educational system promoting seamless academic progression. Therefore,the nurse should include that barriers to diploma nurses receiving their BSN be removed.the IOM recommendations do not include that baccalaureate trained nurses do not need further academic training.the IOM recommends that nurses be full partners versus followthe lead of physicians in changingthe healthcare system.the IOM also recommended that there be better data collection and improved information infrastructure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 20. Chapter 1: Introduction to Nursing - Page 20 ________________________________________ Question 19: (see full question) The diploma nurse is considering obtaining a baccalaureate degree. Which degree shouldthe nurse investigate? You selected: Correct Explanation: The diploma nurse considering obtaining a baccalaureate degree should investigate RN to BSN programs. This degree is designed for registered nurses with a diploma degree.the DNP is designed asthe terminal degree (doctorate degree) for nursing practice.the accelerated degree is designed for people with a baccalaureate degree, not in nursing to obtain their BSN in 1 to 2 years.the MSN is designed for nurses with a baccalaureate degree to obtain a masters degree in nursing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, pp. 14-16. Chapter 1: Introduction to Nursing - Page 14 ________________________________________ Question 20: (see full question) Which ofthe following isthe best example of a nurse inthe role of counselor? You selected: Correct Explanation: Whenthe nurse is acting as a counselor,the nurse uses therapeutic interpersonal skills to facilitatethe client's problem-solving and decision-making skills.the best example isthe nurse allowingthe client to verbalize their feelings, as verbalizing feelings letsthe client gain a better perspective of their situation for problem solving and for coming to terms withthe situation. Tellingthe client aboutthe side effects of a medication is a form of teaching. Providing test results tothe physician is communication, and ensuring a client has follow-up care at a free clinic is advocacy. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11. Chapter 1: Introduction to Nursing - Page 11 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 12 min Total Questions: 20 Questions answered: 20 Number correct: 19 95% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 1 Quiz taken My Mastery Level: 2.00 Class Average: 2.44 congrats! Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 12 min Total Questions: 20 Questions answered: 20 Number correct: 19 95% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 1 Quiz taken My Mastery Level: 2.00 Class Average: 2.44 Answer Key Question 1: (see full question) An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses.the infection control nurse informsthe group that most needlestick injuries result from which ofthe following? You selected: Recapping a needle Correct Explanation: Most needlesticks occur during recapping, so nurses are instructed to never recap needles. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 2: (see full question) Which ofthe following practices is a correct application of infection control practices? You selected: A nurse performs handwashing each time she removes a pair of gloves. Correct Explanation: Handwashing should be performed afterthe removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 3: (see full question) A client has sexual intercourse with someone infected with HIV.the vehicle of transmission is You selected: Semen Correct Explanation: Vehicle transmission involvesthe transfer of microorganisms by way of vehicles, or contaminated items that transmit pathogens. For example, food can carry Salmonella. In this case, semen can carry human immunodeficiency virus. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 535. Chapter 23: Asepsis and Infection Control - Page 535 ________________________________________ Question 4: (see full question) A nurse is taking care of a client with tuberculosis who has developed resistance tothe ordered antibiotic. Which type of client is most likely at increased risk for infection? You selected: Older adult Correct Explanation: Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 536-537. Chapter 23: Asepsis and Infection Control - Page 536 ________________________________________ Question 5: (see full question) Which ofthe following is an accurate guideline forthe use of PPE? You selected: Replace gloves if they are visibly soiled. Correct Explanation: If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before enteringthe client's room and glasses should not be substituted for protective eyewear. Work should progress from “clean” areas to “dirty” areas. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 570-572. Chapter 23: Asepsis and Infection Control - Page 570 ________________________________________ Question 6: (see full question) An acute medicine unit of a hospital currently has a number of clients who have tested positive for methicillin-resistantStaphylococcus aureus (MRSA). Which ofthe following measures shouldthe nursing staff prioritize in preventingthe spread of MRSA to clients who are currently MRSA-negative? You selected: Diligent handwashing practices Correct Explanation: As with all forms of infection, thorough handwashing isthe most important infection-control measure. It is inappropriate to reduce clients' length of stay based on their MRSA status, and prophylaxis is not normally used. It is unnecessary to wear gloves at all times onthe unit. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 545-546. Chapter 23: Asepsis and Infection Control - Page 545 ________________________________________ Question 7: (see full question) When a nurse picks up a client's contaminated tissue without gloves and fails to wash his hands sufficiently,the nurse provides forthe client's organisms to be spread by which type of transmission? You selected: Contact Correct Explanation: Direct contact involves body surface–to–body surface contact, causingthe physical transfer of organisms between an infected or colonized host and a susceptible host. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 534-535. Chapter 23: Asepsis and Infection Control - Page 534 ________________________________________ Question 8: (see full question) You have completed an intervention with a patient. There is no visible soiling on your hands. Which ofthe following techniques is recommended bythe Centers for Disease Control (CDC) for hand hygiene? You selected: Decontaminate hands using an alcohol-based hand rub. Correct Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 9: (see full question) When preparing to use a bottle of sterile saline for a dressing change,the nurse notes thatthe date it was opened was two days previous. What shouldthe nurse do? You selected: Obtain a new bottle of sterile saline Correct Explanation: The nurse should obtain a new bottle of sterile saline, as most solutions are considered sterile for 24 hours after they are opened. Shakingthe bottle will not impact its sterility. Switching to sterile water is not indicated. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 ________________________________________ Question 10: (see full question) You are donning a pair of sterile gloves. You correctly donthe first glove, but inadvertently insertthe thumb and index finger intothe thumb hole ofthe second glove.the glove remains intact. Which ofthe following actions is most appropriate? You selected: Continue to donthe glove, then usethe other gloved hand to carefully insertthe finger intothe proper hole. Correct Explanation: It is appropriate to adjustthe gloves but touching sterile surface to sterile surface. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 571. Chapter 23: Asepsis and Infection Control - Page 571 ________________________________________ Question 11: (see full question) To eliminate needlesticks as potential hazards to nurses,the nurse should You selected: Slidethe needle intothe cap and deposit it in a puncture-proof plastic container Incorrect Correct response: Immediately deposit uncapped needles into puncture-proof plastic container Explanation: All uncapped needles should be placed in puncture-proof plastic units immediately after use. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 12: (see full question) Upon review of a client's microbiology culture results,the nurse recognizes which organism as indicative of normal flora? You selected: Escherichia coli inthe intestinal tract Correct Explanation: Escherichia coli resides inthe intestinal tract, is normal flora, and does not cause harm or infection inthe client. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 534. Chapter 23: Asepsis and Infection Control - Page 534 ________________________________________ Question 13: (see full question) When leavingthe room of a client requiring contact precautions after helping an unlicensed personnel (UP) bathethe client,the nurse observesthe unlicensed personnel taking gloves off by graspingthe inside of one gloved hand withthe opposite gloved hand and peeling it off. What isthe proper action ofthe nurse? You selected: Demonstrate proper glove removal tothe unlicensed personnel. Correct Explanation: It is important forthe unlicensed personnel to learn how to remove gloves correctly.the nurse should demonstrate proper glove removal tothe unlicensed personnel. There is no need to reportthe unlicensed personnel tothe unit manager. Reassigningthe unlicensed personnel is not appropriate. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 544. Chapter 23: Asepsis and Infection Control - Page 544 ________________________________________ Question 14: (see full question) Surgical asepsis is defined as You selected: Absence of all microorganisms Correct Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 539. Chapter 23: Asepsis and Infection Control - Page 539 ________________________________________ Question 15: (see full question) A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated? You selected: The nurse is caring for a client with a C. difficile infection. Correct Explanation: Controversy exists regardingthe use of alcohol-based handrubs when C. difficile organisms have been identified. Alcohol does not kill C. difficile spores. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 543. Chapter 23: Asepsis and Infection Control - Page 543 ________________________________________ Question 16: (see full question) A patient is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? You selected: Surgical asepsis technique Correct Explanation: Surgical asepsis technique isthe technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly inthe operating room, labor and delivery areas, and certain diagnostic testing areas, are also used bythe nurse atthe patient’s bedside. Procedures that involvethe insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reducethe number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique wherethe client is protected fromthe nurse, other health care providers, and visitors. A client that has immune system disorders wherethe client might not be able to fight off an organism would be kept in an environment to minimize exposure tothe organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn to not carrythe organism via droplet from exposed client to others. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 ________________________________________ Question 17: (see full question) The use of alcohol-based hand rubs for hand hygiene in healthcare facilities is approved bythe Centers for Disease Control (CDC), butthe Joint Commission (TJC) discourages its use. You selected: False Correct Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 540. Chapter 23: Asepsis and Infection Control - Page 540 ________________________________________ Question 18: (see full question) For which ofthe following clients wouldthe use of Standard Precautions alone be appropriate? You selected: An incontinent client in a nursing home who has diarrhea Correct Explanation: Standard Precautions apply to blood and all body fluids, secretions, and excretions, except sweat. Transmission-Based Precautions are used in addition to Standard Precautions for clients hospitalized with suspected infection by pathogens that can be transmitted by airborne, droplet, or contact routes, such as isthe case in answers A, B, and D. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 550. Chapter 23: Asepsis and Infection Control - Page 550 ________________________________________ Question 19: (see full question) A nurse who is takingthe vital signs of a client with acute diarrhea is ordered to attend to another client. What isthe highest priority nursing actionthe nurse must perform before leavingthe client's room? You selected: Thorough handwashing Correct Explanation: Sincethe client has an infectious disease,the most important nursing action is to perform thorough handwashing before leavingthe client's room and before touching any other client, personnel, environmental surface, or client care item. Spraying a disinfectant before leavingthe client's room, or placing one bag of contaminated items in another is notthe most important nursing action in this case. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. Nurses removethe personal protective equipment that is most contaminated first to preservethe clean uniform underneath. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 539. Chapter 23: Asepsis and Infection Control - Page 539 ________________________________________ Question 20: (see full question) A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient? You selected: “Have you had any unusual symptoms after blowing up balloons?” Correct Explanation: Awareness of a latex allergy is important for safe home care. Nurses need to ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 548. Chapter 23: Asepsis and Infection Control - Page 548 Question 1: (see full question) Which level of health care provider may makethe decision to apply physical restraints to a client? You selected: Correct Explanation: Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such asthe Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician's assistant. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 ________________________________________ Question 2: (see full question) An boy 18 years of age is brought tothe emergency department with a head injury.the nurse knows that adolescents are vulnerable to injuries related to which ofthe following? You selected: Correct Explanation: Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling fromthe bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 702-704. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 3: (see full question) Which statement indicates that a family understandsthe teaching that has been provided bythe nurse related to car seat safety for their 9-month-old infant? You selected: Correct Explanation: The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat inthe back seat ofthe car until they are 2 years, or until they reachthe maximum height and weight forthe car seat. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 700-701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 ________________________________________ Question 4: (see full question) One ofthe leading causes of death inthe United States, particularly in southwestern states, is drowning. How canthe nurse assist in lowering this statistic? You selected: Correct Explanation: The principles of injury control have interventions centered at three primary levels:the individual level, providing education about safety hazards and prevention strategies;the design phase, using engineering and environmental controls; andthe regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 696. Chapter 26: Safety, Security, and Emergency Preparedness - Page 696 ________________________________________ Question 5: (see full question) A home care nurse provides health education to parents regardingthe care of their toddler. Which ofthe following precautions shouldthe nurse suggestthe parents take to protectthe toddler from drowning? You selected: Correct Explanation: The parents should not leavethe toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away fromthe pool may make them more curious. Monitoringthe activities ofthe toddler is not always feasible. Allowingthe child to swim with friends does not ensure safety. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 700-701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 ________________________________________ Question 6: (see full question) The nurse is applying wrist restraints on a client and notes thatthe client is unable to move his right arm. What isthe appropriate action bythe nurse? You selected: Correct Explanation: The nurse should apply onlythe left wrist restraint. Asthe client is unable to movethe right arm, this arm does not need restraining. Vest restraints and wrist restraints are typically utilized to meet different client needs, so they are not usually interchanged for one another. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 722. Chapter 26: Safety, Security, and Emergency Preparedness - Page 722 ________________________________________ Question 7: (see full question) Which ofthe following statements about restraints used inthe acute care setting is true? You selected: Correct Explanation: A valid physician or licensed independent practitioner's order is required forthe use of restraints, regardless of setting. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 719. Chapter 26: Safety, Security, and Emergency Preparedness - Page 719 ________________________________________ Question 8: (see full question) An administrative assistant of a large factory visitsthe medical unit and tellsthe nurse she is having pain inthe right wrist, numbness inthe index finger, and decreased mobility ofthe right hand.the nurse suspectsthe client has what? You selected: Correct Explanation: Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of th ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 9: (see full question) The nurse needs to planthe interventions necessary to reduce fall risks forthe older adult clients at her facility. Which isthe strongest indicator that a client is at risk for falls? You selected: Correct Explanation: Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls. Cardiovascular medications, being forgetful, or using an assistive device do not necessarily predispose a client to falling. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 687. Chapter 26: Safety, Security, and Emergency Preparedness - Page 687 ________________________________________ Question 10: (see full question) A nurse responds tothe call bell and finds another nurse evacuatingthe client fromthe room, which has caught fire. Which ofthe following actions shouldthe nurse take? You selected: Correct Explanation: The nurse should pullthe fire alarm lever. As perthe RACE principle of fire management,the flow of activities should be rescue, alarm, confine, and extinguish.the client had already been evacuated by another nurse, sothe next action should be to pullthe fire alarm lever, followed by confinement ofthe fire and extinguishing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 ________________________________________ Question 11: (see full question) What is an appropriate nursing intervention to include inthe plan of care for a client with smallpox? You selected: Correct Explanation: Clients with smallpox should receive strict contact and airborne precautions for duration of illness and supportive care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 12: (see full question) If a client is exposed to Viral Hemorrhagic Fevers, which clinical manifestations wouldthe nurse assess inthe client? You selected: Flu-like symptoms and a characteristic rash Incorrect Correct response: Explanation: Anthrax exposure can result in skin lesions that progress to necrotic ulcers and fever. Exposure to viral hemorrhagic fevers can result in Petechial hemorrhages and hypotension. Botulism exposure presents with Skeletal muscle paralysis and blurred vision. Small pox exposure presents with flu-like symptoms and a characteristic rash. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 13: (see full question) The school nurse is preparing a presentation about safety promotion for middle school students. Which topic shouldthe nurse plan to include? You selected: Correct Explanation: Seat belt use is an important safety precaution to teach audience of all ages. Improper or lack of seat belt use increasesthe risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 14: (see full question) Which ofthe following reasons best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk? You selected: Correct Explanation: As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 ________________________________________ Question 15: (see full question) The nurse is caring for an 80-year-old patient who was admitted tothe hospital in a confused and dehydrated state. Afterthe patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists fromthe restraints. What would bethe most appropriate nursing intervention for this patient? You selected: Correct Explanation: Physical restraints increasethe possibility ofthe occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death.the best action in this situation is forthe nurse to removethe restraint, stay withthe patient and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leavingthe restraints onthe patient to talk to her is going to cause further agitation and bruising of her wrists.the patient’s condition dictates whenthe patient is discharged, not confusion and agitation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 26, Safety, Security, and Emergency Preparedness, pp. 708-710 ________________________________________ Question 16: (see full question) An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information shouldthe nurse teachthe parents about concussions? You selected: Correct Explanation: Frequent neurologic assessments are crucial after a traumatic brain injury, to assess for subtle changes as they begin. Helmets are meant to protectthe wearer, but head injury can still occur. "Passing off" an injury as something that kids get and then they are fine is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsenthe child’s symptoms andthe injury itself. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 701-702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 701 ________________________________________ Question 17: (see full question) A school-aged child is admitted tothe Emergency Room withthe diagnosis of a concussion following a collision when playing football. Afterthe collision,the parents state that he was “knocked out” for a few minutes before recognizing his surroundings. What isthe priority assessment whenthe nurse first seesthe patient? You selected: Correct Explanation: Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation. Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than two years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment, and assessment comes before intervention inthe nursing process and more assessment is needed for this client beforethe need for an IV line is determined. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 699, 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 699 ________________________________________ Question 18: (see full question) A client in a long-term care facility has become increasingly unsteady.the nurses are worried thatthe client will climb out of bed and fall. Which ofthe following measures would be a high priority recommendation for this client? You selected: Correct Explanation: Raising all side rails onthe bed would be a restraint, and may increasethe client’s risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would putthe client at a greater risk for a fall. Using restraints are not an option at this time, but placingthe client in a bed with a bed alarm would help to prevent a fall. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 26: Safety, Security, and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 ________________________________________ Question 19: (see full question) The nurse is providing care for a client that was involved in a nuclear terrorism attack, and, as a result, has sustained radiation burns.the nurse also knows thatthe client's history states that he was exposed to a high dose of radiation. What canthe nurse expect this client to be at risk for based onthe degree of exposure tothe radiation? You selected: Correct Explanation: Bone marrow depression and cancer can occur later in clients that are exposed to high doses of radiation exposure.the skin, kidneys, and intestines are organs most sensitive to radiation, but these diseases are not specific to this exposure. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 716. Chapter 26: Safety, Security, and Emergency Preparedness - Page 716 ________________________________________ Question 20: (see full question) A student nurse overhears another nurse talking to a group of students about work relate injuries.the student nurse understands thatthe nurse needs further education when she makes which statement? You selected: Correct Explanation: Injuries should never be considered “part ofthe job.” OSHA standards andthe involvement of safety committees help ensure a safe workplace. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 689 Answer Key Question 1: (see full question) The nurse is creating a plan of care forthe older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What isthe most appropriate nursing diagnosis to include in this client's plan of care? You selected: Correct Explanation: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in readingthe labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 705-706. Chapter 26: Safety, Security, and Emergency Preparedness - Page 705 ________________________________________ Question 2: (see full question) The nurse caring for a client with smallpox would anticipate this client being on which type of precautions? Select all that apply. You selected: Correct Explanation: Smallpox is spread via direct contact and inhalation of droplets. Therefore,the client would be put on contact precautions, as well as respiratory precautions. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 3: (see full question) A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires inthe home? You selected: Correct Explanation: Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 693. Chapter 26: Safety, Security, and Emergency Preparedness - Page 693 ________________________________________ Question 4: (see full question) What isthe primary role ofthe nurse inthe care of clients that experience domestic violence? You selected: Identifying health education and counseling measures forthe family Incorrect Correct response: Explanation: The nurse is oftenthe initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition ofthe potential or actual threat to safety is crucial, andthe nursing assessment may play a vital role in identifying a harmful environment. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 704-705. Chapter 26: Safety, Security, and Emergency Preparedness - Page 704 ________________________________________ Question 5: (see full question) A staff development nurse is providing an in-service to a group of nurses onthe use of restraints in healthcare facilities. Which ofthe following is an example of a chemical restraint? You selected: A dose of an analgesic Incorrect Correct response: Explanation: Drugs that are used to control behavior and are not included inthe person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 707. Chapter 26: Safety, Security, and Emergency Preparedness - Page 707 ________________________________________ Question 6: (see full question) When educating families on fire safety inthe home, which information is important forthe nurse to emphasize? You selected: Keep a fire extinguisher in a closet. Incorrect Correct response: Explanation: The whole family should regularly practice a fire escape plan, such as crawling onthe floor, using escape routes, and having a meeting place outsidethe home in case of fire. Attempting to account for all family members before exitingthe burning structure is dangerous and may result inthe loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in a area with access and not a closet. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 694. Chapter 26: Safety, Security, and Emergency Preparedness - Page 694 ________________________________________ Question 7: (see full question) During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of what type of terrorism? You selected: Nuclear terrorism Incorrect Correct response: Explanation: Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities. Bioterrorism involvesthe deliberate spread of pathogenic organisms intothe community. Chemical terrorism involvesthe deliberate release of a chemical compound forthe purpose of causing mass destruction. Nuclear terrorism involvesthe dispersal of radioactive materials intothe environment forthe purpose of causing injury and death. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 714-716. Chapter 26: Safety, Security, and Emergency Preparedness - Page 714 ________________________________________ Question 8: (see full question) What best describesthe nurse’s role in disaster preparedness? You selected: Correct Explanation: Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 717. Chapter 26: Safety, Security, and Emergency Preparedness - Page 717 ________________________________________ Question 9: (see full question) The nurse is conducting a community program on car seat safety.the nurse determines that additional education is needed when a participant states which ofthe following? You selected: "I should securethe car seat tightly withthe seat belt." Incorrect Correct response: Explanation: The nurse should determine that additional information is needed whenthe participant states that a front facing car seat should be bought whenthe child is 1 year old.the child should be kept inthe rear facing car seat until 2 years of age. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 700. Chapter 26: Safety, Security, and Emergency Preparedness - Page 700 ________________________________________ Question 10: (see full question) A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety? You selected: Correct Explanation: Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn.the chinstrap should fit snuggly, not loosely, and young children that are secured in a bicycle passenger seat must also wear a helmet. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 701 ________________________________________ Question 11: (see full question) The nurse overhears an older client's son talking to her in a very aggressive and violent way. Whenthe nurse walks intothe room,the son changes and speaks kindly to his mother andthe health care providers. What shouldthe nurse do about this observation? You selected: Correct Explanation: In 90% of elder abuse cases that are reported,the person doingthe abusing is a family member.the best thing to do would be forthe nurse to getthe client alone so that she can discussthe relationship that was observed. Documentingthe behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury tothe client.the nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 706. Chapter 26: Safety, Security, and Emergency Preparedness - Page 706 ________________________________________ Question 12: (see full question) An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would bethe most serious fall-related injury? You selected: Correct Explanation: Falls can occur at any age, but a large percentage of elderly adults in long-term settings suffer a fall. Hip fractures are amongthe most serious fall-related injuries. Fractures can cause pain, permanent disability, and even death. A fractured ulna may be painful but would not causethe same potential for complications as a hip fracture. Lacerations and contusions may be uncomfortable forthe client but will heal with limited risk for further complications. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 692. Chapter 26: Safety, Security, and Emergency Preparedness - Page 692 ________________________________________ Question 13: (see full question) The nurse is caring for a client in a posey vest restraint.the restraint was ordered at 0800.the last nursing client assessment and need for restraint was documented at 1000. It is now 1200. What isthe appropriate action bythe nurse? You selected: Correct Explanation: Assessment and documentation of a client in restraints should occur at least every hour. Although it has been longer than an hour sincethe last documented assessment,the nurse should immediately assessthe client and documentthe findings.the nurse should never falsify documentation by documenting that an assessment was done at at time when it was not completed.the restraints should not be discontinue unless it is appropriate to do so, and there is no need to contactthe physician at this time. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 ________________________________________ Question 14: (see full question) A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which ofthe following interventions shouldthe nurse implement to ensure electrical safety? You selected: Correct Explanation: The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back tothe ground. Using an extension cord may be an electrical hazard. Tapingthe electrical cord tothe ground and runningthe electrical cord underthe carpet are not appropriate actions for electrical safety. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 712. Chapter 26: Safety, Security, and Emergency Preparedness - Page 712 ________________________________________ Question 15: (see full question) The unlicensed personnel tellsthe nurse that a client is very confused and trying to get out of bed without assistance. What isthe appropriate action bythe nurse? You selected: Correct Explanation: The nurse should attempt to preventthe client confused client from getting out of bed by themselves to prevent a fall usingthe least restrictive action first. In this case, it would be to initiatethe use of a bed alarm. Putting up all 4four siderails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort whenthe client is in danger of harming themselves or others. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 ________________________________________ Question 16: (see full question) A child is playing soccer and is involved in a head collision with another player. Which assessment findings shouldthe nurse be alert to that may indicate a concussion? (Select all that apply.) You selected: Correct Explanation: Concussions are a frequently seen sports injury in school age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 17: (see full question) Which statement indicates that a family understandsthe teaching that has been provided bythe nurse related to car seat safety for their 3-year-old child? You selected: Correct Explanation: The American Academy of Pediatrics recommends that all children overthe age of 2 be placed in a front-facing car seat based onthe child’s weight and height. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p 701. ________________________________________ Question 18: (see full question) A nurse is preparing discharge education for a client with a newborn baby. What isthe highest priority item that must be included inthe education plan? You selected: Correct Explanation: The client should restrainthe baby in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Lockingthe cabinets and giving warm bottles of formula tothe baby are secondary teachings. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 699-700. Chapter 26: Safety, Security, and Emergency Preparedness - Page 699 ________________________________________ Question 19: (see full question) A child football player has been diagnosed with an uncomplicated concussion and is being discharged home on cognitive rest. When preparing this child’s teaching plan, what shouldthe nurse include that will helpthe family understand what is meant by cognitive rest? You selected: Correct Explanation: The treatment for an uncomplicated concussion is physical and cognitive rest. Reading, watching television, and playing games of any kind are examples of cognitive activities that should be avoided untilthe athlete is cleared. Lifting objects and playing football are examples of physical activities only, andthe need for 8 hours of sleep does not directthe family inthe limitations of cognitive activity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 20: (see full question) A nurse is preparing to file a safety event report after a client experienced a fall.the nurse is aware that which statement below is correct regardingthe filing of a safety event report? You selected: Correct Explanation: The nurse completesthe safety event report immediately after an accident and is responsible for recordingthe incident and its effect onthe client inthe medical record.the safety event report is not a part ofthe medical record and should not be mentioned inthe documentation. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 712. Chapter 26: Safety, Security, and Emergency Preparedness - Page 712 Answer Key Question 1: (see full question) A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include inthe client’s plan of care would be which ofthe following? You selected: Client will recognizethe need for self-care. Incorrect Correct response: Explanation: Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not meanthe client does not want to participate in hygiene and personal care. An appropriate goal would be to havethe client actively participate in hygiene and self-care. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 910. Chapter 30: Hygiene - Page 910 ________________________________________ Question 2: (see full question) A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitatethe client's rest? You selected: Correct Explanation: A backrub is used after a bath or as a nursing intervention forthe following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication betweenthe nurse andthe client. Stimulatingthe environment through conversation or multiple stimuli will only increasethe level of alertness ofthe client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 917. Chapter 30: Hygiene - Page 917 ________________________________________ Question 3: (see full question) Which ofthe following is a recommended guideline when removing contact lenses from a client's eyes? You selected: Correct Explanation: Gentle pressure should be used to center hard or gas-permeable lenses onthe cornea. Once removed, lenses should be placed inthe appropriate container, identifyingthe right and left lens. If an eye injury is present,the lenses should not be removed because ofthe danger of causing an additional injury. Ifthe lenses cannot be removed, they should be removed withthe appropriate tool designated forthe type of lenses in place. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 919-920. Chapter 30: Hygiene - Page 919 ________________________________________ Question 4: (see full question) The nurse is caring for a female client who is unconscious. You should pay special attention to cleaning which ofthe following areas ofthe body? You selected: Correct Explanation: Skin fold areas may be sources of odor and skin breakdown if not cleaned and dried properly. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 934. Chapter 30: Hygiene - Page 934 ________________________________________ Question 5: (see full question) A nurse is assessingthe client’s ability to perform ear care. Which statement bythe client requires further teaching bythe nurse? You selected: Correct Explanation: Healthy ears require little to no care. Cerumen (ear wax) can accumulate causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipethe auricles andthe twisted end of a washcloth can be used to clear cerumen fromthe ear canal. Clients should be educated to not use cotton-tipped applicator because it may push cerumen further back intothe ear canal. Bobby pins and sharp objects should never be used to remove cerumen because they can puncturethe tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping ofthe mold, and monitoring for dead batteries. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 921. Chapter 30: Hygiene - Page 921 ________________________________________ Question 6: (see full question) A nursing instructor is explainingthe benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understandsthe concepts when she liststhe following benefits orally tothe class. Select all that apply. You selected: Correct Explanation: Bathing serves a variety of purposes including: cleansing; acting as a skin conditioner; helping to relax a person; promoting circulation by stimulatingthe skin’s peripheral nerve endings and underlying tissues; serving as a musculoskeletal exercise through activity involved in bathing, thereby improving joint mobility and muscle tone; stimulatingthe rate and depth of respiration; promoting comfort through muscle relaxation and skin stimulation; providing sensory input; and helping improve self-image. Bathing also provides a means to establishing a therapeutic relationship. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 911-912. Chapter 30: Hygiene - Page 911 ________________________________________ Question 7: (see full question) When an adult client from Indonesia refuses a complete bath onthe day after abdominal surgery,the nurse should ... You selected: Correct Explanation: Preferences for hygiene vary widely among individuals and across cultures. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 903. Chapter 30: Hygiene - Page 903 ________________________________________ Question 8: (see full question) A nurse is teaching a patient how to care for her dentures. Which ofthe following is a recommended teaching guideline? You selected: Correct Explanation: Encouragethe patient to wear her dentures, if not contraindicated. Dentures enhance appearance, assist with eating, facilitate speech, and maintainthe gum line. Denture fit may be altered with long periods of nonuse. Encouragethe patient to refrain from wrappingthe denture in paper towels or napkins because they could be mistaken for trash. Encouragethe patient to refrain from placingthe dentures inthe bed clothes because they can be lost inthe laundry. Store dentures in cold water when not inthe patient's mouth. Leaving dentures dry can cause warping, leading to discomfort when worn (Holman, et al., 2005). (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 918. Chapter 30: Hygiene - Page 918 ________________________________________ Question 9: (see full question) A nurse is performing an admission assessment on a client. What is an appropriate question to ask when assessingthe client’s self-care hygiene measures? You selected: Correct Explanation: When assessing a client’s self-care patterns and feelings, it is important to understandthe client’s perceptions regarding bathing and elicit personal care preferences. Although it is important to incorporate preferences, it may not be possible to allow clients to bring products from home if they are in specialty care environments. Asking questions about body odor may sound judgmental and may causethe client to feel judged, which may prohibitthe ability to form a trusting relationship withthe nurse. A clear threat to health must be present before a nurse can decide a client's hygiene practices are inadequate. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 912. Chapter 30: Hygiene - Page 912 ________________________________________ Question 10: (see full question) A nurse caring forthe skin of patients of different age groups should consider which accurately described condition? You selected: Correct Explanation: Adolescents have enlarges sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining tothe mucous membranes. Secretions from skin glands occur later than age 3 months. Whilethe skin may have more wrinkles as a person ages,the skin actually becomes thinner with age. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 30, Hygiene, p. 900 ________________________________________ Question 11: (see full question) A 55-year-old client has just undergone surgery for a knee replacement. He asksthe nurse if he can shave because his face is itching fromthe stubble. What information is a priority forthe nurse to verify prior to shavingthe client? You selected: Correct Explanation: Shaving guidelines note that pharmacological considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving,the client is asking to shave so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed atthe client’s request. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 922-923. Chapter 30: Hygiene - Page 922 ________________________________________ Question 12: (see full question) A nurse is examining an adult client with inflammation ofthe gums.the nurse observes bleeding gums. How shouldthe nurse recordthe findings inthe client's medical record? You selected: Correct Explanation: The nurse should recordthe findings as gingivitis. Gingivitis is a condition in which there is inflammation ofthe gums. This usually happens when there is improper cleaning of teeth or injury tothe gums from overly vigorous brushing or flossing. Gingivitis is usually associated with bleeding gums. Caries, plaque, and tartar do not show inflammation ofthe gums. Cavities usually occur when there is combination of sugar, plaque, and bacteria inthe teeth, which eventually erodethe tooth enamel. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907. Chapter 30: Hygiene - Page 907 ________________________________________ Question 13: (see full question) When providing oral care, which ofthe following doesthe nurse recognize asthe most important component ofthe oral care process? You selected: Correct Explanation: Followingthe steps for cleaningthe mouth thoroughly is more important thanthe agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning ofthe oral cavity. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 917. Chapter 30: Hygiene - Page 917 ________________________________________ Question 14: (see full question) Which ofthe following health problems is most clearly suggestive of a history of inadequate dental care? You selected: Correct Explanation: Periodontitis, or periodontal disease, is a marked inflammation ofthe gums that also involves degeneration ofthe dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency while dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907. Chapter 30: Hygiene - Page 907 ________________________________________ Question 15: (see full question) Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? You selected: Correct Explanation: As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a person ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 903. Chapter 30: Hygiene - Page 903 ________________________________________ Question 16: (see full question) A client has been recently admitted tothe hospital unit following a suspected stroke, and a family member states thatthe client's soft contact lenses are still in place. Which ofthe following solutions shouldthe nurse use forthe storage ofthe client's lenses after removal? You selected: Correct Explanation: Contact lenses are most commonly stored in normal saline. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 919-920. Chapter 30: Hygiene - Page 919 ________________________________________ Question 17: (see full question) A patient with iron deficiency has a common complication that results in an inflammation ofthe tongue. What isthe term used for this condition? You selected: Correct Explanation: Glossitis is an inflammation ofthe tongue. Gingivitis is an inflammation ofthe gingival,the tissue that surroundsthe teeth (gums). Periodontitis is a marked inflammation ofthe gums that also involves degeneration ofthe periosteum and bone. Stomatitis is an inflammation ofthe oral mucosa. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907. Chapter 30: Hygiene - Page 907 ________________________________________ Question 18: (see full question) A client is being discharged today fromthe hospital.the nurse delegates morning care tothe unlicensed assistive personnel (UAP).the assessment finds thatthe client is able to stand and ambulate independently without weakness or dizziness.the nurse will delegate what type of care to be provided based onthe assessment findings? You selected: Correct Explanation: Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowingthe client to shower independently would be appropriate.the client is not unstable enough to prohibit hygiene measures. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 30: Hygiene, pp. 903-904. Chapter 30: Hygiene - Page 903 ________________________________________ Question 19: (see full question) Foot care is an essential part of routine hygiene. What is an important nursing consideration when planning foot care for diabetic patients? You selected: Correct Explanation: Foot care is an essential part of routine hygiene. Clients with diabetes have decreased sensation, placing them at risk for injury and burns. Soakingthe feet should be avoided. Feet should be inspected daily, cleaned with warm water and mild soap, carefully dried, especially betweenthe toes, and lotion should be applied tothe tops ofthe toes and bottom ofthe feet but not betweenthe toes, because increased moisture can lead to infection.the cutting of toenails is institution specific and if cutting is permitted, attention should be given to not cuttingthe toenails too close tothe skin, cutting straight across, and using emery boards for sharp edges. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 923-924. Chapter 30: Hygiene - Page 923 ________________________________________ Question 20: (see full question) The acute care nurse is preparing to bathe a patient and notices thatthe patient is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which ofthe following actions bythe nurse is most appropriate? You selected: Correct Explanation: The gown should be removed without disconnectingthe IV equipment or cuttingthe gown. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 936-937. Chapter 30: Hygiene - Page 936 Answer Key Question 1: (see full question) A nurse is promoting exercise and activities for an elderly patient. Which teaching point would be appropriate for this patient? You selected: Correct Explanation: The client should be encouraged to develop an exercise program that specifies warm-up and cool-down activities (walking, stretching).the client should not be encouraged to quickly increasethe repetitions for arm and leg exercises.the client should not continue to exercise when feeling weak, this could lead to injury.the client should not be taught to force joints to meet their natural limit and beyond prior to modifying exercises. This could lead to injury. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1082. Chapter 32: Activity - Page 1082 ________________________________________ Question 2: (see full question) The nurse has been teaching a client about health promotion and exercise.the nurse knowsthe client understandsthe teaching whenthe client states what? You selected: "I should exercise for an hour everyday.” Incorrect Correct response: Explanation: Inviting a friend to exercise with will addthe support of a buddy. Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be built gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes three or four times per week. Alternating types of exercise will help to avoid boredom. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1080. Chapter 32: Activity - Page 1080 ________________________________________ Question 3: (see full question) The nursing student learns in Fundamentals thatthe primary purpose for using proper body mechanics is for which ofthe following reasons? You selected: Primarily protectsthe nurse from injury Incorrect Correct response: Explanation: When nurses use their bodies to perform therapies, to assist clients with movement, or to move equipment, they benefit fromthe effective use of body mechanics to prevent injury to themselves and others. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1060. Chapter 32: Activity - Page 1060 ________________________________________ Question 4: (see full question) What is a benefit of regular exercise over time? You selected: Correct Explanation: Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasingthe risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back tothe heart against gravity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1048. Chapter 32: Activity - Page 1048 ________________________________________ Question 5: (see full question) Which nursing actions wouldthe nurse perform when assisting patients with passive ROM exercises? (Select all that apply.) You selected: Correct Explanation: The nurse would adjustthe bed tothe flat position or as low asthe client can tolerate.the nurse would begin ROM exercises atthe client’s head and move down one side ofthe body at a time.the nurse would move each joint in a smooth, rhythmic manner.the nurse would not raisethe bed tothe highest position, but at a position that is waist high tothe nurse.the nurse would not perform each exercise 10 to 15 times, rather 2 to 5 times.the nurse would not use a flat palm, rather a cupping hold to support joints during ROM exercises. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1105. Chapter 32: Activity - Page 1105 ________________________________________ Question 6: (see full question) When moving a client up in bed withthe assistance of another caregiver,the nurse should: You selected: Correct Explanation: Positioningthe arms acrossthe chest proves assistance, reduces friction, and prevents hyperextension ofthe neck. Before attempting to move a client up in bed,the nurse should reviewthe medical record andthe nursing plan of care. This validatesthe correct client and correct procedure, identification of limitation, and ability. Reviewingthe medical record and plan of care also identifies use of an algorithm to prevent injury and assistance in determiningthe best plan for client movement.the head ofthe bed should be flat, or as low asthe client can tolerate that will help to decreasethe gravitational pull ofthe upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from underthe client’s head facilitates movement. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1096-1098. Chapter 32: Activity - Page 1096 ________________________________________ Question 7: (see full question) A nurse is caring for patients with alterations in mobility. Which nursing interventions are recommended for these patients? (Select all that apply.) You selected: • For constipation, increase fluid intake and roughage. • For impaired skin integrity, repositionthe patient in correct alignment at least every 1 to 2 hours. Incorrect Correct response: Explanation: The nurse would implementthe following nursing interventions when caring for clients with alterations in mobility.the nurse would havethe client sleep sitting up or in an elevated position for orthostatic hypotension.the nurse would havethe client increase fluid intake and roughage (if not contraindicated) to address constipation concerns.the nurse would repositionthe client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues.the client would decreasethe cardiac workload if lying inthe prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1052. Chapter 32: Activity - Page 1052 ________________________________________ Question 8: (see full question) When assisting a client fromthe bed into a wheelchair,the nurse assessesthe client for signs of dizziness upon standing. For what adverse condition isthe nurse assessingthe client? You selected: Correct Explanation: The nurse would stand in front ofthe client and assess for any balance problems or complaints of dizziness upon standing, due to orthostatic hypotension. Standing in front ofthe client prevents falls or injuries. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1075. Chapter 32: Activity - Page 1075 ________________________________________ Question 9: (see full question) A nurse is preparing to turn a hospitalized client age 65 years. Which ofthe following is a recommended guideline for performing this skill? You selected: Correct Explanation: After placingthe bed in a comfortable working position (usually elbow height ofthe caregiver), position a nurse on either side ofthe bed, put a friction-reducing sheet underthe client, and usethe leg muscles to pullthe client tothe side. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1063. Chapter 32: Activity - Page 1063 ________________________________________ Question 10: (see full question) The nurse is caring for a client who is on bed rest and was just turned tothe left side. Which ofthe following actions should you take next to decreasethe risk of impaired skin integrity? You selected: Correct Explanation: Positioningthe shoulder blade in this manner removes pressure fromthe bony prominence. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1095. Chapter 32: Activity - Page 1095 ________________________________________ Question 11: (see full question) The nurse is teaching a new graduate nurse aboutthe most common causes of back injuries.the nurse knows thatthe new graduate understandsthe concepts of back injuries when she/he states that back injuries: You selected: Correct Explanation: Many nurses believe that back pain is a routine consequence ofthe job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contribute tothe prevention of back injuries and pain. Back injuries can occur when repositioning uncooperative clients. Back injuries cannot be prevented by use of a gait belt. Inappropriate use ofthe gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods of times can contribute to back injuries. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1059-1061. Chapter 32: Activity - Page 1059 ________________________________________ Question 12: (see full question) A nurse applies padded boots to maintainthe foot in dorsiflexion on a client who is comatose.the nurse is protectingthe client from what? You selected: Correct Explanation: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in whichthe foot is fixed in plantar flexion. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1066. Chapter 32: Activity - Page 1066 ________________________________________ Question 13: (see full question) When a client is lifted or held by a nurse,the additional weight becomes a part ofthe nurse's weight and should be ... You selected: Correct Explanation: Maintaining balance involves keepingthe spine in vertical alignment,the feet positioned for a broad base of balance, andthe body weight close tothe center of gravity. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1060-1061. Chapter 32: Activity - Page 1060 ________________________________________ Question 14: (see full question) The nurse uses gait belts when assisting patients to ambulate. Which patient would be a likely candidate for this assistive device? You selected: Correct Explanation: The gait belt is used to helpthe patient stand and provides stabilization during pivoting. Gait belts also allowthe nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bedrest. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1064. Chapter 32: Activity - Page 1064 ________________________________________ Question 15: (see full question) The nurse is assisting a patient fromthe bed into a wheelchair. Which ofthe following is a recommended guideline for this procedure? You selected: Putthe chair atthe foot ofthe bed. Incorrect Correct response: Explanation: When assisting a client fromthe bed into a wheelchair,the nurse would placethe bed inthe lowest position and raisethe head ofthe bed to a sitting position.the nurse would make surethe bed brakes are locked and putthe wheelchair next tothe bed, lockingthe brakes ofthe chair. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1102-1105. Chapter 32: Activity - Page 1102 ________________________________________ Question 16: (see full question) The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would bethe nurse's next action? You selected: Correct Explanation: When turning a client in bed,the nurse would use a friction-reducing sheet to pullthe client tothe edge ofthe bed that is oppositethe sidethe client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending onthe individual client. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1095-1098. Chapter 32: Activity - Page 1095 ________________________________________ Question 17: (see full question) The nurse moves a person’s arm from an outstretched position to a position atthe side ofthe patient’s body. What isthe term used to describe this type of body movement? You selected: Correct Explanation: Adduction is a lateral movement of a body part towardthe midline ofthe body. An example of adduction is when a person’s arm is moved from an outstretched position to a position alongsidethe body. Abduction is a lateral movement of a body part away fromthe midline ofthe body. An example of abduction is when a person’s arm is moved away fromthe body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement isthe circling ofthe arm atthe shoulder, as in bowling or a serve in tennis. Extension isthe state of being in a straight line. An example of extension is when a person’s cervical spine is extended,the head is held straight onthe spinal column. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041. Chapter 32: Activity - Page 1041 ________________________________________ Question 18: (see full question) A nurse is recommending aerobic exercise for a patient who is overweight. Which exercise mightthe nurse suggest? You selected: Correct Explanation: The exercise that is aerobic in this question is swimming. Aerobic exercise is also known as cardio exercise.the other options listed are anaerobic exercise. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1082 ________________________________________ Question 19: (see full question) A home care nurse visits a client with Parkinson's disease.the nurse observes thatthe client has rhythmic, repetitive movements ofthe hands.the home care nurse documents this as which ofthe following? You selected: Correct Explanation: Tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. A tremor usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation. Athetosis is movement characterized by slow, irregular, twisting motions. Dystonia is similar to athetosis but usually involves larger areas ofthe body. Ataxia is a general term used to describe impaired muscle coordination. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1047. Chapter 32: Activity - Page 1047 ________________________________________ Question 20: (see full question) Two nurses are moving a client up in bed. What motion wouldthe nurses use to counteractthe client's weight? You selected: Correct Explanation: The nurses would use a rocking motion to counteractthe client's weight.the nurses would shift their weight back and forth, from back leg to front leg, count to three, and then movethe client up towardthe head ofthe bed. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1096. Chapter 32: Activity - Page 1096 Answer Key Question 1: (see full question) Which ofthe following conditions will lead to an increase in cardiac output? You selected: Correct Explanation: Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls. Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 588. Chapter 24: Vital Signs - Page 588 ________________________________________ Question 2: (see full question) A client has smoked most of his life and has labored respirations. He is experiencing You selected: Correct Explanation: Dyspnea describes respirations that require excessive effort. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594. Chapter 24: Vital Signs - Page 594 ________________________________________ Question 3: (see full question) A client being treated for hypertension is monitoring her own BP at home. She was informed bythe nurse to take three measurements at one sitting and average them together to get a BP to record. Her measurements at one sitting were 140/86, 125/78, and 130/82. She wants to know if she averaged them correctly. Which isthe correct average? You selected: 130/82 Incorrect Correct response: Explanation: Ideally it is recommended that when monitoring BP at home,the client should use a validated BP monitor and measurethe BP three times at one sitting and then average them together. To average,the three systolic BPs are added together andthe divided by 3 to get tothe nearest whole number using normal rounding rules. Then addthe three diastolic BP readings and divide that number by 3 also to givethe client an average BP. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604. Chapter 24: Vital Signs - Page 604 ________________________________________ Question 4: (see full question) A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess pulse in this client? You selected: Correct Explanation: An apical pulse is assessed when giving medications that alter heart rate and rhythm. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591. Chapter 24: Vital Signs - Page 591 ________________________________________ Question 5: (see full question) While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes thatthe client's respiratory rate is 8 breaths/minute. How willthe nurse interpret this finding? You selected: Correct Explanation: The normal respiratory rate for adults is 12 to 20 breaths/min. Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depressesthe respiratory center, resulting in slow breathing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594. Chapter 24: Vital Signs - Page 594 ________________________________________ Question 6: (see full question) A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for two weeks. When she calls and reports her BP readings tothe nurse,the nurse notes an elevated BP inthe morning.the client states that she wakes up, has her daily cup of coffee and takes her BP before eating as she was instructed. What shouldthe nurse recommend to this client? You selected: Correct Explanation: A client should be taught to avoid food, coffee, and alcohol 30 minutes before taking a measurement. There is no need for this client to come immediately tothe office; it is usually recommended that clients take their BP inthe morning andthe evening to get a record of BP readings over time. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 603. Chapter 24: Vital Signs - Page 603 ________________________________________ Question 7: (see full question) Which ofthe following sites results in measuring a client's core body temperature? You selected: Correct Explanation: Rectal temperature is considered to bethe most accurate route for obtaining core body temperature. Surface body temperatures are measured at oral (sublingual), temporal, and axillary sites. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p.588. Chapter 24: Vital Signs - Page 588 ________________________________________ Question 8: (see full question) Based upon circadian rhythms, when wouldthe nurse notethe highest temperature during a 24-hour period? You selected: Correct Explanation: Body temperature fluctuates throughoutthe day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582. Chapter 24: Vital Signs - Page 582 ________________________________________ Question 9: (see full question) An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop shortly after getting up from her nap. She followed up with her health care practitioner and was diagnosed with orthostatic hypotension. What isthe most appropriate nursing diagnosis to be included inthe teaching plan for this patient at this time? You selected: Correct Explanation: Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure fromthe sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 597. ________________________________________ Question 10: (see full question) A nurse is assessingthe pulse volume of a client with influenza.the nurse notes thatthe client has a thready pulse. Which ofthe following is a description of a thready pulse? You selected: Correct Explanation: Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 589. Chapter 24: Vital Signs - Page 589 ________________________________________ Question 11: (see full question) An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading? You selected: Correct Explanation: It is not uncommon for elderly persons to have body temperatures less than 97.6° because normal temperature drops as a person ages. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582. Chapter 24: Vital Signs - Page 582 ________________________________________ Question 12: (see full question) The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC).the client states, "I just finished my coffee right before you came in. Can I have another cup?" Which ofthe following responses bythe nurse is most appropriate? You selected: Correct Explanation: Although an inaccurate thermometer may have caused a falsely elevated temperature,the more likely reason is consumption of a hot beverage; drinking another hot beverage would make any other oral thermometer's result inaccurate. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 603. Chapter 24: Vital Signs - Page 603 ________________________________________ Question 13: (see full question) Clients demonstrating apnea have what? You selected: Correct Explanation: Apnea,the absence of respirations, is often described bythe length of time in which respirations do not occur. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594. Chapter 24: Vital Signs - Page 594 ________________________________________ Question 14: (see full question) A client that has been taught to monitor her pulse callsthe nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just belowthe wrist onthe side closest tothe body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What doesthe nurse recognize that she is doing wrong? You selected: Correct Explanation: A client is taught to take his or her own pulse before certain medications or after exercise, depending onthe individual client's needs. When teaching a client to take his or her own pulse,the nurse should teachthe client to sit down and place an arm on a hard service withthe palm upward. Then using three fingers,the client should feel just belowthe wrist onthe outer side ofthe arm forthe pulse.the client should be taught not to press too hard orthe pulse can be obliterated and to use a watch or clock with a second hand to countthe pulse. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604. Chapter 24: Vital Signs - Page 604 ________________________________________ Question 15: (see full question) A nurse is assessing an apical pulse on a cardiac client.the client is taking digoxin, which is a cardiac medication.the nurse can anticipate thatthe digoxin will do what? You selected: Decreasethe blood volume. Incorrect Correct response: Explanation: Some cardiac medications, such as digoxin, whose action is specific tothe work ofthe heart, slowthe heart rate while also strengtheningthe force of contraction to increase cardiac output. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 589. Chapter 24: Vital Signs - Page 589 ________________________________________ Question 16: (see full question) A nurse can most accurately assess a client's heart rate and rhythm by which ofthe following methods? You selected: Correct Explanation: To assessthe apical pulse,the nurse placesthe stethoscope overthe left ventricle.the stethoscope is placed atthe level ofthe fifth intercostals space left mid-clavicular line. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 592. Chapter 24: Vital Signs - Page 592 ________________________________________ Question 17: (see full question) The nurse is taking a rectal temperature on a patient who reports feeling lightheaded duringthe procedure. What would bethe nurse’s priority action in this situation? You selected: Correct Explanation: Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can causethe pulse and blood pressure to drop significantly causingthe patient to feel light-headed; thereforethe thermometer should be removed immediately andthe pulse and blood pressure assessed.the physician can be called after assessingthe patient.the temperature is notthe priority at this time. Assistance for CPR would be determined ifthe patient’s condition worsens. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 588-589 ________________________________________ Question 18: (see full question) A pulse deficit isthe difference between ... You selected: Correct Explanation: When a pulse deficit is present,the radial pulse is always lower thanthe apical pulse rate. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591. Chapter 24: Vital Signs - Page 591 ________________________________________ Question 19: (see full question) A nurse is calculatingthe cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/minute. What number wouldthe nurse document for this assessment? You selected: Correct Explanation: Cardiac output is determined by multiplyingthe stroke volume bythe heart rate/minute, which equals 5,850 mL. Cardiac output and peripheral resistance determine both systolic and diastolic pressures. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 594 ________________________________________ Question 20: (see full question) A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which ofthe following health problems shouldthe nurse consider when client falls occur? You selected: Correct Explanation: Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597. Chapter 24: Vital Signs - Page 597 Answer Key Question 1: (see full question) When teaching a client about factors that may increase his or her BP readings, what shouldthe nurse include inthe teaching plan? Select all that apply. You selected: Correct Explanation: Some factors that may causethe BP to increase include age, circadian rhythm (late afternoon), food, exercise, weight (obesity), emotional state, race, and medications. Female gender before menopause and prone body position are usually associated with lower BP readings. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 596. Chapter 24: Vital Signs - Page 596 ________________________________________ Question 2: (see full question) A nurse applies a cuff ofthe automated blood pressure device aroundthe client's arm in preparation for serial blood pressure recordings.the nurse checksthe cuff frequently based on which rationale? You selected: Promote speedy venous return tothe heart Incorrect Correct response: Explanation: When using electronic automated blood pressure devices for serial blood pressure recording, frequently checkingthe cuffed limb ensures adequate arterial perfusion and venous drainage between measurements.the nurse does not checkthe cuffed limb to see if it is warm or cold, but to ensure that there is adequate arterial perfusion and venous drainage between measurements. Elevatingthe arm abovethe head between cuff measurements automatically speeds venous return tothe heart. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599. Chapter 24: Vital Signs - Page 599 ________________________________________ Question 3: (see full question) A nurse is assessingthe blood pressure of a team of healthy athletes atthe heath care facility. Which ofthe following observations can be made bythe nurse and athletes by measuringthe blood pressure? You selected: Correct Explanation: Measuringthe blood pressure helps to assessthe efficiency ofthe client's circulatory system. Blood pressure measurements reflectthe ability ofthe arteries to stretch,the volume of circulating blood, andthe amount of resistancethe heart must overcome when it pumps blood. Measuringthe blood pressure does not help in assessingthe thickness of blood, oxygen level inthe blood, orthe volume of air enteringthe lungs. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597. Chapter 24: Vital Signs - Page 597 ________________________________________ Question 4: (see full question) What isthe pulse pressure of a client whose blood pressure is 132/82 mm Hg? You selected: Correct Explanation: Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction.the numerator isthe systolic pressure;the denominator isthe diastolic pressure.the difference betweenthe two is calledthe pulse pressure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594. Chapter 24: Vital Signs - Page 594 ________________________________________ Question 5: (see full question) A nurse is assessingthe blood pressure of a client usingthe Korotkoff sound technique.the nurse notes thatthe phase I sound disappears for 2 seconds. What shouldthe nurse document onthe progress record? You selected: Correct Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening inthe diameter ofthe artery takes place inthe phase II ofthe Korotkoff sound technique. An adult diastolic pressure takes place inthe phase IV ofthe Korotkoff sound technique. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 601. Chapter 24: Vital Signs - Page 601 ________________________________________ Question 6: (see full question) The nurse is assessing a patient’s brachial artery blood pressure. Which nursing actions are performed correctly? (Select all that apply.) You selected: •the nurse notesthe point onthe gauge at whichthe first faint but clear sound appears •the nurse centersthe bladder ofthe cuff overthe brachial artery about midway onthe arm. •the nurse hasthe patient lying or sitting down withthe forearm supported atthe level ofthe heart andthe palm ofthe hand upward. Incorrect Correct response: Explanation: Pressure inthe cuff applied directly tothe artery providesthe most accurate readings. BP measured withthe arm belowthe level ofthe right atrium ofthe heart may produce a falsely high reading; if belowthe level ofthe heartthe readings may be falsely too low. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. Placingthe cuff overthe patient’s clothing prevents hearingthe blood pressure accurately.the first faint but clear sound isthe systolic pressure. False readings are likely to occur if there is congestion of blood inthe limb while obtaining repeated readings that are less than 1 minute apart. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 616-619 ________________________________________ Question 7: (see full question) A nurse is assessingthe respirations of a 60-year-old female patient and finds thatthe patient is breathing so shallowly thatthe respirations cannot be counted. What would bethe appropriate initial nursing intervention in this situation? You selected: Correct Explanation: Ifthe respirations are too shallow to count it is easier to count respirations by auscultatingthe lung sounds.the nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculatethe respiratory rate per minute. Ifthe respiratory rate is irregular,the nurse should count for a full minute.the nurse notifiesthe physician ofthe respiratory rate andthe shallowness ofthe respirations following assessment. Pain typically causes vital signs to elevate.the nurse cannot administer oxygen without a physician’s order. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 615 ________________________________________ Question 8: (see full question) You are preparing to assess a patient's oral temperature. You should plan to placethe thermometer probe in which ofthe following areas ofthe patient's mouth? You selected: Correct Explanation: Whenthe probe rests deep inthe posterior sublingual pocket, it is in contact with blood vessels lying close tothe surface. None ofthe other areas provide as much contact with blood vessels. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 611. Chapter 24: Vital Signs - Page 611 ________________________________________ Question 9: (see full question) The nurse is teachingthe parents of an infant with an irregular heartbeat how to checkthe pulse rate.the infant’s pulse is very high and irregular. What willthe nurse have to do in order to teach these parents how to monitor their infant’s pulse rate? You selected: Correct Explanation: If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid,the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is alsothe preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor,the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant’s pulse accurately. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 590. Chapter 24: Vital Signs - Page 590 ________________________________________ Question 10: (see full question) The nurse places a client experiencing labored breathing in an upright position.the nurse notes thatthe client is able to breathe more easily in this upright position and documents this condition onthe chart as which ofthe following? You selected: Correct Explanation: Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs fromthe abdominal cavity away fromthe diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to periods during which there is no breathing. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594. Chapter 24: Vital Signs - Page 594 CHAPTER 23 FUNDAMENTALS: ACTIVITY articulation, joint The terms ______ and ______ refer to wherethe bone meet.  skeletal The framework of bones,the joints between them, and cartilage that protects our organs and allows us to move is calledthe ______ system.  skeletal Functions ofthe ______ system include: supportingthe soft tissue ofthe body maintaining body form and posture; protecting crucial components ofthe body such asthe brain, lungs, heart, and spinal cord; furnishing surfaces forthe attachment of muscles, tendons, and ligaments, which pull onthe individual bones to produce movement; providing storage for minerals like calcium and fat; and producing blood cells through hemopoiesis.  long _______ bones are found inthe upper and lower extremities and contribute to height and length. Ex: femur, humerus.  short ______ bones are located inthe wrist and ankle and contribute to movement.  flat _______ bones are relatively thin and contribute to shape (structural contour). Ex: ribs and several skull bones.  irregular ______ bones are all those bones not included inthe long, short, or flat classifications. Ex: bones ofthe spinal column and jaw.  diarthrosis _______, or synovial joints, joints in which there is aa potential space betweenthe articulating bones, are freely moving joints.  ball and socket ______ joints are freely movable joints wherethe rounded head of one bone fits into a cup-like cavity inthe other; flexion-extensionabduction-adduction, and rotation can occur. Ex: shoulder and hip joints.  condyloid ______ joints are freely movable joints wherethe oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur. Ex: wrist joint.  gliding ______ joints are freely movable joints where articular surfaces are flat; flexion-extension and abduction-adduction can occur. Ex: carpal bones of wrist and tarsal bones of feet.  hinge ______ joints are freely movable joints where a spool-like surface of one bone fits into a concave surface of another bone; only flexion-extension can occur. Ex: elbow, knee, ankle joints.  pivot ______ joints are freely movable joints where a ringlike structure turns on a pivot; movement is limited to rotation, for example, turning a door knob. Ex: joints betweenthe atlas and axis and betweenthe proximal ends ofthe radius andthe ulna.  saddle ______ joints are freely movable joints where bone surfaces are convex on one side and concave onthe other; movements are side to side and back and forth. Ex: joint betweenthe trapezium and metacarpal ofthe the thumb.  diarthrodal Movements possible at _______ joints include abduction, adduction, flexion, extension, and rotation.  fibrous _______ joints are immovable (synarthrosis) joints where there is no joint cavity; connective tissue betweenthe bones. Ex: sutures betweenthe bones ofthe skull.  cartilaginous ______ joints are slightly movable (amphiarthrosis) joints where there is no joint cavity; cartilage betweenthe bones. Ex: pubic symphysis, joints betweenthe bodies of vertebrae.  synovial ______ joints are freely movable (diarthrosis) joints where there is a joint cavity containing fluid. Ex: gliding, hinge, pivot, condyloid, saddle, ball and socket joints.  ligaments _______ are tough fibrous bands of connective tissue that bind joints together and connect bones and cartilage.  tendons _______ are strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone.  cartilage _______ is hard, non-vascular connective tissue found inthe joints as well as inthe nose, ear, thorax, trachea, and larynx. It functions as a shock absorber and as a bearing surface that reduces friction betweenthe moving parts ofthe joint.  skeletal ______ muscle works with tendons and bones to movethe body.  cardiac ______ muscle formsthe bulk ofthe heart and producesthe regular contractions that createthe heartbeat.  smooth (visceral) _______ muscle formsthe walls ofthe hollow organs, such asthe stomach and intestines, and is inthe walls of blood vessels and other hollow tubes, such as ureters, that connect internal organs.  afferent The ______ nervous systems conveys information from receptors inthe periphery ofthe body tothe CNS. Ex: light pressure onthe nose.  efferent The ______ system conveysthe response formthe CNS to skeletal muscles by way ofthe somatic nervous system. Ex: muscle inthe arm, wrist and hand contract, andthe fingers brush a fly fromthe face.  labyrinthine ______ sense isthe sense of position and movement is provided bythe sensory organ inthe inner ear, which are stimulated by body movement (changes in head position) and transmit these impulses tothe cerebellum.  proprioceptor (kinesthetic) ______ sense informsthe brain ofthe location of a limb or body part as a result of joint movement stimulating special nerve endings in muscles, tendons, and fascia.  visual (optic) _______ reflexes impressions contribute to posture by alertingthe person to spatial relationship withthe environment (nearness of ceilings, walls, furniture, condition ofthe floor, etc.)  extensor (stretch) _______ reflexes; when they are stretched beyond a certain point (when knees buckle under), their stimulation causes a reflex contraction that aids a person to re-establish erect posture (straightenthe knee).  patient _______ care ergonomics isthe practice of designing equipment and work tasks to conform tothe capability ofthe worker in relation to patient care.  orthopedics ______ refers tothe correction or prevention of disorders of body structure used in locomotion.  tonus A patient on complete bed rest is in danger of losing muscle ______, which is usedthe state of slight contraction.  contractures If bed rest is prolonged there is danger of developing ______ which is permanent contraction of a muscle ifthe patient does not have exercise and joint motion and if good posture is not maintained.  negative Disease characterized by a larger breakdown of protein than that which is manufactured leads to _______ nitrogen balance (anorexia nervosa and certain cancers) that results in muscle wasting and decreased physical energy for movement and work.  b A client 80 years of age experienced dysphagia (impaired swallowing) inthe weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How shouldthe nurse best positionthe client? a) Semi-Fowler's b) Fowler's c) Low-Fowler's d) Protective supine  a The nurse is helping a client walk inthe hallway whenthe client suddenly reaches forthe handrail and states, "I feel so weak. I think I am going to pass out." Which ofthe following initial actions bythe nurse is appropriate? a) Supportthe client's body against yours and gently slidethe client ontothe floor. b) Firmly graspthe client's gait belt. c) Apply oxygen and wait several minutes forthe weakness to pass. d) Askthe client to lean againstthe wall while you obtain a wheelchair. e) Askthe patient, "When wasthe last time you ate?"  d A nurse is providing care for a client who has been newly admitted tothe long-term care facility. What isthe primary criterion forthe nurse's decision whether to use a mechanized assistive device for transferringthe client? a)the client's age b)the client's cognitive status c)the client's body weight d)the client's ability to assist  b The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would bethe nurse's next action? a) Pushthe client tothe edge ofthe bed to whichthe client will be turning. b) Movethe client to edge ofthe bed oppositethe side that client will be turning. c) Pullthe client tothe edge ofthe bed to whichthe patient will be turning. d) Pushthe client tothe opposite side ofthe bed.  a A patient is preparing to mobilize forthe first time followingthe surgical removal of a bunion on her left foot. How shouldthe nurse instructthe patient to ambulate with her crutches? a) "Try to avoid putting too much pressure on your armpits withthe tops ofthe crutches." b) "Keep your crutches as close as possible to your feet when you're walking." c) "When you rise from a chair, use your left foot to stabilize yourself." d) "Keep your elbows well away from your sides in order to keep yourself as stable as possible."  c A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which ofthe following nursing actions is most likely to promote safe handling of this client? a) Post written instructions atthe client's bedside to supplement spoken instructions. b) Ask forthe client's feedback frequently during transfers. c) Provide tothe client brief, clear instructions that are phrased positively. d) Ask forthe client's input onthe timing and technique for transfers.  c A nurse teaches a student nursethe importance of ambulating patients to preventthe effects of immobility on body systems. Which ofthe following is one of these effects? a) Decreased cardiac workload b) Increased appetite c) Impaired circulation d) Increased muscle mass  b, c, f Select all answer choices that apply. A nurse is teaching an elderly patient how to use a walker. Which ofthe following instructions ensures accurate use of this device? Select all that apply. a) Movethe walker forward 12 to 18 inches and set it down. b) Line upthe top ofthe walker withthe crease onthe inside of your wrist. c) Keep arms relaxed atthe side. d) Step forward with your right foot supporting weight on your legs. e) Place your hands onthe grips and flex your elbows about 10 degrees. f) Stand betweenthe back legs ofthe walker.  c A nurse is preparing to turn a hospitalized client age 65 years. Which ofthe following is a recommended guideline for performing this skill? a) Use back muscles to pullthe client tothe side. b) Position a nurse atthe top and bottom ofthe bed. c) Position a friction-reducing sheet underthe client. d) Placethe bed in its lowest position.  isotonic ______ exercise involves muscle shortening and active movement. Ex: ADL, swimming, walking, jogging, biking.  isometric ______ exercise involves muscle contraction without shortening. Ex: contraction ofthe quads and gluteal muscles.  isokinetic ______ exercise involves muscle contraction with resistance.the resistance is provided at a constant rate by an external device, which has a capacity for variable resistance. Ex: rehabilitation for knee and elbow injuries and lifting weights; weight training.  d While performing passive range-of-motion exercises onthe lower extremities of a patient with a spinal cord injury,the nurse assesses permanent flexion ofthe muscles. What term willthe nurse use to document this finding related tothe muscles? a) Ankylosis b) Tonus c) Atrophy d) Contractures  ankylosis _______ is a consolidation and immobilization of a joint.  b The nurse is preparing to move a patient using a powered full-body sling lift. Which ofthe following is a recommended action in this procedure? a) Placethe sling evenly on top ofthe patient. b) Lowerthe side rail onthe side ofthe bed being worked on. c) Rollthe patient tothe middle ofthe bed. d) Lowerthe side rail onthe opposite side ofthe bed being worked on.  b The nurse is preparing a client to be turned in bed. In what position wouldthe nurse placethe client to begin this procedure? a) Lying prone b) Lying flat c) Lying flat with feet raised slightly d) Sitting up  c After positioning a client to move fromthe bed into a wheelchair, how wouldthe nurse stand when helpingthe client to sit up onthe side ofthe bed? a) Tothe dominant side ofthe client, with legs together and one foot nearthe head ofthe bed b) Nearthe client's hip, with legs together c) Nearthe client's hip, with legs shoulder-width apart and one foot nearthe head ofthe bed d) Tothe nondominant side ofthe client, with legs together and one foot nearthe head ofthe bed.  d During a physical examination,the patient reports that he is a marathon runner whenthe nurse inquires aboutthe patient's level of physical activity.the nurse identifies running as which type of exercise? a) Passive exercise b) Isometric exercise c) Isokinetic exercise d) Isotonic exercise  c Which ofthe following is an accurate step to prevent or minimize damage from this fall? a)the nurse should graspthe gait belt and pullthe client's body backward away from his or her body. b)the nurse should place his or her feet close together with one foot in front ofthe other. c)the nurse should gently slidethe client down his or her body tothe floor. d)the nurse should rock his or her pelvis out onthe opposite side ofthe client.  paresis Impaired muscle strength or weakness is termed _____.  paralysis The absence of strength secondary to nervous impairment is called ______.  b When an older adult client walks with her knees slightly flexed and body leaning,the nurse determines thatthe client ... a) requires a better walking shoe b) is demonstrating a common gait forthe older adult c) should have an orthopedic consultation d) requires crutches for mobility  a When a patient independently moves all ofthe joints through their normal motions, it is referred to as active range of motion (AROM). a) True b) False  tremors ______ are rhythmic, repetitive movements that can occur at rest or when movement is initiated. They usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation.  b A home care nurse visits a client with Parkinson's disease.the nurse observes thatthe client has rhythmic, repetitive movements ofthe hands.the home care nurse documents this as which ofthe following? a) Dystonia b) Tremor c) Ataxia d) Athetosis  c A client who is immobile complains of severe pain inthe right flank.the physician diagnosesthe client with renal calculi. This condition often results from a) Increased serum phosphorous b) Decreased serum phosphorous c) Increased serum calcium d) Decreased serum calcium  calculi Urinary stasis and an increased serum calcium level promotethe formation of renal _______.  d Whenthe client restricts use of her dominant arm because of pain andthe nurse notes thatthe measurement ofthe circumference ofthe client's nondominant arm is greater than her dominant arm,the nurse determines thatthe lack of use has resulted inthe dominant arm's a) Dystrophy b) Hypertrophy c) Malrotation d) Atrophy  b A nurse is teaching a patient how to walk with a cane. Which ofthe following is an accurate guideline for using this device? a)the patient should holdthe cane inthe hand onthe same side asthe leg withthe most severe deficit. b) When taking a step forward,the heel ofthe foot should be slightly beyondthe tip ofthe cane. c)the patient should stand with as much weight as possible placed onthe feet, usingthe cane for balance. d) When taking a step,the patient should advancethe stronger leg forward ahead ofthe cane and follow withthe weaker leg.  d The cardiac response to exercise is well-researched and documented. Which ofthe following is a cardiovascular response to regular exercise? a) Decreased circulation of fibrinolysin b) Increased heart rate and blood pressure c) Decreased blood flow to all body parts d) Increased efficiency ofthe heart  exercise Regular ______ produces cardiovascular responses such as an increased efficiency ofthe heart, decreased heart rate and blood pressure, increased blood flow to all body parts, and increased circulation of fibrinolysin.  d Two nurses are moving a client up in bed. What motion wouldthe nurses use to counteractthe client's weight? a) Shift their weight back and forth fromthe legs tothe back muscles. b) Rockthe client back and forth to raisethe client up in bed. c) Turnthe client from side to side while pushing upward. d) Shift their weight back and forth, from back leg to front leg.  a When turning a patient in bed, what positioning instructions wouldthe nurse givethe patient before usingthe friction-reducing sheet to turnthe patient? a) Crossthe arms acrossthe chest and crossthe legs. b) Crossthe arms acrossthe chest and keepthe legs straight. c) Keepthe arms atthe sides andthe legs crossed. d) Keepthe arms folded loosely atthe abdomen andthe legs straight.  a When assisting a client fromthe bed into a wheelchair,the nurse assessesthe client standing up and noticesthe client is weak and unsteady. What would bethe recommended nursing intervention in this situation? a) Returnthe client tothe bed. b) Placethe client intothe wheelchair. c) Usethe call bell to summonthe assistance of another nurse. d) Allowthe client to keep standing for several minutes until balance returns.  b A group of nursing students are reviewingthe aspects of motor function control bythe nervous system.the students demonstrate understanding of this information when they identify which ofthe following as a function ofthe cerebellum? a) Transmissing of impulses tothe spinal cord b) Coordination of movement motor activities c) Inhibition with dampening of impulses d) Initiation of voluntary motor activity  cerebellum The ______ coordinates motor activities of movement.  cerebral cortex The _______ initiates voluntary motor activity.  pyramidal, extrapyramidal The ________ tract transmits impulses tothe spinal cord.the ________ tract inhibits and dampens impulses.  c A client who is postoperative from a hip fracture repair should be turned on the a) Affected side b) Back c) Unaffected side d) Stomach  d An orthopedic client is instructed to tightenthe gluteus muscles and relax. This is an example of an a) Anaerobic exercise b) Isotonic exercise c) Aerobic exercise d) Isometric exercise  isometric ______ exercise is static exercise by whichthe client tenses a muscle, holding it stationary while maintaining tension.  b Once applied, antiembolism stockings should not be removed untilthe primary care provider writes an order to discontinue them. a) True b) False  c The nurse is teaching a patient how to perform range-of-motion exercises onthe toes. What motions would be accomplished by curlingthe toes downward, spreadingthe toes apart, and then bringing them together? a) Rotation, extension, abduction, and adduction b) Rotation, dorsiflexion, and plantar flexion c) Flexion, extension, abduction, and adduction d) Flexion, inversion, and eversion  a For which one ofthe following patients would a pneumatic compression device (PCD) be indicated? a) A postoperative patient with a knee replacement who has a history of cancer b) A postoperative patient suspected of having deep vein thrombosis (DVT) c) A postoperative patient with arterial occlusive disease d) A patient with severe edema following a hip replacement  PCD (pneumatic compression device) ______'s are contraindicated in patients with suspected or existing DVT. They should not be used for patients with arterial occlusive disease, severe edema, cellulitis, phlebitis, a skin graft, or an infection ofthe extremity.  d The nurse has askedthe client to grasp his overbed trapeze and pull his torso up offthe surface ofthe bed. What movement willthe client perform with his arms? a) Adduction b) Abduction c) Dorsiflexion d) Flexion  flexion ______ is achieved when a body part is bent, as whenthe elbow is bent andthe upper arm and forearm are brought together.  adduction, abduction ______ and ______ denote lateral movement to and fromthe body, and dorsiflexion is backward bending ofthe hand or foot.  c A client is discharged to his daughter's home. He weighs 250 pounds and is immobile.the nurse should instructthe daughter onthe use of a a) Three-person lift b) Transfer with a gait belt c) Hydraulic lift d) Stand-up assist lift  d When transferring a client from bed to a stretcher,the nurses working together turnthe client to position a transfer board partially underneaththe patient. What isthe rationale for using a transfer board in this procedure? a) To protectthe client's head from hittingthe headboard. b) To liftthe client offthe bed. c) To slidethe board withthe client ontothe stretcher. d) To reduce friction asthe client is pulled laterally ontothe stretcher.  a A nurse uses proper body mechanics to move a client up in bed. Which ofthe following is a guideline for using these techniques properly? a) Facethe direction of movement. b) Twist body atthe waist when lifting. c) Keep feet together to provide a base of support. d) Keep body weight higher than center of gravity.  b The physician's admitting orders indicate thatthe client is to be placed in a Fowler's position. Upon positioning this client, how much willthe nurse elevatethe head ofthe bed? a) 90 degrees b) 45 to 60 degrees c) 30 degrees d) 15 to 20 degrees  d While receiving a report,the nurse learns that a client has paraplegia.the nurse will plan care for this client based uponthe understanding thatthe client has which ofthe following? a) Paralysis affecting one-half ofthe body b) Weakness affecting one-half ofthe body c) Paralysis ofthe legs and arms d) Paralysis ofthe legs  b When teaching range-of-motion exercises to a caregiver, a nurse movesthe arm ofthe patient laterally to an upright position abovethe head, and then returns it tothe original position. What term is used to describe this body movement? a) Extension b) Abduction c) Flexion d) Rotation  c What motion is being provided forthe shoulder whenthe nurse raises a patient's arm atthe side untilthe upper arm is in line withthe shoulder, bendsthe elbow at a 90-degree angle, movesthe forearm upward and downward, and returnsthe arm tothe side? a) Abduction b) Adduction c) Rotation d) Flexion  a A nurse is teaching a patient how to walk with a cane. Which ofthe following is an accurate guideline for using this device? a) When taking a step forward,the heel ofthe foot should be slightly beyondthe tip ofthe cane. b) When taking a step,the patient should advancethe stronger leg forward ahead ofthe cane and follow withthe weaker leg. c)the patient should holdthe cane inthe hand onthe same side asthe leg withthe most severe deficit. d)the patient should stand with as much weight as possible placed onthe feet, usingthe cane for balance.  d Which ofthe following wouldthe nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured? a.Fluid volume excess b. A contracture c. Osteoporosis d. Negative nitrogen balance  b When a patient is using a cane for maximal support, the nurse is aware thatthe patient should do which of the following? a. Holdthe cane onthe weaker side b. Distribute weight evenly betweenthe feet and the cane c. Keepthe elbow that is holdingthe cane straight and stiff d. Advancethe weaker foot ahead ofthe cane  a The nurse is turning a patient in bed. Where wouldthe nurse stand when usingthe friction-reducing sheet to turnthe patient tothe opposite side ofthe bed? a) Oppositethe patient's center. b) Atthe patient's center. c) Atthe patient's head. d) Atthe patient's feet.  d Which ofthe following clients would be an appropriate candidate to move by using a powered stand-assist device? a) A comatose client who is being taken for x-rays b) A car accident victim with fractures in both legs who is being moved to another room c) An obese client who has Alzheimer's disease and is being escorted tothe shower room d) An alert client after knee replacement surgery who is being assisted to ambulate  b The nurse recognizesthe value of passive range-of-motion exercises inthe care of patients who have been confined to bed for extended periods.the nurse should use particular caution if performing these exercises with which patients? a) Elderly patients b) Nonresponsive patients c) Obese patients d) Acutely ill patients  c, e, f Select all answer choices that apply. Which ofthe following are effects of immobility onthe body? Select all that apply. a) Cerumen buildup b) Decreased anal tone and sensation c) Impaired circulation and skin breakdown d) Diminished saliva production e) Urinary stasis, infection f) Decreased muscle strength  b The nurse is helping a patient with musculoskeletal alterations to perform range-of-motion exercises. In what order wouldthe nurse performthe exercises forthe patient? a) Fromthe feet, tothe arms, tothe head. b) Fromthe head and down one side ofthe body at a time. c) Fromthe head, tothe arms, tothe legs. d) Fromthe arms, tothe head, tothe legs. Answer Key Question 1: (see full question) The nursing assistant is preparing to helpthe client make a lateral transfer fromthe bed to a stretcher.the client informsthe nurse that he is able to move ontothe stretcher without her help. What isthe nurse's best response? You selected: "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin." Incorrect Correct response: Explanation: Ifthe client is fully able to assist inthe transfer,the nurse should allowthe client to completethe movement independently, with supervision for safety. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1071-1072. Chapter 32: Activity - Page 1071 ________________________________________ Question 2: (see full question) After positioning a client to move fromthe bed into a wheelchair, how wouldthe nurse stand when helpingthe client to sit up onthe side ofthe bed? You selected: Correct Explanation: When assistingthe client fromthe bed into a wheelchair,the nurse would take position nearthe client's hip, with legs shoulder-width apart and one foot nearthe head ofthe bed. This ensures thatthe nurse's center of gravity is placed nearthe client's greatest weight, to assistthe client to a sitting position safely. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1102-1105. Chapter 32: Activity - Page 1102 ________________________________________ Question 3: (see full question) During range-of-motion exercises,the nurse turnsthe sole of a patient's foot towardthe midline and then turnsthe sole ofthe foot outward. Which type of movement is this nurse promoting by these actions? You selected: Internal and external rotation ofthe ankle Incorrect Correct response: Explanation: Inversion and eversion are movements ofthe ankle. Inversion isthe movement ofthe sole ofthe foot inward. Eversion isthe movement ofthe sole ofthe foot outward. Internal rotation isthe turning of a body part on its axis towardthe midline ofthe body. External rotation isthe turning of a body part on its axis away fromthe midline ofthe body. Dorsiflexion isthe backward bending ofthe hand or foot. Plantar flexion is flexion ofthe foot. Flexion isthe state of being bent. Extension isthe state of being in a straight line. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041. Chapter 32: Activity - Page 1041 ________________________________________ Question 4: (see full question) When working with a client who has a fractured wrist,the nurse applies what knowledge aboutthe bones inthe body? You selected: The wrist is classified as an irregular bone. Incorrect Correct response: Explanation: Short bones contribute to movement and are located inthe wrist and ankle.the wrist is classified as a short bone. Long bones, such asthe femur and humerus, are located inthe upper and lower extremities and contribute to height and length.the flat bones are relatively thin and contribute to shape.the flat bones are found inthe ribs and several ofthe skull bones and contribute to shape (structural contour). (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1038. Chapter 32: Activity - Page 1038 ________________________________________ Question 5: (see full question) The nurse is assisting an elderly client with dementia to get dressed after morning care. Which statement would be most beneficial tothe patient? You selected: Correct Explanation: When communicating with client’s with dementia, instructions should be given in clear, short sentences that offer simple, step-by-step instructions. “Put your arm in this sleeve” gives one step inthe process of getting dressed. “Put on your shirt” involves many steps and should be broken down intothe steps of putting on a shirt. Similarly, “Put your pants on and zipthe zipper,” should be broken down into steps and given in clear, short sentences. Further, putting on pants and zipping a zipper involves many steps and may be too complicated forthe client with dementia to follow. Instructions should be phrased positively asthe client may not registerthe “Don’t” and may putthe shoes on, ifthe nurse states “Don’t put on your shoes yet.” (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1061. Chapter 32: Activity - Page 1061 ________________________________________ Question 6: (see full question) When an older adult client walks with her knees slightly flexed and body leaning,the nurse determines thatthe client ... You selected: Correct Explanation: Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor isthe shift inthe center of gravity. To compensate for this shift,the knees flex slightly for support. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 7: (see full question) A nurse is teaching a patient how to walk with crutches. Which teaching points are recommended guidelines for this activity? (Select all that apply.) You selected: • Keep elbows close to sides. • Prevent crutches from getting closer than 3 inches tothe feet. • Usethe swing-to gait for patients who may bear weight on one foot. Incorrect Correct response: Explanation: The client should keepthe elbows close to their sides.the crutches should not be any closer than 12 inches fromthe feet.the client should usethe four-point gait if they can bear weight on both feet. When climbing stairs,the client should advancethe unaffected leg pastthe crutches, then place weight onthe unaffected leg. Thenthe client should advancethe affected leg and thenthe crutches tothe step.the swing-to gait is for individuals who can bear weight on both feet. This technique cannot be used with individuals who can bear weight on only one foot.the two-point gait is used with individuals who can bear weight on both feet. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1079. Chapter 32: Activity - Page 1079 ________________________________________ Question 8: (see full question) One ofthe most common injuries/risks associated with exercise in a healthy person is: You selected: Correct Explanation: Orthopedic problems caused by irritation of bones, tendons, ligaments, and sometimes muscles arethe most common injuries associated with exercise. With exercise, healthy individuals benefit from improved respiratory functioning, including improved alveolar ventilation, decreased work of breathing and improved diaphragmatic excursion. Major cardiac events in a healthy person is minimal, althoughthe risk is much higher for those with known or suspected cardiovascular disease.the rhythmic contraction and relaxation of muscle groups during exercise results in increased muscle mass, tone, strength, and increased joint mobility. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1051. Chapter 32: Activity - Page 1051 ________________________________________ Question 9: (see full question) The nurse is assisting a patient fromthe bed into a wheelchair. Which ofthe following is a recommended guideline for this procedure? You selected: Correct Explanation: When assisting a client fromthe bed into a wheelchair,the nurse would placethe bed inthe lowest position and raisethe head ofthe bed to a sitting position.the nurse would make surethe bed brakes are locked and putthe wheelchair next tothe bed, lockingthe brakes ofthe chair. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1102-1105. Chapter 32: Activity - Page 1102 ________________________________________ Question 10: (see full question) The nurse is assisting a client with limited mobility to turn in bed. After successfully turningthe client tothe side, where wouldthe nurse place an additional pillow? You selected: Correct Explanation: The nurse would placethe pillow underthe client's back to provide support and help maintainthe proper position. More than one pillow underthe client’s head is not necessary. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1095-1098. Chapter 32: Activity - Page 1095 ________________________________________ Question 11: (see full question) The nurse is preparing a client to be turned in bed. In what position wouldthe nurse placethe client to begin this procedure? You selected: Correct Explanation: The nurse would positionthe bed so thatthe client is lying flat on his/her back and then raisethe bed to a comfortable working height. This facilitates movingthe client tothe side in order to performthe turn in bed. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1071. Chapter 32: Activity - Page 1071 ________________________________________ Question 12: (see full question) Logrolling requiresthe nurse to use supportive devices in turningthe client, in order to ... You selected: Correct Explanation: Logrolling is a technique used for turning clients who have had surgery or an injury involvingthe back or spine. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1073. Chapter 32: Activity - Page 1073 ________________________________________ Question 13: (see full question) The client is ambulating inthe room and walks around a bedside table. What isthe best explanation for whythe client does not bump intothe table? You selected: Correct Explanation: The client has awareness of spatial relationships (where objects are located in space). This ability comes fromthe visual or optic reflexes.the labyrinthine sense relates tothe sensory organs inthe inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space. Whenthe extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture, such as whenthe knee buckles under,the reflex contraction aidsthe person to straightenthe knee. This does not contribute to perception of where objects are in space. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1043. Chapter 32: Activity - Page 1043 ________________________________________ Question 14: (see full question) A client with a hip fracture is returning tothe orthopedic unit, andthe orders indicate thatthe client should be turned by logrolling. What statement is correct regarding logrolling? You selected: Correct Explanation: Logrolling requiresthe assistance of two or three nurses. Logrolling will maintain straight alignment whenthe client is being turned.the nurse should avoid twistingthe client's head, spine, shoulders, knees, or hips while logrolling.the nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1072-1073. Chapter 32: Activity - Page 1072 ________________________________________ Question 15: (see full question) A nurse performing range of motion exercises on a bed-fast patient movesthe patient’s chin down ontothe chest and then back to an upright position.the nurse then tiltsthe head as far as possible to each shoulder. What therapeutic movement isthe nurse achieving with this exercise? You selected: Correct Explanation: When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keepthe body in straight alignment when turningthe client. Two or three nurses can accomplish this safely by logrolling a patient. Do not try to logrollthe client without enough help. Do not twistthe client’s head, spine, shoulders, knees, or hips while logrolling. A friction-reducing sheet is used for other transfers, but not withthe logrolling technique.the nurse would have a client cross their arms on their chest with other transfers, but not withthe logrolling technique. A nurse should be on both sides ofthe bed of a client who is being logrolled, not just onthe side thatthe client is being turned. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1072. Chapter 32: Activity - Page 1072 ________________________________________ Question 16: (see full question) A nurse performing range-of-motion exercises on a bedfast patient movesthe patient's chin down ontothe chest and then back to an upright position.the nurse then tiltsthe head as far as possible to each shoulder. What therapeutic movement isthe nurse achieving with this exercise? Select all that apply. You selected: Correct Explanation: Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints particularly weight-bearing joints, characterized bythe deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction betweenthe moving parts ofthe joint. Ifthe client experienced a fall and subsequent hip fracture, mobility would be more impaired.the client would have difficulty walking. Also, this does not addressthe client’s question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answerthe client’s question of why there is pain. Further, although it is also true that loss of muscle tone is common as people age, it may cause weakness, but not cause pain with walking. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 17: (see full question) Which type of mobility aids would be most appropriate for a client who has poor balance? You selected: A single-ended cane with a straight handle Incorrect Correct response: Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness becausethe handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 32: Activity, p. 1078. Chapter 32: Activity - Page 1078 ________________________________________ Question 18: (see full question) The nurse is assessing a patient who is bedridden. For which condition wouldthe nurse consider this patient to be at risk? You selected: Correct Explanation: In a bedridden client,the kidneys and ureters are level, and urine remains inthe renal pelvis for a longer period of time before gravity causes it to move intothe ureters and bladder. Urinary stasis favorsthe growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increasethe risk for urinary tract infection in an immobile patient. Immobility also predisposesthe patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone;the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume.the client would be at risk for decreased movement of secretion inthe respiratory tract, due to lack of lung expansion.the client would suffer from decreased metabolic rate due to being bedridden.the client would not have an increase in circulating fibrinolysin. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1053. Chapter 32: Activity - Page 1053 ________________________________________ Question 19: (see full question) The nurse would like to elevatethe client’s arms to promote ventilation in a client with chronic obstructive pulmonary disease. What intervention shouldthe nurse implement? You selected: Correct Explanation: A small pillow may be used to elevatethe extremities, shoulders, or incisional wounds. Instructingthe client to placethe arms onthe side rails will place pressure onthe arms and affect circulation tothe extremity. Elevatingthe head ofthe bed (fowler’s) will not elevatethe arms. Trochanter rolls are used to supportthe hips and legs so thatthe femurs do not rotate outward. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 8:the Healthcare Delivery System, p. 60 ________________________________________ Question 20: (see full question) When assessingthe physical activity of clients,the nurse would be most concerned about which client? You selected: Correct Explanation: Although further assessments should be done to avoid assumptions and stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive.the nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work.the mother of small children would be involved in housecleaning and chasing afterthe 2- and 4-year old. Walking is a commonly prescribed exercise and going tothe mall provides a safe environment where walking would be available. A Native American who hunts is engaging in culturally related physical activity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1054. Chapter 32: Activity - Page 1054 Chapter 23: Activity A group of nursing students are reviewingthe aspects of motor function control bythe nervous system.the students demonstrate understanding of this information when they identify which ofthe following as a function ofthe cerebellum? a) Coordination of movement motor activities b) Initiation of voluntary motor activity c) Transmissing of impulses tothe spinal cord d) Inhibition with dampening of impulses Answer: Coordination of movement motor activities Explanation:the cerebellum coordinates motor activities of movement.the cerebral cortex initiates voluntary motor activity.the pyramidal tract transmits impulses tothe spinal cord.the extrapyramidal tract inhibits and dampens impulses.  A nurse recommends a regular exercise program for a patient who has difficulty sleeping.the patient asks how this will help. How wouldthe nurse respond? a) "Exercise can help you control your weight." b) "The fresh air will stimulate your metabolism." c) "Take my word for it. It sure helped me." d) "Improved sleep is one benefit of regular exercise." Answer: "Improved sleep is one benefit of regular exercise." Explanation: Some ofthe most important benefits of regular exercise are psychological. Improved sleep is a benefit of regular exercise.  Which ofthe following postural deformities might be assessed in a teenager? a) rickets b) scoliosis c) osteoporosis d) kyphosis Answer: scoliosis Explanation: Scoliosis, a lateral curvature ofthe spine, would most likely be assessed in a teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in children.  A college student fell and sprained his right ankle.the student health physician recommendsthe student use crutches to facilitate healing. Which ofthe following wouldthe nurse teachthe student? a)the crutches should be as long asthe student is tall. b) Walk fast and use long steps when usingthe crutches. c)the support ofthe body should be inthe axilla. d)the support ofthe body should bethe hands and arms. Answer:the support ofthe body should bethe hands and arms. Explanation: Teachthe patient thatthe support of body weight should come primarily onthe hands and arms when usingthe crutches, not inthe axillary area, where pressure may damage nerves and cut off circulation.  A nurse is following a plan of care for passive range-of-motion (ROM) exercises. What specifics will be included onthe plan? a) Request family be available twice a day to perform ROM. b) Do ROM exercises two times a day, each exercise two to five times. c) Move each joint untilthe patient complains of pain. d) Askthe patient to demonstrate ROM at 9 a.m. each day. Answer: Do ROM exercises two times a day, each exercise two to five times. Explanation: Do not move joints tothe point of pain. Passive ROM exercises should be done twice a day, with each exercise carried out two to five times.  An 80-year-old patient experienced dysphagia (impaired swallowing) inthe weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How shouldthe nurse best positionthe patient? Answer: High-Fowler's Explanation: A high-Fowler's position optimizes cardiac function and respiratory function in addition to beingthe best position for eating.the patient's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.  A nurse is ambulating a patient who has had a stroke.the patient has paresis onthe right side ofthe upper body. Where wouldthe nurse stand to walkthe patient? Answer: onthe weak side  A nurse is caring for an elderly client at a health care facility. What problem might a nurse observe in an elderly client as a result of age-related postural changes? Answer: Limited or unsteady mobility  Which ofthe following ambulatory aids could a nurse suggest to assist a client who has weakness in one side of his body? Cane  The nurse is assisting a patient with limited mobility to turn in bed. After successfully turningthe patient tothe side, where wouldthe nurse place an additional pillow? Supportingthe back  A nurse is demonstratingthe proper use of body mechanics to a group of nursing students. Which ofthe following would be most appropriate forthe nurse to do? a) Keep knees locked in position b) Stand with legs wide apart c) Hold objects away fromthe body d) Approachthe work fromthe side Stand with legs wide apart  The nurse is assisting with range-of-motion exercises for a patient who is on bed rest following surgery. How often wouldthe nurse perform each range-of-motion exercise? a) One time b) Eight times c) Ten to twelve times d) Two to five times Two to five times  Two nurses are moving a patient up in bed. What motion wouldthe nurses use to counteractthe patient's weight? Shift their weight back and forth, from back leg to front leg  A nurse is assisting a client to ambulate atthe health care facility using a walking belt. How doesthe walking belt assistthe client when ambulating? a) Allowsthe nurse to supportthe client b) Helpsthe client to practice ambulating c) Enablesthe client to stand and support body weight d) Aidsthe client in extendingthe leg Allowsthe nurse to supportthe client  A patient with a hip fracture is returning tothe orthopedic unit, andthe orders indicate thatthe patient should be turned by logrolling. What statement is correct regarding logrolling? a) Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. b) Logrolling will maintain straight alignment whenthe patient is sitting in a chair. c) Logrolling can be performed by one experienced nurse. d) It is acceptable to twistthe patient's head, but notthe hips, while logrolling. Use a draw sheet  A nurse uses proper body mechanics to move a patient up in bed. Which ofthe following is a guideline for using these techniques properly? a) Facethe direction of movement. b) Keep feet together to provide a base of support. c) Keep body weight higher than center of gravity. d) Twist body atthe waist when lifting. Facethe direction of movement  A patient is preparing to mobilize forthe first time followingthe surgical removal of a bunion on her left foot. How shouldthe nurse instructthe patient to ambulate with her crutches? a) "Keep your elbows well away from your sides in order to keep yourself as stable as possible." b) "When you rise from a chair, use your left foot to stabilize yourself." c) "Keep your crutches as close as possible to your feet when you're walking." d) "Try to avoid putting too much pressure on your armpits withthe tops ofthe crutches." "Try to avoid putting too much pressure on your armpits withthe tops ofthe crutches."  A nurse at a health care facility is caring for clients using crutches to ambulate. In which ofthe following clients wouldthe nurse observe a four-point walking gait? a) Clients with amputated limbs who are learning to use prosthetic limbs b) Clients who have more coordination and balance c) Clients with one amputated, injured, or disabled extremity d) Clients with disabilities such as arthritis or cerebral palsy Clients with disabilities such as arthritis or cerebral palsy  While performing passive range-of-motion exercises onthe lower extremities of a patient with a spinal cord injury,the nurse assesses permanent flexion ofthe muscles. What term willthe nurse use to document this finding related tothe muscles? a) Contractures b) Atrophy c) Tonus d) Ankylosis Contractures  You are helping a patient walk inthe hallway whenthe patient suddenly reaches forthe handrail and states, "I feel so weak. I think I am going to pass out." Which ofthe following initial actions by are appropriate? Select all that apply. a) Supportthe patient's body against yours and gently slidethe patient ontothe floor. b) Askthe patient to lean againstthe wall while you obtain a wheelchair. c) Apply oxygen and wait several minutes forthe weakness to pass. d) Askthe patient, "When wasthe last time you ate?" e) Firmly graspthe patient's gait belt. Supportthe patient's body against yours and gently slidethe patient ontothe floor  The cardiac response to exercise is well-researched and documented. Which ofthe following is a cardiovascular response to regular exercise? a) Increased efficiency ofthe heart b) Decreased blood flow to all body parts c) Decreased circulation of fibrinolysin d) Increased heart rate and blood pressure Increased efficiency ofthe heart  When explainingthe benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which ofthe following exercises shouldthe nurse tellthe client to perform? a) Aerobic exercise b) Body building c) Weight lifting d) Push-ups Aerobic exercise  What term is used to document impaired muscle strength or weakness? a) paresis b) paralysis c) spasticity d) flaccidity Paresis  A 60-year-old client who uses a walker to aid ambulation is being discharged fromthe health care facility. Which ofthe following changes should be made tothe homes of older adults to increase safety? Select all that apply. a) Ensure that there are no electric cords inthe passageway. b) Repaintthe house to a color that promotes well-being. c) Add railings and grab bars tothe bathrooms and entrance. d) Replace scatter rugs with secure mats. e) Ensure that allthe rooms inthe house are brightly lit. Replace scatter rugs with secure mats. Ensure that there are no electric cords inthe passageway. Add railings and grab bars tothe bathrooms and entrance.  A nurse is working with a female client with osteoporosis on an exercise program.the nurse instructsthe client to increase her tolerance gradually.the nurse determines thatthe teaching was effective whenthe client states which ofthe following? a) "My initial goal is to exercise every day ofthe week." b) "I need to avoid weight-bearing exercises." c) "Strength training will be of little benefit to me." d) "If I experience pain when I'm exercising, I should stop." "If I experience pain when I'm exercising, I should stop."  A nurse is performing a general physical assessment for a client. What isthe most important thingthe client can do to promote work endurance? a) Hold objects closer tothe body b) Rest between periods of exertion c) Keepthe feet apart when holding objects d) Twist and stretch muscles during work Rest between periods of exertion  A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise shouldthe nurse assistthe client with in this case? a) Continuous passive motion machine b) Range of motion exercises c) Active exercises d) Aerobic exercises Range of motion exercises  The nurse is assisting a patient fromthe bed into a wheelchair. Which ofthe following is a recommended guideline for this procedure? a) Raisethe head ofthe bed to a sitting position. b) Placethe bed inthe highest position. c) Putthe chair atthe foot ofthe bed. d) Make surethe bed brakes are unlocked. Raisethe head ofthe bed to a sitting postion  A nurse is assessingthe musculoskeletal system of a client during an initial visit tothe clinic.the assessment reveals insufficient joint lubrication inthe knees.the nurse documents this finding as which ofthe following? a) Crepitus b) Chorea c) Scoliosis d) Swelling Crepitus  A nurse is caring for an inactive client and assistingthe client in performing range-of-motion exercises. What care shouldthe nurse take when performing range-of-motion exercises? a) Changethe pattern of exercises each time b) Perform different movements with each extremity c) Place pillows and other positioning devices d) Move each joint until there is resistance but no pain Move each joint until there is resistance but no pain  A nurse performing range-of-motion exercises on a bedfast patient movesthe patient's chin down ontothe chest and then back to an upright position.the nurse then tiltsthe head as far as possible to each shoulder. What therapeutic movement isthe nurse achieving with this exercise? Select all that apply. a) Dorsiflexion b) Extension c) Pronation d) Flexion e) Adduction • Flexion • Extension  An obstetrical nurse is preparing to help a patient up from her bed and tothe bathroom 3 hours afterthe woman delivered her baby. Which ofthe following actions shouldthe nurse perform first? a) Position a walker in front ofthe patient to provide stability. b) Explain tothe patient howthe nurse will assist her. c) Havethe patient stand for 30 seconds prior to walking. d) Enlistthe assistance of another nurse orthe physiotherapist. Explain tothe patient howthe nurse will assist her.  The nurse adjusts a patient's bed to a comfortable working height in order to turn a patient. What would bethe nurse's next action? a) Movethe patient to edge ofthe bed oppositethe side that patient will be turning. b) Pushthe patient tothe edge ofthe bed to whichthe patient will be turning. c) Pushthe patient tothe opposite side ofthe bed. d) Pullthe patient tothe edge ofthe bed to whichthe patient will be turning. Answer: Movethe patient to edge ofthe bed oppositethe side that patient will be turning.  Bedrest, with resultant immobility, affectsthe whole body. What is one effect onthe musculoskeletal system? a) impaired gas exchange b) decreased sensory stimulation c) increased risk for contractures d) increased risk for venous thrombosis increased risk for contractures  A nurse is providing care for a patient who has been newly admitted tothe long-term care facility. What isthe primary criterion forthe nurse's decision whether to use a mechanized assistive device for transferringthe patient? a)the patient's body weight b)the patient's cognitive status c)the patient's ability to assist d)the patient's age Patient's ability to assist  When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what shouldthe nurse observethe client for? a) Tone and strength ofthe muscles b) Upper arm strength c) Walking gait d) Pallor, weakness, or dizziness Pallor, weakness, or dizziness  The nurse is preparing to move a patient using a powered full-body sling lift. Which ofthe following is a recommended action in this procedure? a) Lowerthe side rail onthe side ofthe bed being worked on. b) Placethe sling evenly on top ofthe patient. c) Lowerthe side rail onthe opposite side ofthe bed being worked on. d) Rollthe patient tothe middle ofthe bed. Lowerthe side rail onthe side ofthe bed being worked on.  A nurse is caring for an athlete who has been provided with a cervical collar to immobilizethe neck following a neck injury. What isthe most important advantage of mechanical immobilization of a body part? a) Heals wounds and infected injuries b) Treats structural damage and deformity c) Allows movement while injuries heal d) Relieves pain and muscle spasm Relieves pain and muscle spasm  The nurse has askedthe patient to grasp his overbed trapeze and pull his torso up offthe surface ofthe bed. What movement willthe patient perform with his arms? a) Abduction b) Flexion c) Adduction d) Dorsiflexion Flexion  Moving joint or extremity towardthe midline ofthe body Adduction  Moving a joint or extremity away fromthe midline ofthe body Abduction  Turning a joint or extremity on its axis towardthe body's midline Rotation, internal  Turning a joint or extremity on its axis away fromthe body's midline Rotation, external  Decreasingthe angle between two bones Flexion  Straightening a joint Extension  Moving a joint past normal extension Hyperextension  Turningthe body or a body part to face upward Supination  Turningthe body or a body part facing downward Pronation  Moving a body part in widening circles Circumduction  Turningthe feet inward so toes point towardthe mid line ` Inversion  Turningthe feet outward so toes point away fromthe midline Eversion  Touchingthe thumb to each finger Opposition  Anaerobic excercise= endurance training. can't extract enough oxygen  aerobic exercise promotes Cardiovascular conditioning  Static excerise by whichthe patient tenses a muscle, holding it stationary while maintaining tension Isometric  Client lays face down.Arms cushion head or may be flexed. After abdominal surgery and in clients with respiratory or spinal problems Prone  Client lays flat on back.Alternative for people on bed rest Supine  Sitting position raisesthe client's head 80 to 90 degrees. Improves cardiac output, promotes ventilation, and eases eating,talking and watching tv. Fowler's When explainingthe benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which ofthe following exercises shouldthe nurse tellthe client to perform? aerobic exercise  Which ofthe following ambulatory aids could a nurse suggest to assist a client who has weakness in one side of his body? A cane  The nurse is teaching a new graduate nurse aboutthe most common causes of back injuries.the nurse knows thatthe new graduate understandsthe concepts of back injuries when she/he states that back injuries: can occur when repositioning uncooperative clients.  A client who tore his quadriceps muscle during a soccer match is being treated at a health care facility.the physician has prescribed exercise forthe quadriceps muscles in order to rehabilitatethe client. How shouldthe client perform quadriceps setting exercises? By alternatively tensing and relaxingthe muscles  A nurse is providing care for a client who has been newly admitted tothe long-term care facility. What isthe primary criterion forthe nurse's decision whether to use a mechanized assistive device for transferringthe client? the clients ability to assist  A nurse is assisting a client to ambulate atthe health care facility using a walking belt. How doesthe walking belt assistthe client when ambulating? allowsthe nurse to supportthe client  A client with a hip fracture is returning tothe orthopedic unit, andthe orders indicate thatthe client should be turned by logrolling. What statement is correct regarding logrolling? Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.  A nurse is caring for a client whose fractured leg is in a cast. Which ofthe following ambulatory devices couldthe nurse suggest forthe client to ambulate atthe health care facility? axillary crutch  The nurse is caring for a client who has been on bed rest.the primary care provider has just written a new order forthe client to sit inthe chair three times a day. Which ofthe following actions will be most effective to transferthe client safely intothe chair? Havethe client sit onthe side ofthe bed for several minutes before moving tothe chair.  Which postural deformity might be assessed in a teenager? scoliosis  When moving a client up in bed withthe assistance of another caregiver,the nurse should: havethe client foldthe arms acrossthe chest.  What body system benefitsthe most from aerobic exercises? cardiovascular  The cardiac response to exercise is well-researched and documented. Which ofthe following is a cardiovascular response to regular exercise? Increased efficiency ofthe heart  A nurse is preparing to turn a hospitalized client age 65 years. Which ofthe following is a recommended guideline for performing this skill? Position a friction-reducing sheet underthe client.  A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise shouldthe nurse assistthe client with in this case? Range of motion exercises  A client 80 years of age experienced dysphagia (impaired swallowing) inthe weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How shouldthe nurse best positionthe client? fowlers  When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what shouldthe nurse observethe client for? pallor, weakness, and dizziness  A college student fell and sprained his right ankle.the student health physician recommendsthe student use crutches to facilitate healing. Which ofthe following wouldthe nurse teachthe student? A college student fell and sprained his right ankle.the student health physician recommendsthe student use crutches to facilitate healing. Which ofthe following wouldthe nurse teachthe student?  An immobile person has decreased movement of respiratory secretions. What condition is a greater risk as a result? respiratory tract infection  The 55 year-old client who is newly diagnosed with osteoarthritis ofthe hips asksthe nurse why it hurts when walking. What isthe nurse's best response? "You have lostthe padding in your joints andthe friction causes pain."  The nurse is assessingthe developmental level of children in a pediatric clinic.the nurse would be most concerned about which client? The 24-month-old child who is unable to walk unassisted  A nurse is caring for an inactive client and assistingthe client in performing range-of-motion exercises. What care shouldthe nurse take when performing range-of-motion exercises? Move each joint until there is resistance but no pain  A nurse teaches a student nursethe importance of ambulating patients to preventthe effects of immobility on body systems. Which ofthe following is one of these effects? impaired circulation  A nurse is assessingthe musculoskeletal system of a client during an initial visit tothe clinic.the assessment reveals insufficient joint lubrication inthe knees.the nurse documents this finding as which ofthe following? crepitus  A nurse uses proper body mechanics to move a client up in bed. Which ofthe following is a guideline for using these techniques properly? Facethe direction of movement.  A group of nursing students are reviewingthe aspects of motor function control bythe nervous system.the students demonstrate understanding of this information when they identify which ofthe following as a function ofthe cerebellum? Coordination of movement motor activities  The nurse is assisting an elderly client with dementia to get dressed after morning care. Which statement would be most beneficial tothe patient? "Put your arm in this sleeve."  The nurse is caring for a client who is on bed rest and was just turned tothe left side. Which ofthe following actions should you take next to decreasethe risk of impaired skin integrity? Pullthe shoulder blade forward and out from underthe client.  The nurse is assessingthe client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement.the nurse documents this finding as: spasticity.  A home care nurse visits a client with Parkinson's disease.the nurse observes thatthe client has rhythmic, repetitive movements ofthe hands.the home care nurse documents this as which ofthe following? tremor  A nurse is demonstratingthe proper use of body mechanics to a group of nursing students. Which ofthe following would be most appropriate forthe nurse to do? Stand with legs wide apart  While performing passive range-of-motion exercises onthe lower extremities of a patient with a spinal cord injury,the nurse assesses permanent flexion ofthe muscles. What term willthe nurse use to document this finding related tothe muscles? contractures  What is a benefit of regular exercise over time? decreased heart rate  A nurse is caring for a comatose patient. What can happen tothe feet if they are unsupported inthe dorsiflexed position? plantar flexion and footdrop  A patient is preparing to mobilize forthe first time followingthe surgical removal of a bunion on her left foot. How shouldthe nurse instructthe patient to ambulate with her crutches? "Try to avoid putting too much pressure on your armpits withthe tops ofthe crutches."  A nurse is working with a female client with osteoporosis on an exercise program.the nurse instructsthe client to increase her tolerance gradually.the nurse determines thatthe teaching was effective whenthe client states which ofthe following? Answer Key Question 1: (see full question) Two nurses are moving a client up in bed. What motion wouldthe nurses use to counteractthe client's weight? You selected: Correct Explanation: The nurses would use a rocking motion to counteractthe client's weight.the nurses would shift their weight back and forth, from back leg to front leg, count to three, and then movethe client up towardthe head ofthe bed. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1096. Chapter 32: Activity - Page 1096 ________________________________________ Question 2: (see full question) The nurse has askedthe client to grasp his overbed trapeze and pull his torso up offthe surface ofthe bed. What movement willthe client perform with his arms? You selected: Adduction Incorrect Correct response: Explanation: Flexion is achieved when a body part is bent, as whenthe elbow is bent andthe upper arm and forearm are brought together. Adduction and abduction denote lateral movement to and fromthe body, and dorsiflexion is backward bending ofthe hand or foot. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1041. Chapter 32: Activity - Page 1041 ________________________________________ Question 3: (see full question) The nurse has been teachingthe client about how to use a walker safely.the nurse knowsthe teaching has been effective whenthe client: You selected: Correct Explanation: A walker is mechanical aide that enhancesthe client's balance and ability to bear weight. Teaching is usually done by physical medicine or physical therapy, butthe nurse should continue to assessthe client’s ability to use it properly.the client should step intothe walker when walking, rather than walking behind it. When rising from a seated position,the arms ofthe chair should be used for support, notthe walker.the client should be cautioned to avoid pushingthe walker out too far in front. Also,the client should avoid leaning overthe walker, but should stay upright as he/she moves. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1077-1078. Chapter 32: Activity - Page 1077 ________________________________________ Question 4: (see full question) The nurse is caring for a client who is on bed rest and was just turned tothe left side. Which ofthe following actions should you take next to decreasethe risk of impaired skin integrity? You selected: Correct Explanation: Positioningthe shoulder blade in this manner removes pressure fromthe bony prominence. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1095. Chapter 32: Activity - Page 1095 ________________________________________ Question 5: (see full question) Which patient wouldthe nurse place in a protective prone position? You selected: Correct Explanation: A nurse would place a client prone to hyperextension ofthe spine in a protective prone position. A nurse would place a client prone to edema ofthe hand in Fowler’s position. A nurse would place a client prone to internal shoulder rotation and adduction in protective supine position. A nurse would place a client prone to flexion contracture ofthe neck in protective supine position. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1069. Chapter 32: Activity - Page 1069 ________________________________________ Question 6: (see full question) The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would bethe nurse's next action? You selected: Correct Explanation: When turning a client in bed,the nurse would use a friction-reducing sheet to pullthe client tothe edge ofthe bed that is oppositethe sidethe client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending onthe individual client. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1095-1098. Chapter 32: Activity - Page 1095 ________________________________________ Question 7: (see full question) The nurse is assessingthe developmental level of children in a pediatric clinic.the nurse would be most concerned about which client? You selected: Correct Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raisethe head, but this is not expected at this age for all 3-month olds. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month olds. Stacking blocks is accomplished by most 3-year olds, although 18 months is early. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 8: (see full question) Using proper body mechanics, which motions wouldthe nurse make to move an object? You selected: Correct Explanation: Usethe internal girdle and a long midriff to stabilizethe pelvis and to protectthe abdominal viscera when stooping, reaching, lifting, or pulling.the internal girdle is made by contractingthe gluteal muscles inthe buttocks downward andthe abdominal muscles upward. It is helped further by making a long midriff by stretchingthe muscles inthe waist.the nurse would not relaxthe stomach muscles or usethe muscles ofthe back when moving an object.the nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1060. Chapter 32: Activity - Page 1060 ________________________________________ Question 9: (see full question) The nurse is performing range-of-motion exercises on a patient’s arm.the nurse starts by liftingthe arm forward to abovethe head ofthe patient. Which action wouldthe nurse perform next? You selected: Correct Explanation: The nurse would returnthe joint to a neutral position, that is, its normal position of alignment, when finishing each exercise. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1073. Chapter 32: Activity - Page 1073 ________________________________________ Question 10: (see full question) A nurse applies padded boots to maintainthe foot in dorsiflexion on a client who is comatose.the nurse is protectingthe client from what? You selected: Correct Explanation: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in whichthe foot is fixed in plantar flexion. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1066. Chapter 32: Activity - Page 1066 Chapter 29:Medications A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer? 0.7 cc p.737  A nurse is administering medication to a patient via a gastric tube and finds thatthe medicine entersthe tube and thenthe tube becomes clogged. What isthe appropriate intervention in this situation? Use a syringe to plungethe tube to try to dislodgethe medication. p.744  The medical chart of a newly admitted patient notes a penicillin allergy, yetthe physician has just written an order for an antibiotic inthe same drug family after reviewingthe patient's wound culture and sensitivity. How shouldthe nurse respond to this situation? Withholdthe medication untilthe potential drug allergy has been addressed bythe care team p.735  A nurse is caring for a client undergoing IV therapy.the nurse knows that intravenous administration of medication is appropriate in which ofthe following situations? Whenthe client has disorders that affectthe absorption of medications p.755  A nurse is performing a sensitivity test on a patient. What would bethe best type of injection to use for this procedure? Intradermal p.749  The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? Standing order p.733  A nurse is explaining to a clientthe correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which ofthe following is a feature of a metered-dose inhaler? It is a canister that contains pressurized medication. p.763  A nurse needs to administer a continuous medication drip to a client.the nurse knows that, for a continuous infusion, he or she will likely need to add medication to which ofthe following volumes of IV solution? 500 to 1,000 mL p.756  A nurse needs to use a moisturizer for an elderly client with dry skin. Why isthe onset ofthe medication action atypical in an elderly client? Diminished subcutaneous fat p.730  To which ofthe following patients wouldthe nurse be most likely to administer a PRN medication? A patient who is complaining of pain near her surgical site p.733  When educating an elderly client aboutthe administration of medication during discharge teaching,the nurse notes thatthe client is having difficulty comprehendingthe instruction. What intervention shouldthe nurse follow in this case to ensurethe client's safety? Involve a second responsible person inthe instruction. p.744  An elderly client with pneumonia has been prescribedthe use of a bronchodilator bythe physician. What shouldthe nurse monitor in a client taking an inhaled bronchodilator? Heart rate pp.763-764  The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which ofthe following represent these five rights? Select all that apply. • Medication • Patient • Route • Dosage p.738  A nurse is using an 18-gauge needle to administer a medication to a client.the nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which ofthe following features? Larger diameter p.745  A nurse educator is teaching a student nurse how to choosethe correct needle for an injection. Which ofthe following guidelines for needle selection might they discuss? Asthe gauge number becomes larger,the size ofthe needle becomes smaller p.745  The primary reason forthe Controlled Substances Act is To prevent drug abuse p.739  A nurse is administering a hepatitis B shot intramuscular. What would bethe appropriate site for administration? Deltoid p.752  A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which ofthe following responsibilities doesthe nurse have to complete when handling narcotic medications? Select all that apply. • Count each narcotic medication atthe change of each shift • Record each medication used fromthe stock supply • Maintain an accurate account ofthe use ofthe medication p.739  A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which ofthe following isthe most suitable angle when administering an intradermal injection? 10-degree angle p.788  Which ofthe following patients receives a drug that requires parenteral route? A woman who has been ordered intravenous antibiotics p.735  A nurse is providing care for a patient who has a history of dementia. Which ofthe following methods shouldthe nurse use in order to determinethe patient's identity prior to medication administration? Checkthe patient's identification band. p.739  Which ofthe following accurately describes a recommended guideline when administering oral medications to patients? If a child refuses to take medication,the medication can be crushed and added to a small amount of food. p.744  When administering heparin subcutaneously,the nurse should Never aspirate p.750  Which medication system allows for client independence? Self-administered medication system p.741  The maintenance of client safety with medication administration is of primary importance in healthcare.the most commonly used system for billing and record keeping is the Automated medication-dispensing system p.736  An acute care facility followsthe unit dose supply method to supply medication tothe clients. What is meant bythe unit dose supply method? Self-contained packets that hold one tablet or capsule for individual clients p.773  Which ofthe following are included inthe "five rights for medication administration"? Select all that apply. • Right medication • Right route • Right dose • Right time p.738  The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate forthe nurse to follow when administering a drug via this route? Flushthe tube with water between each drug administered. p.744  What isthe term used forthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity? Therapeutic range p.732  A client with dry skin has been prescribed inunction. Which ofthe following shouldthe nurse do to promote absorption ofthe ointment? Rubbingthe ointment intothe skin p.757  A nurse needs to administer a prescribed injection to a toddler. Which ofthe following injection sites is most suitable forthe client? Vastuslateralis site p.752  A graduate nurse is administering several medications to a newly admitted patient. Who is legally responsible forthe drugs administered by this nurse? The nurse administeringthe drugs p.735  A nurse should readthe instructions stated on a vial container before reconstituting it and administering it to a client. Which ofthe following instructions are stated onthe label of a vial container? Amount of diluent to be added p.749  The nurse is caring for a client who has problems coordinating his breathing withthe inhaler use. Therefore,the client is unable to receivethe full dose. Which ofthe following would help maximize drug absorption in this client? Spacer p.764  A nurse is administering a prescribed dose of medication to a client through a medication lock. How often shouldthe nurse flushthe medication lock to maintain patency? Every 8 to 12 hours p.806-807  A client has been prescribed nasal medication. What care shouldthe nurse take to avoid potential complications due tothe administration of this medication? Reviewthe client's medication, allergy, and medical history p.735  When treating a client at a health care facility with nitroglycerin paste, how canthe nurse prevent contamination inthe client during application? Avoid touchingthe application with bare fingers p.758  A physician has orderedthe nurse to administer a subcutaneous injection to a client. Which ofthe following factors shouldthe nurse consider when selecting a syringe and needle? Select all that apply. • Viscosity ofthe drug • Size ofthe client • Type of medication p.746  A nurse atthe health care facility needs to administer an otic application for a client with an earache. What shouldthe nurse do after instillingthe prescribed eardrops inthe client's ear? Askthe client to maintainthe position for some time p.761  A nurse is administering a subcutaneous injection to a client. What isthe common maximum volume of a subcutaneous injection? 1 mL p.749  A nurse is caring for a client inthe nursing unit whenthe physician, duringthe rounds, prescribes a medication forthe client. What appropriate action shouldthe nurse take to ensurethe accuracy ofthe verbal medication order? Askthe physician to write outthe order p.732  A physician at a health care facility suggeststhe use of a metered-dose inhaler for an asthmatic client. Which ofthe following describesthe mechanism of a metered-dose inhaler? A canister containing medication that is released whenthe container is compressed p.763  A nurse is using a volume control set to administer a dose of prescribed medication to a client.the nurse opensthe lower clamp untilthe tubing is filled with fluid and then reclamps it. Which ofthe following statements explainsthe nurse's action? Purges air fromthe tubing p.804  A nurse brings a clientthe prescribed dose of medication and finds thatthe client is not inthe unit. What shouldthe nurse do in this case? Returnthe medication tothe medication cart or medication room. p.739  A nurse is administering an injection to a client at a 15-degree angle.the client has a venous access port. Which ofthe following injections can be administered at this angle? Intradermal p.789  A nurse needs to administer a prescribed medication to a client using IV push. In which ofthe following ways isthe medication being administered tothe client? Bolus administration p.756  A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO.the drug is available as 125 mcg tablets. How many ofthe tablets willthe nurse administer? 0.5 125 mcg = 0.125 mg. 0.0625 mg/0.125 mg = 0.5 tablets p.737  A nurse has to administer a subcutaneous injection to a client. For which ofthe following clients canthe nurse administer a subcutaneous injection at a 90-degree angle? Obese clients p.750  After teaching a group of nursing students about pharmacokinetics,the instructor determines thatthe teaching was successful whenthe students identify which ofthe following asthe process by whichthe medication is delivered tothe target cells and tissues? Distribution p.727  A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which ofthe following actions shouldthe nurse perform when administering oral medication tothe client? Avoid administering medication prepared by another nurse. p.738-739  Which ofthe following clients is likely to have altered metabolism of medications? Elderly p.730  A client suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product willthe physician order to restore intravascular volume? Albumin p.730  A nurse is administering intermittent IV medication to an active adolescent. Which ofthe following IV systems could be used to allowthe patient more freedom? Peripheral venous access device p.757  A nurse atthe health care facility is preparingthe medication dosage for a client. Why shouldthe nurse read and comparethe label onthe medication withthe MAR at least three times (before, during, and after) while preparingthe medication for administration? Ensures thatthe right medication is given atthe right time bythe right route p.738  Which ofthe following medication-administration systems protectsthe client by identifyingthe rights of medication administration? Barcode Medication Administration p.736.  A nurse is caring for a client who is being tube fed. What care shouldthe nurse take when administering medications through an enteral tube? Avoid crushing sustained-release pellets p.743  A nurse needs to administer medications to a client through an intravenous port. Which ofthe following actions shouldthe nurse perform to ascertain thatthe IV catheter is inthe vein? Observethe tubing nearthe insertion device p.800  A nurse is applying a nitroglycerine transdermal patch to a patient. Which ofthe following isthe preferred site to use? chest p.758  A nurse is administering insulin to a diabetic patient. Which ofthe following are three recommended times to checkthe label before administration? Select all that apply. • When reaching forthe container or unit dose package • After retrieval fromthe drawer and compared withthe CMAR • When replacingthe container tothe drawer or shelf p.738  According tothe nurse practice act,the nurse is liable for Clarifying a physician order p.777  A nurse is administering enoxaparin, (blood thinner) to a patient with DVT, viathe subcutaneous route. Which ofthe following is a recommended guideline when administering a subcutaneous injection? Subcutaneous injections are administered intothe adipose tissue layer just belowthe epidermis and dermis p.750  The nurse is preparingthe dosage for a client as perthe medication administration record. Which ofthe following precautions shouldthe nurse take when preparing medications? Avoid relabeling containers with missing labels p.738  Children's medication dosages are most often calculated usingthe child's body surface area and weight p.738  A nurse is applying a vaginal cream to a patient with a vaginal infection. Which ofthe following is a recommended guideline for this application? Cleanse area at vaginal orifice with washcloth and warm water p.763  A nurse at a health care facility has to instill ear drops in a client.the nurse knows that which ofthe following techniques varies for an adult and child client? Manipulation ofthe client's ear to straightenthe auditory canal p.761  What is involved inthe absorption, distribution, metabolism, and excretion of medication? Pharmacokinetics p.725  A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which ofthe following actions shouldthe nurse perform to ensure that allthe medication is equally distributed when withdrawing? Tapthe top ofthe ampule before withdrawingthe medicine Tappingthe top ofthe ampule distributes allthe medication tothe lower portion ofthe ampule. Tappingthe barrel ofthe syringe nearthe hub does not distribute medication equally but movesthe air towardthe needle. Insertingthe filter needle inthe ampule ensures sterility ofthe needle. Using a smaller or bigger gauge needle does not ensure that allthe medication is equally distributed when withdrawing. p.746  Whenthe client demonstrates a rash 30 minutes after she has taken a dose of penicillin,the nurse recognizes thatthe client is likely demonstrating which type of drug reaction? Allergy p.728  Following an allergic reaction to a medication,the nurse should Instructthe client to wear an identification addressingthe allergy p.770  A nurse caring for a client with diarrhea needs to establish an intravenous (IV) access to administer fluids and medication. When explaining intravenous access tothe client, which ofthe following wouldthe nurse most likely incorporate intothe description? Insertion of a needle into a peripheral vein p.755  A nurse is using an IV port when administering medication to a client. Which ofthe following IV administrations hasthe greatest potential to cause life-threatening changes? Bolus administration p.756  Which parenteral route of administration hasthe longest absorption time? Intradermal p.749  A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which ofthe following precautions shouldthe nurse take when combining drugs? Withdraw exact amounts of each drug from each container. p.748  A physician has prescribedthe use of Lubriderm lotion, which is an inunction application, for a client with complaints of dry skin. Which ofthe following information shouldthe nurse tellthe client regardingthe correct method of usage? The medication is administered by rubbing it intothe skin p.735  A client with an infection is receiving intravenous antibiotic therapy.the client has an intermittent infusion device in place.the nurse flushesthe device with normal saline solution before administeringthe antibiotic based on which rationale? To prevent blood clot formation p.756  A nurse is caring for a client with an intravenous catheter. When administering medication throughthe intravenous port,the nurse pinchesthe tubing upstream fromthe port when instilling it withthe drug. Which ofthe following reasons explainsthe nurse's action? Ensures administration of medication tothe client p.800  A nurse instills eardrops into a patient's ear to soften a wax buildup. Which ofthe following is a guidelinethe nurse should follow? If both ears are to be treated, wait 5 minutes before instilling drops inthe second ear. p.761  A nurse has administered an injection to a client. Which ofthe following interventions shouldthe nurse perform to reduce discomfort and provide quick relief? Apply pressure tothe site during needle withdrawal. p.797  A client diagnosed with anemia is receiving a blood transfusion.the client develops urticaria accompanied by wheezing and dyspnea not long afterthe transfusion starts.the nurse interprets this as indicative of which ofthe following? Allergic reaction p.728  When performing a piggyback infusion,the nurse lowersthe container of primary solution approximately 10 inches belowthe height ofthe secondary solution. Which ofthe following reasons explainsthe nurse's action? Uses gravity to infusethe secondary medication p.804  A nurse is bunchingthe tissue of a client when administering a subcutaneous injection to a client.the nurse knows that which ofthe following isthe reason for bunching when injecting subcutaneously? To avoid instilling medication withinthe muscle p.750  You are preparing supplies for a tuberculosis screening. You should choose which ofthe following syringes and needles? 1 mL syringe; 1/2 half-inch, 26-gauge needle p.749  The nurse is preparing to administer meperidine (Demerol) as an intramuscular injection in an adult patient's deltoid site. Which ofthe following needles shouldthe nurse select for this injection? 1"; 22 gauge p.754  When administering oral medications, which ofthe following practices shouldthe nurse follow? Select all that apply. • Perform hand hygiene before and after medication administration. • Stay atthe bedside untilthe patient has swallowed allthe medications. • Verifythe patient's response tothe medication 30 minutes after administration, or as appropriate forthe drug. p.733  A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which ofthe following actions shouldthe nurse perform to prevent gastric reflux? Helpthe client into a Fowler's position. P.744  Which ofthe following actions are included inthe required "checks" for safe medication administration? Select all that apply • Readthe medication label when reaching forthe unit dose package. • Readthe medication label just before administering a unit dose medication tothe patient. • Readthe medication label after retrievingthe medication fromthe drawer. p.738  A client with allergy has been advised to have an allergy test.the nurse needs to administer an injection tothe client for allergy testing. Which ofthe following injection routes is most suitable for allergy testing? Intradermal p.749  A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which ofthe following precautions shouldthe nurse take when storing narcotic medications? In a double-locked drawer p.739  A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline.the nurse understand that this type of infusion is used for which situation? Medications that need to be infused over 20 to 60 minutes p.756  You are caring for a patient who just returned fromthe postanesthesia care unit (PACU) and rates current pain as "9 out of 10." Which ofthe following prescribed medications will providethe fastest relief from pain? Intravenous morphine sulfate p.755  Which ofthe following are recommended guidelines forthe nurse who is administering a piggyback intermittent intravenous infusion of medication? Attach infusion tubing tothe medication container by insertingthe tubing spike intothe port with a firm push and twisting motion. p.802  A nurse is administering an intramuscular injection to a client usingthe zig-zag technique. Which ofthe following actions shouldthe nurse perform to prevent leaking and ensure sealing of medication inthe subcutaneous and dermal layers of tissue? Withdrawthe needle and release taut skin immediately after injection. p.797  You need to prepare an insulin pen for injection of a prescribed dose of insulin. Arrangethe following steps inthe correct order. Cleanthe tip ofthe pen with alcohol. Screwthe correct needle ontothe tip ofthe pen. Dialthe dose selector to 2 units. Holdthe pen upright and pressthe plunger firmly. Watch for a drop of insulin atthe needle tip. Verifythe dose selector returned to "0." p.751  You are preparing to administer an intramuscular injection. After insertingthe needle, you should gently pull back onthe syringe plunger and observe for blood inthe syringe. True p.750  A nurse is administering a piggyback infusion to a client with second-degree burns. Which ofthe following describesthe most important feature of a piggyback infusion? A parenteral drug is given in tandem with IV solution pp.756-757  A nurse is caring for an elderly client with a vaginal yeast infection. Which ofthe following actions shouldthe nurse perform when instillingthe medication inthe client's vagina? Applythe medication beforethe client goes to sleep. p.763  You are preparing to draw up a medication that is supplied in a glass ampule. Arrangethe following steps inthe correct order. Wrap a small gauze pad around neck of ampule. Break off top ofthe ampule. Attach filter needle tothe syringe. Withdraw medication. Discard filter needle. Attach sterile administration device tothe syringe. p.778  A nurse receives doctor's orders to mix a patient's insulin in a syringe with two other medications. What isthe recommended guideline in this situation? Callthe pharmacist to determine compatibility ofthe drugs. p.748  A nurse needs to administer a subcutaneous injection to a client. Which ofthe following alternative techniques shouldthe nurse use to reduce discomfort? Select all that apply. • Numbthe skin with an ice pack beforethe injection • Insert and withdrawthe needle without hesitation • Instillthe medication slowly and steadily p.755  A nurse is reviewing information about prescribed drug in a drug handbook in preparation for administration to a client. When reading aboutthe drug,the nurse identifies which name asthe generic name? Ampicillin sodium p.725  Regarding medication administration, what must occur atthe change of shifts? The narcotics forthe division are counted p.739  A nurse at a health care facility administers a prescribed drug to a client and does not record doing so inthe medical administration record.the nurse who comes duringthe next shift, assuming thatthe medication has not been administered, administersthe same drug tothe client again.the nurse onthe previous shift calls to informthe health care facility thatthe administration ofthe drug to this client inthe earlier shift was not recorded. What shouldthe nurse on duty do immediately upon detection ofthe medication error? Checkthe client's condition. p.767  A post-surgical patient's MAR provides for PRN administration of a number of analgesics by various routes. Which ofthe following routes will likely providethe most rapid pain relief forthe patient? Intravenous p.755  A physician atthe health care facility orders 500 mg of a medication to be administered bythe oral route, four times a day for a client.the medication is available in a form of 250 mg per 5 mL. What quantity ofthe medication shouldthe nurse administer tothe client? 10 mL The nurse needs to administer 10 mL ofthe medication as perthe physician's prescription inthe medication order.the nurse usesthe following formula in order to calculatethe amount of medication to administer: Desired Dose/Dose on Hand (supplied dose) Quantity. Applyingthe formula tothe information provided inthe medication order: 500 mg/250 mg 5 mL = 10mL. p.737  The nurse is educating a client with a peripheral intravenous infusion of dextrose 5%. What isthe most important information to share withthe client who has an IV infusing inthe right hand? Cautionthe client not to bendthe right wrist p.757  Which ofthe following is an accurate guideline for patient teaching regardingthe use of a DPI? Instructthe patient that if mist can be seen fromthe mouth or nose,the DPI is being used incorrectly. p.766  A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which ofthe following would bethe most effective method to administer this medication? Administer a continuous subcutaneous infusion of morphine. p.750  A nurse uses a nitroglycerin paste to dilatethe coronary arteries of a client atthe health care facility. What shouldthe nurse do facilitatethe medication absorption? Place application paper on a non-hairy area of skin p.758  A nurse needs to administer an injection to a client inthe deltoid site. Which ofthe following actions shouldthe nurse perform to avoidthe risk of damagingthe radial nerve and artery? Draw an imaginary line atthe axilla betweenthe acromion and brachial vessels. p.753  You are preparing to administer a rectal suppository to an adult patient. How far should you plan to insertthe suppository? Three inches p.764  The physiologic and biochemical effects of a drug onthe body defines Pharmacodynamics p.727  A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to Provide access forthe administration of insulin p.755  A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which ofthe following explains why inhalation is a good route for medication administration? It allowsthe lungs to quickly absorbthe medication. p. 763 Please allow access to your computer’s microphone to use Voice Recording. Having trouble? Click here for help.  Chapter 23: Activity A nurse is assisting a client with his bed bath.the client states, "I can do it myself."the nurses best response is? "I will set up your bath for you. I will come back and help you with your back."  A 78 year old client with diabetes needs to have his toenails trimmed. It is important forthe nurse to ? A - Remove ingrown toenails B - protectthe foot from blisters C - Cutthe nail straight across D - Soakthe foot in witch hazel C  For which ofthe following patients is foot care likelythe highest priority? A - A patient who has experience postoperative pneumonia and has been placed on a ventilator B - A patient who has been diagnosed with Alzheimer disease and whose mobility is decreasing C - A patient who is obese and has a diagnosis of type 1 diabetes D - A patient who has chronic renal failure and requires hemodialysis three times weekly. C  Upon review ofthe patient's orders,the nurse notes thatthe patient was recently starting on an anticoagulant. What is an appropriate consideration when assistingthe patient with morning hygiene? Providethe patient with an electric shaver.  Upon assessment,the nurse determinesthe patient has a body mass index (BMI) of 45. This finding indicatesthe patient is which ofthe following? Extremely Obese  A nurse is caring for a client with a history of cardiac and vascular disease. Which ofthe following fats shouldthe nurse allow inthe client's diet for his condition? a) Unsaturated fats b) Saturated fats c) Hydrogenated fats d) Trans fats A - Unsaturated Fats  Prior to starting a tube feeding,the nurse assessesthe pH and color ofthe patient's gastric contents and receives a pH reading of 6.2 andthe aspirate is off-white in color. Based upon these findings, where isthe tip ofthe tube most likely located? a) Large intestine b) Respiratory tract c) Small intestine d) Stomach B - Respiratory Tract  Mrs. R. has developed an abscess following abdominal surgery and her food intake has been decreasing overthe past 2 weeks. Which ofthe following laboratory findings may suggestthe need for nutritional support? a) Low random blood glucose levels b) Low serum albumin levels c) Proteinuria d) Increased white blood cells B - Low serum albumin levels  Which ofthe following nutritional guidelines should a nurse provide to a patient who is enteringthe second trimester of her pregnancy? a) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." b) "Maintain your regular calorie intake, but take some supplements and emphasize organic foods." c) "The more food energy you consume,the greaterthe chances that you will have a healthy pregnancy." d) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables." A - Youll need to eat more calories and to make sure you eat a balanced diet high in nutrients.  During a visit tothe pediatrician's office, a mother inquires about adding solid foods tothe diet of her 6-month-old infant. What doesthe nurse informthe mother? a) Adding solid foods is fine at this age, but avoid iron-fortified foods. b) New foods should be introduced one at a time for a period of 5 to 7 days. c) A new solid food should be introduced daily tothe infant's diet for a week. d) It is too early to add solid foods tothe infant's diet. B - New foods should be introduced one at a time for a period of 5-7 days.  The nurse has observed that a patient's food intake has diminished in recent days. What intervention shouldthe nurse perform in order to stimulatethe patient's appetite? a) Offer nutritional supplements and explainthe potential benefits of each. b) Reducethe frequency of meals in order to allowthe patient to develop an appetite. c) Offer larger meals and encouragethe patient to eat as much as he or she is comfortable with. d) Try to ensure thatthe patient's food is attractive and sufficiently warm. D - Try to ensure thatthe patient's food is attractive and sufficiently warm.  A nurse is caring for a visually impaired client. How shouldthe nurse managethe feeding for this client? a) Informthe client about what kind of food is being offered with each mouthful. b) Request a full-liquid, mechanically soft diet forthe client. c) Ensure that one portion of food is swallowed before offering another. d) Develop a rapport withthe client, and promote continuity of care. A - Informthe client about what kind of food is being offered with each mouthful.  The nurse is preparing to administer a patient's tube feeding. How shouldthe nurse positionthe patient prior to beginningthe infusion? a) Withthe head ofthe bed at 30 to 45 degrees b) Supine c) In a left side-lying position d) Inthe high Fowler's position A - Withthe head ofthe bed at 30-45 degrees.  The nurse should beginthe process of removing a patient's nasogastric (NG) tube by doing which ofthe following? Confirmingthe physician's order to removethe tube.  The nurse is caring for a patient on a telemetry unit following a myocardial infarction.the patient has undergone numerous medication changes sincethe event. Which ofthe following foods should be avoided when a client is taking Coumadin following a myocardial infarction? a) Orange juice b) Spinach c) Milk d) Wheat bread B - Spinach  A client who has bleeding tendencies has a deficiency in which vitamin? a) Vitamin B b) Vitamin C c) Vitamin K d) Vitamin A C - Vitamin K  The nurse is caring for a client with dysphagia. Which ofthe following is a primary responsibility ofthe nurse with regard to feedingthe client? a) Reinforcethe desired response by praising, touching, and smiling atthe client. b) Informthe client aboutthe kind of food being offered with each mouthful. c) Keep oral and pharyngeal suctioning equipment atthe client's bedside. d) Develop a rapport withthe client and promote continuity of care. C - Keep oral and pharyngeal suctioning equipment atthe client's bedside.  The nurse caring for a patient for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure shouldthe nurse implement to assistthe patient in improving his nutritional intake? a) Encourage his daughter to prepare food at home and bring it tothe patient. b) Provide bland meals. c) Provide distractions whilethe patient is fed so that he will eat more. d) Serve large meals and encouragethe patient to eat as much as possible. A - encourage his daughter to prepare food at home and bring it tothe patient.  Which type of feeding tube would be most appropriate for a patient requiring enteral feeding for a long period of time. Gastrostomy tube  A nurse is administering a prescribed dose of IV fluid to a young client with anorexia atthe healthcare facility. When reviewingthe client's medical record, which ofthe following wouldthe nurse identify as a possible cause forthe client's anorexia? a) Motion sickness b) General anesthesia c) Gastrointestinal dysfunction d) Inner ear infection C - Gastrointestinal dysfunction  A nurse is caring for a client with a wound infection.the dietician has prescribed a diet rich in vitamin A.the client asksthe nurse, "Why do I need Vitamin A?"the nurse integrates an understanding of which ofthe following as a major reason when responding tothe client? a) It helps maintain healthy epithelium b) It maintains normal mineralization of cartilage c) It promotes renal reabsorption of calcium d) It mobilizes phosphorus from bone A - It helps maintain healthy epithelium  Which ofthe following is a fat-soluble vitamin? a) Vitamin B12 b) Vitamin B6 c) Vitamin E d) Vitamin C C - Vitamin E  The charge nurse is observing a new nurse care for a patient who is receiving a continuous feeding through a nasogastric feeding tube. Which ofthe following actions bythe new nurse would require intervention bythe charge nurse? a)the new nurse placesthe patient inthe left lateral recumbent position. b)the new nurse changes gloves before preparingthe feeding bag. c)the new nurse interruptsthe feeding every 4 hours and aspirates gastric contents. d)the new nurse asksthe patient if nausea or abdominal pain is present. A -the new nurse placesthe patient inthe left lateral recumbent position.  A nurse is preparing a teaching plan for a client who is obese and has diabetes mellitus. Which ofthe following wouldthe nurse include when discussingthe the effect of diabetes on nutrition? a) Cells cannot use glucose to produce energy. b)the digestion of fats and protein is altered. c) Intolerance to gluten occurs. d) Glucose levels ofthe blood are reduced A - Cells cannot use glucose to produce energy.  Which ofthe following laboratory results indicatesthe presence of malnutrition? a) Hemoglobin (Hgb) 11.3 g/dL b) Hematocrit (Hct) 56% c) Creatinine 1.9 mg/dL d) Serum albumin 2.8 g/dL D - Serum albumin 2.8 g/dL  A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What isthe term for this type of nutrition? a) Total parenteral nutrition (TPN) b) Percutaneous endoscopic jejunostomy tube (PEJ) c) Percutaneous endoscopic gastrostomy tube (PEG) d) Partial or peripheral parenteral nutrition (PPN) A - Total parenteral nutrition (TPN)  A 20-year-old woman has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources fromthe woman's diet? a) Decreased production of antibodies b) Decreased water absorption inthe colon c) Impaired vitamin absorption d) Impaired tissue growth and repair C - Impaired vitamin absorption  A nurse prepares to insert a nasointestinal tube to provide nutrition to a patient. Which ofthe following is a recommended guideline for this procedure? a) Measure tube fromthe tip ofthe nose tothe ear lobe and fromthe ear lobe tothe xiphoid process. b) Placethe patient on his or her left side. c) Add 10 to 12 inches for intestinal placement. d) Placethe tube inthe intestine and allow it to advance through peristalsis A - Measure tube fromthe tip ofthe nose tothe ear lobe and fromthe ear lobe tothe xiphoid process.  You arethe nurse caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid? a) Potassium b) Iodine c) Sodium d) Magnesium B - Iodine  A nurse is caring for a pregnant client who is a strict vegetarian. What type of diet shouldthe client follow? a) A diet rich in sodium b) A diet rich in protein c) A diet lower in calcium and iron d) A diet rich in fat B - A diet rich in protein  A nutritionist helps to plan a diet for a patient with type 2 diabetes. Which ofthe following foods is a carbohydrate that should be included to help improve glucose tolerance? a) Milk b) Oatmeal c) Nuts d) Eggs B - Oatmeal  You are caring for a patient who has dysphagia and is unable to eat independently. You are preparing to assistthe patient in eating a meal. Which ofthe following actions is appropriate? a) Create a positive social environment by askingthe patient about childhood food memories. b) Arrange food items in a clock face pattern and informthe patient what time on a clock corresponds to each food item. c) Encouragethe patient to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm. d) Speak tothe patient but limitthe need forthe patient to respond verbally while chewing and swallowing. D - Speak tothe patient but limitthe need forthe patient to respond verbally while chewing and swallowing.  A patient is interested in losing 15 pounds, and she informsthe nurse she is counting her calorie intake each day.the patient has a goal of losing 1 pound a week until she reaches her goal.the patient asksthe nurse how many calories she should decrease daily to lose a pound a week. What isthe nurse's best response? a) 300 calories/day b) 400 calories/day c) 200 calories/day d) 500 calories/day D - 500 calories/day  You are using a large syringe to administer an intermittent feeding to a patient who has a nasogastric feeding tube. Which ofthe following methods should you use to increasethe flow rate ofthe formula? a) Attachthe syringe to a syringe pump and setthe infusion rate to 250 mL/hr. b) Raisethe height ofthe syringe. c) Askthe patient to bear down whilethe formula is infusing. d) Usingthe plunger ofthe syringe, steadily infusethe formula overthe desired period of time. D - Usingthe plunger ofthe syringe, steadily infusethe formula overthe desired period of time.  Insertion of a nasogastric tube into a patient who has facial fractures can result in misplacement ofthe tube intothe patient's brain. a) False b) True B - True  Which ofthe following is an appropriate intervention when unexpected situations occur duringthe administration of a tube feeding? a) Ifthe patient complains of nausea after tube feeding, lowerthe head ofthe bed and administer an antiemetic. b) Ifthe tube becomes clogged when aspirating contents, use warm water and gentle pressure to removethe clog. c) Ifthe tube is found to be inthe stomach instead ofthe esophagus, followthe recommended steps to replacethe tube. d) When checking for residue, if a large amount is aspirated, replacethe residue before feeding. B - Ifthe tube becomes clogged when aspirating contents, use warm water and gentle pressure to removethe clog  The AACN has provided a directive regarding best practice for verification of feeding tube placement. Which ofthe following is NOT an expected practice for tube placement? a) Bedside techniques, including measuringthe pH and observingthe appearance of fluid withdrawn fromthe tube, should be used to assess tube location at regular intervals. b)the mark onthe tube's entrance site tothe nose or mouth should be observed routinely to assess for a change in length ofthe external portion ofthe tube. c) Radiographic confirmation of correct tube placement on all critically ill patients who are to receive feedings or medications via blindly inserted gastric or small bowel tubes following initial use. d)the tube's entrance site tothe nose or mouth should be marked andthe length documented immediately after radiographic confirmation of correct tube placement. C - radiographic confirmation of correct tube placement on all critically ill patients who are to receive feedings or medications via blindly inserted gastric or small bowel tubes following initial use.  Which ofthe following is an accurate step when removing a nasogastric tube? a) Before removingthe tube, discontinue suction and separatethe tube from suction. b) Attach a syringe and flush with 30 mL of water or normal saline solution. c) Placethe patient in a protective supine position. d) Quickly and carefully remove tube whilethe patient breathes out. A - Before removingthe tube, discontinue suction and separatethe tube from suction.  Regarding medication administration, what must occur atthe change of shifts? a)the narcotics forthe division are counted b)the LPNs only onthe division count medications c)the medications forthe division are counted d)the client's medications must be drawn up A -the narcotics forthe division are counted  What is involved inthe absorption, distribution, metabolism, and excretion of medication? a) Pharmacodynamics b) Pharmacotherapeutics c) Pharmacology d) Pharmacokinetics D - Pharmacokinetics  A nurse is caring for a client who is being tube fed. What care shouldthe nurse take when administering medications through an enteral tube? a) Avoid crushing sustained-release pellets b) Add medications tothe formula c) Use cold water when mixing powdered medications d) Mix allthe medications together in 15 mL of water A - avoid crushing sustained-release pellets  Ifthe dosage is inappropriate for a client, who is responsible? a) Nurse b) Medical technician c) Physician d) Pharmacist A - Nurse  Which one ofthe following medications would most likely be administered via a transdermal patch? a) Hormonal medications b) Antidepressants c) Antibiotics d) Epinephrine A - Hormonal medications  A nurse is caring for a client undergoing IV therapy.the nurse knows that intravenous administration of medication is appropriate in which ofthe following situations? a) Whenthe drug needs to be administered only once b) Whenthe client wants to avoidthe discomfort of an intradermal injection c) Whenthe drug needs to act onthe client very slowly d) Whenthe client has disorders that affectthe absorption of medications D - Whenthe client has disorders that affectthe absorption of medications  At what point shouldthe nurse performthe first ofthe three checks of medication administration? a) When reviewingthe patient's medication administration record (MAR) b) After retrievingthe drug fromthe drawer of a drug cart c) Asthe nurse reaches forthe drug package or container d) Atthe beginning of a shift C - Asthe nurse reaches forthe drug package or container  A nurse is using an 18-gauge needle to administer a medication to a client.the nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which ofthe following features? a) Shorter length b) Greater length c) Smaller diameter d) Larger diameter D - Larger Diameter  Drugs known to cause birth defects are called a) Pregnancy sensitivity b) Umbilical cross c) Teratogenic d) Nosocomial C - Teratogenic  A nurse is caring for a client with typhoid at a health care facility.the nurse checksthe medication order inthe client's chart forthe drugs prescribed tothe client. Which ofthe following is a required component ofthe medication order? a) Client's age b) Client's name c) Client's diagnosis d) Client's signature A - Clients name  A nurse educator is teaching a student nurse how to choosethe correct needle for an injection. Which ofthe following guidelines for needle selection might they discuss? a) When giving an injection,the amount ofthe medication directsthe choice of gauge. b) When looking at a needle package,the first number isthe length in inches andthe second number isthe gauge or diameter ofthe needle. c)the size ofthe syringe is directed bythe viscosity ofthe medication to be given. d) Asthe gauge number becomes larger,the size ofthe needle becomes smaller. D - Asthe gauge number becomes larger,the size ofthe needle becomes smaller.  Children's medication dosages are most often calculated usingthe child's body surface area and a) Height b) Weight c) Diagnosis d) Age B - Weight  You are preparing to administer a transdermal medication. How should this be accomplished? a) You should injectthe medication into a body cavity. b) You should injectthe medication just belowthe dermis ofthe skin. c) You should applythe medication directly tothe skin. d) You should askthe patient to swallowthe medication. C - You should applythe medication directly tothe skin.  A nurse brings a clientthe prescribed dose of medication and finds thatthe client is not inthe unit. What shouldthe nurse do in this case? a) Informthe head nurse aboutthe client's absence. b) Returnthe medication tothe medication cart or medication room. c) Leavethe medication onthe client's bedside table. d) Informthe physician aboutthe client's absence. B - Returnthe medication tothe medication cart or medication room  An elderly client with pneumonia has been prescribedthe use of a bronchodilator bythe physician. What shouldthe nurse monitor in a client taking an inhaled bronchodilator? a) Heart rate b) Body temperature c) Physical mobility d) Pupil dilation A - Heart rate  A client at a health care facility has been prescribed scopolamine, to be administered transdermally. Which ofthe following statements describes transdermal application? a) Drugs within a thick base applied, not rubbed, intothe skin b) Drugs placed againstthe mucous membrane ofthe inner cheek c) Drugs bonded to an adhesive and applied tothe skin d) Drugs placed underthe tongue and allowed to dissolve slowly C - Drugs bonded to an adhesive and applied tothe skin  Which medication system allows for client independence? a) Self-administered medication system b) Bar Code Medication Administration c) Automated medication-dispensing system d) Unit dose system A - Self-administered medication system  A nurse needs to administer an insulin injection to a client with diabetes. Which ofthe following actions shouldthe nurse perform to prevent bruising ofthe injection site? Select all that apply. a) Changethe needle before injecting b) Avoid aspiratingthe plunger after placingthe needle c) Stretchthe injection site taut before administeringthe injection d) Rotatethe injection sites with each injection e) Massagethe site before administeringthe injection A - Changethe needle before injecting. D - Rotatethe injection sites with each injection B - Avoid aspiratingthe plunger after placingthe needle  A nurse is performing a sensitivity test on a patient. What would bethe best type of injection to use for this procedure? a) Intradermal b) Intramuscular c) Subcutaneous d) None ofthe above A - Intradermal  A nurse at a health care facility has to instill ear drops in a client.the nurse knows that which ofthe following techniques varies for an adult and child client? a) Amount of time before instilling medication inthe client's opposite ear b) Position in whichthe client remains until medication reachesthe eardrum c) Dilution ofthe medication drops before instilling inthe client's ear d) Manipulation ofthe client's ear to straightenthe auditory canal D - Manipulation ofthe medication drops before instilling inthe client's ear  To which ofthe following patients wouldthe nurse be most likely to administer a PRN medication? a) A patient whose asthma is treated with inhaled corticosteroids b) A patient who is complaining of pain near her surgical site c) A patient who requires daily medication to control hypertension d) A patient who is experiencing severe and unprecedented chest pain B - A patient who is complaining of pair near her surgical site  A nurse is administering intermittent IV medication to an active adolescent. Which ofthe following IV systems could be used to allowthe patient more freedom? a) Peripheral venous access device b) Intravenous infusion c) Volume-control administration set d) Continuous intravenous infusion A - peripheral venous access device  When administering heparin subcutaneously,the nurse should a) Never aspirate b) Aspirate beforethe injection c) Aspirate after injection d) Vigorously massagethe site A - Never aspirate  A nurse needs to administer an intradermal injection to a client. Which ofthe following isthe most common site for administering an intradermal injection? a) Chest b) Back c) Forearm d) Stomach C - Forearm  When instructing a client regarding sublingual application,the nurse should informthe client that which ofthe following is contraindicated when administeringthe drug? a) Swallowingthe medication b) Talking when takingthe medication c) Performing physical activities d) Takingthe medication on an empty stomach A - Swallowingthe medication  A nurse is providing care for a patient who has a history of dementia. Which ofthe following methods shouldthe nurse use in order to determinethe patient's identity prior to medication administration? a) Cross-referencethe MAR withthe patient's medical record. b) Askthe patient his or her name prior to givingthe drug. c) Checkthe patient's identification band. d) Enlistthe help of a colleague who is familiar withthe patient. C - Checkthe patient's identification band  A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which ofthe following actions shouldthe nurse perform to prevent gastric reflux? a) Administerthe medication over several minutes. b) Helpthe client into a Fowler's position. c) Check for drug allergies inthe client's history. d) Add diluted medication tothe syringe. B - Helpthe client into a Fowler's position  A nurse needs to administer an intramuscular injection to a thin and frail elderly client. Which ofthe following actions shouldthe nurse perform to avoid strikingthe bone when injecting? a) Pinchthe muscular tissue. b) Obtain an x-ray ofthe injection site. c) Massagethe injection site. d) Inject using subcutaneous rather than intramuscular technique. A - Pinchthe muscular tissue  The Z-track technique is utilized during drug administration by which ofthe following routes? a) Intramuscular b) Intravenous c) Intradermal d) Subcutaneous A - Intramuscular  A nurse is administering a hepatitis B shot intramuscularly. What would bethe appropriate site for administration? a) Scapula b) Ventrogluteal c) Vastuslateralis d) Deltoid D - deltoid  What isthe term used forthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity? a) Half-life b) Peak level c) Trough level d) Therapeutic range D - Therapeutic range  The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which ofthe following represent these five rights? Select all that apply. a) Pharmacy b) Route c) Prescribing physician d) Medication e) Dosage f) Patient Medication Patient Dosage Route  A severe allergic reaction from a medication requires a) Atarax b) Asprin c) Epinephrine d) Dopamine C - Epinephrine  A nurse is administering a prescribed dose of medication to a client through a medication lock. How often shouldthe nurse flushthe medication lock to maintain patency? a) Every 36 to 48 hours b) Every 8 to 12 hours c) Every 1 or 2 hours d) Every 72 to 96 hours B - Every 8-12 hours  Which ofthe following accurately describes a recommended guideline when administering oral medications to patients? a) Assume thatthe patient isthe authority on whether or notthe medication was swallowed. b) If a pill is dropped, it should be briefly immersed in saline to remove any dirt or germs. c) If a child refuses to take medication,the medication can be crushed and added to a small amount of food. d) If a patient vomits immediately after receiving oral medications, readministerthe medication. C - If a child refuses to take medication,the medication can be crushed and added to a small amount of food  A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which ofthe following explains why inhalation is a good route for medication administration? a) It allowsthe lungs to quickly absorbthe medication. b) It prevents unpleasant aftertastes associated with oral medications. c) It eliminatesthe potential of suffocation and asphyxia. d) It eliminates bad breath. It allowsthe lungs to quickly absorbthe medication  A nurse is administering a subcutaneous injection to a client. What isthe common maximum volume of a subcutaneous injection? a) 3 mL b) 0.01 mL c) 1 mL d) 0.05 mL 1 mL  A nurse needs to instill eye medication in a client with conjunctivitis. Which ofthe following actions shouldthe nurse take to distributethe medication overthe surface ofthe eye? a) Askthe client to blink his eye. b) Make a pouch inthe lower eyelid. c) Gently rubthe client's eyelids. d) Instill medication drops inthe upper eyelid. Askthe client to blink his eye  A nurse is administering an injection to a client at a 15-degree angle.the client has a venous access port. Which ofthe following injections can be administered at this angle? a) Intradermal b) Intramuscular c) Intravenous d) Subcutaneous Intravenous  A client with dry skin has been prescribed inunction. Which ofthe following shouldthe nurse do to promote absorption ofthe ointment? a) Rubbingthe ointment intothe skin b) Applying inunction with a cotton ball c) Shakingthe contents ofthe ointment d) Warmingthe inunction before application Rubbingthe ointment intothe skin  A nurse is bunchingthe tissue of a client when administering a subcutaneous injection to a client.the nurse knows that which ofthe following isthe reason for bunching when injecting subcutaneously? a) To prevent needle-stick injuries b) To avoid instilling medication withinthe muscle c) To facilitate blood circulation at injection site d) To ensurethe accuracy of landmarking to avoid instilling medication withinthe muscle  A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which ofthe following isthe most suitable angle when administering an intradermal injection? a) 180-degree angle b) 10-degree angle c) 90-degree angle d) 45-degree angle 10-degree angle  A nurse needs to use a moisturizer for an elderly client with dry skin. Why isthe onset ofthe medication action atypical in an elderly client? a) Diminished subcutaneous fat b) Decreased body temperature c) Diminished physical mobility d) Decreased appetite Diminished subcutaneous fat  A physician at a health care facility suggeststhe use of a metered-dose inhaler for an asthmatic client. Which ofthe following describesthe mechanism of a metered-dose inhaler? a) A device that forces liquid drug through a narrow channel using pressurized air b) A propeller-driven device that spins and suspends a finely powdered medication c) A device that forces medication through a narrow channel withthe help of inert gas d) A canister containing medication that is released whenthe container is compressed A canister containing medication that is released whenthe container is compressed  The process by which a drug moves throughthe body and is eventually eliminated is a) Pharmacokinetics b) Pharmacotherapeutics c) Pharmacology d) Pharmacodynamics Pharmacokinetics  A client with allergy has been advised to have an allergy test.the nurse needs to administer an injection tothe client for allergy testing. Which ofthe following injection routes is most suitable for allergy testing? a) Intramuscular b) Intradermal c) Subcutaneous d) Intravenous Intradermal  A nurse needs to administer a prescribed injection to a toddler. Which ofthe following injection sites is most suitable forthe client? a) Dorsogluteal site b) Ventrogluteal site c) Deltoid site d) Vastuslateralis site Vastuslateralis site  An acute care facility followsthe unit dose supply method to supply medication tothe clients. What is meant bythe unit dose supply method? a) Systems that contain frequently used medication for that unit b) Self-contained packets that hold one tablet or capsule for individual clients c) A supply that remains onthe nursing unit for use in emergency d) A container with enough prescribed medications for several days for a client Self-contained packets that hold one tablet or capsule for individual clients  Medications administered that are renal toxic should have frequent assessments of which blood values? a) WBC and platelets b) BUN and creatinine c) RBC and differential d) AST and ALT BUN and creatinine  A nurse is administering pain medication to an 80-year-old man. What altered drug response might be expected due tothe patient's age? a) Increased possibility of drug toxicity due to increased distribution of water-soluble drugs b) Increased possibility of drug toxicity due to higher drug plasma concentrations c) Decreased gastric pH causing stomach irritation d) Increased excretion of drugs, leading to possible increased serum levels/toxicity Increased possibility of drug toxicity due to higher drug plasma concentrations  A nurse is caring for a client inthe nursing unit whenthe physician, duringthe rounds, prescribes a medication forthe client. What appropriate action shouldthe nurse take to ensurethe accuracy ofthe verbal medication order? a) Askthe physician to repeatthe dosage b) Ask a second nurse to listen for accuracy c) Askthe physician to spell outthe medication name d) Askthe physician to write outthe order Askthe Physician to write outthe order  A nurse atthe health care facility is preparingthe medication dosage for a client. Why shouldthe nurse read and comparethe label onthe medication withthe MAR at least three times (before, during, and after) while preparingthe medication for administration? a) Complies withthe medical order and ensures thatthe right dose is given b) Ensures thatthe medication has been administered tothe right client c) Demonstrates timely administration and compliance withthe medical order d) Ensures thatthe right medication is given atthe right time bythe right route Ensures thatthe right medication is given atthe right time bythe right route  A nurse is using an IV port when administering medication to a client. Which ofthe following IV administrations hasthe greatest potential to cause life-threatening changes? a) Secondary administration b) Electronic infusion device c) Continuous administration d) Bolus administration Bolus administration  A client is ordered to receive an intramuscular injection of medication. When preparing to administerthe injection,the nurse selectsthe ventrogluteal site based on which reason? a)the area is free of major blood vessels and fat. b)the site is in close proximity tothe sciatic nerve. c) There is a high possibility of injecting into subcutaneous fat. d)the site lies close tothe radial nerve. The area is free of major blood vessels and fat  When performing a piggyback infusion,the nurse lowersthe container of primary solution approximately 10 inches belowthe height ofthe secondary solution. Which ofthe following reasons explainsthe nurse's action? a) Instills secondary infusion within specified time b) Prevents backfilling withthe primary solution c) Prevents separation fromthe port d) Uses gravity to infusethe secondary medication uses gravity to infusethe secondary medication  When educating an elderly client aboutthe administration of medication during discharge teaching,the nurse notes thatthe client is having difficulty comprehendingthe instruction. What intervention shouldthe nurse follow in this case to ensurethe client's safety? a) Write discharge instructions onthe medication containers. b) Involve a second responsible person inthe instruction. c) Askthe client's physician to provide instruction. d) Ask a second nurse to repeatthe instruction. Involve a second responsible person inthe instrustion  In administering medications,the five rights include patient, drug, route, and time. What isthe fifth right? a) Heart rate b) Dosage c) Intrathecal d) Pain level Dosage  A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which ofthe following would bethe most effective method to administer this medication? a) Administer a continuous subcutaneous infusion of morphine. b) Administer a piggyback intermittent intravenous infusion of morphine. c) Administer an intermittent intravenous infusion of morphine via a volume-control administration set. d) Administer morphine by intravenous bolus or push through an intravenous infusion. Administer a continuous subcutaneous infusion of morphine  A client has been prescribed nasal medication. What care shouldthe nurse take to avoid potential complications due tothe administration of this medication? a) Read and compare labels onthe medication withthe medical record b) Administer medication within 30 to 60 minutes ofthe scheduled time c) Reviewthe client's medication, allergy, and medical history d) Allow sufficient time to preparethe medication with minimal distraction reviewthe client's medication, allergy, and medical history  A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which ofthe following actions shouldthe nurse perform when administering oral medication tothe client? a) Checkthe label ofthe medication container three times atthe bedside. b) Avoid administering medication prepared by another nurse. c) Bringthe prescribed medication in a ceramic cup or glass container. d) Preparethe exact dosage of medication in front ofthe client. Avoid administering medication prepared by another nurse  When treating a client at a health care facility with nitroglycerin paste, how canthe nurse prevent contamination inthe client during application? a) Place an application paper on a clean area of skin. b) Rotatethe site of medication placement. c) Avoid touchingthe application with bare fingers. d) Remove one application before applying another. avoid touchingthe application with bare fingers  A nurse is using a volume control set to administer a dose of prescribed medication to a client.the nurse opensthe lower clamp untilthe tubing is filled with fluid and then reclamps it. Which ofthe following statements explainsthe nurse's action? a) Purges air fromthe tubing b) Removes colonizing microorganisms c) Mixesthe drug throughoutthe fluid d) Provides diluent forthe medication Purges air fromthe tubing  A nurse is administering medication to a patient via a gastric tube and finds thatthe medicine entersthe tube and thenthe tube becomes clogged. What isthe appropriate intervention in this situation? a) Removethe tube and replace it with a new tube. b) Waitthe prescribed amount of time and attempt to administerthe medication again before callingthe physician. c) Use a syringe to plungethe tube to try to dislodgethe medication. d) Callthe physician before instituting any corrective interventions. Use a syringe to plungethe tube to try to dislodgethe medication  A nurse is applying a vaginal cream to a patient with a vaginal infection. Which ofthe following is a recommended guideline for this application? a) Spreadthe labia with dominant hand and introducethe applicator withthe nondominant hand gently, using pushing motion. b) Cleanse area at vaginal orifice with washcloth and warm water. c) Positionthe patient inthe prone position. d) Wipe fromthe sacrum tothe vaginal orifice upward (back to front). Cleanse area at vaginal orifice with washcloth and warm water.  Upon assessment of a patient's wound,the nurse notesthe formation of granulation tissue.the tissue easily bleeds whenthe nurse performs wound care. What isthe phase of wound healing characterized bythe nurse's assessment? a) Maturation phase b) Hemostasis c) Proliferation phase d) Inflammatory phase Proliferation Phase  Which ofthe following activities shouldthe nurse implement to decrease shearing force onthe client with a stage II pressure ulcer? a) Supportthe client from sliding in bed b) Improvethe client's hydration c) Lubricatethe area with skin oil d) Pull client up underthe arms Supportthe client from sliding in bed  When measuringthe size, depth, and wound tunneling of a patient's stage IV pressure ulcer, what action shouldthe nurse perform first? a) Insert a swab intothe wound at 90 degrees. b) Perform hand hygiene. c) Assessthe condition ofthe visible wound bed. d) Measurethe width ofthe wound with a disposable ruler. Perform hand hygiene  A nurse assessingthe wound healing of a patient, documents thatthe wound formed a clean, straight line with little loss of tissue. This wound healed by: a) Primary intention b) Secondary intention c) Tertiary intention d) None ofthe above Primary intention  A nurse is removing sutures fromthe surgical wound of a patient after an appendectomy and notices thatthe sutures are encrusted with blood and difficult to pull out. What would bethe appropriate intervention in this situation? a) Pickthe crusts offthe sutures withthe forceps before removing them. b) Washthe sutures with warm, sterile water and an antimicrobial soap before removing them. c) Do not attempt to removethe sutures because they need more time to heal. d) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures  Upon responding tothe patient's call bell,the nurse discoversthe patient's wound has dehisced. Initial nursing management includes callingthe physician and which ofthe following? a) Pouring sterile hydrogen peroxide intothe abdominal cavity and packing with gauze b) Coveringthe wound area with sterile towels moistened with sterile 0.9% saline c) Holdingthe wound together untilthe physician arrives d) Closingthe wound area with Steri-Strips Coveringthe wound area with sterile towels moistened with sterile 0.9% saline  A nurse caring for a patient who has a surgical wound following a cesarean section notes dehiscence ofthe wound and contactsthe surgeon. Which ofthe following is a finding related to this condition? a)the edges ofthe wound are lightly pulled together. b) There is an accumulation of fluid inthe interstitial tissue. c) There is redness or inflammation of an area as a result of dilation. d) There is an accidental separation ofthe wound. There is an accidental separation ofthe wound  An elderly patient has been admitted tothe hospital with dehydration, andthe nurse has inserted a peripheral intravenous line intothe patient's forearm in order to facilitate rehydration. What type of dressing shouldthe nurse apply overthe patient's venous access site? a) A gauze dressing precut halfway to fit aroundthe IV line b) A transparent film c) A dressing with a nonadherent coating d) A gauze dressing premedicated with antibiotics A transparent film  A nursing student is providing a complete bed bath to a 60-year-old diabetic client.the student is conducting an assessment duringthe bath.the student observes a red raised rash underthe client's breasts. This manifestation is most consistent with which ofthe following conditions? a) A rash related to immobility b) A rash related to a yeast infection c) An allergic reaction to medications d) An allergic reaction to detergent A rash related to a yeast infection  A nurse notes a number of laceration wounds aroundthe cervix ofthe uterus due to childbirth. How couldthe nurse describethe laceration wound inthe client's medical record? a) A separation of skin and tissue in whichthe edges are torn and irregular b) A clean separation of skin and tissue with a smooth, even edge c) A shallow crater in which skin or mucous membrane is missing d) A wound in whichthe surface layers of skin are scraped away A separation of skin and tissue in whichthe edges are torn and irregular  A nurse is treatingthe pressure ulcer of an African American patient. How wouldthe nurse assess for deep tissue injury in this patient? a) Upon palpation,the nurse determines thatthe area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue. b) Upon inspectionthe nurse would notice a purple or maroon localized area of discolored intact skin. c) Upon inspectionthe nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. d) Upon inspection,the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Upon palpation,the nurse determines thatthe area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue  Dehiscence isthe softening of tissue due to excessive moisture. a) False b) True False  A medicalsurgical nurse is assisting a wound care nurse withthe debridement of a patient's coccyx wound. What isthe primary goal of these nurses' action? a) Stimulatingthe wound bed to promotethe growth of granulation tissue b) Removing purulent drainage fromthe wound bed in order to accurately assess it c) Removing dead or infected tissue to promote wound healing d) Removing excess drainage and wet tissue to prevent maceration of surrounding skin Removing dead or infected tissue to promote would healing  A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describesthe common skin characteristics in a child? a) A child's skin becomes less resistant to injury and infection asthe child grows. b) An individual's skin changes little overthe life span. c) In children younger than 2 years,the skin is thicker and stronger than in adults. d) An infant's skin and mucous membranes are easily injured and at risk for infection. aninfants skin and mucous membranes are easily injured and at risk for infection  The nurse would recognize which ofthe following patients as being particularly susceptible to impaired wound healing? a) A patient whose breast reconstruction surgery required numerous incisions b) An obese woman with a history of type 1 diabetes mellitus c) A patient who is NPO (nothing by mouth) following bowel surgery d) A man with a sedentary lifestyle and a long history of cigarette smoking An obese woman with a history of type 1 diabetes mellitus  A home care nurse is visiting an older adult client. Duringthe visit,the client's spouse sustains a minor thermal injury when cooking.the nurse intervenes, doing which ofthe following first? a) Apply any antimicrobial ointment available at home b) Pull off any clothes sticking tothe burnt area c) Flushthe area with copious amounts of cool water d) Refrain from removing any ofthe client's jewelry Flushthe area with copious amounts of cool water  A nurse notes a number of laceration wounds aroundthe cervix ofthe uterus due to childbirth. How couldthe nurse describethe laceration wound inthe client's medical record? a) A clean separation of skin and tissue with a smooth, even edge b) A shallow crater in which skin or mucous membrane is missing c) A wound in whichthe surface layers of skin are scraped away d) A separation of skin and tissue in whichthe edges are torn and irregular A separation of skin and tissue in whichthe edges are torn and irregular  You are preparing to measurethe depth of a patient's tunneled wound. Which ofthe following implements should you use to measurethe depth accurately? a) A sterile tongue blade lubricated with water soluble gel b) Anotic curette c) A sterile, flexible applicator moistened with saline d) A small plastic ruler A sterile flexible applicator moistened with saline  A nurse is cleaningthe wound of a gunshot victim. Which ofthe following is a recommended guideline for this procedure? a) Oncethe wound is cleaned, drythe area with an absorbent cloth. b) Use clean technique to cleanthe wound. c) Cleanthe wound fromthe bottom tothe top and outside to center. d) Cleanthe wound fromthe top tothe bottom and center to outside. Cleanthe would fromthe top tothe bottom and center to outside  The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention.the patient asks, "Why is my wound still open? Will it ever heal?" Which ofthe following responses bythe nurse is most appropriate? a) "As soon asthe infection clears, your surgeon will staplethe wound closed." b) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." c) "Your wound will heal slowly as granulation tissue forms and fillsthe wound." d) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." Your wound will heal slowly as granulation tissue forms and fillsthe wound  Upon assessment ofthe skin of a patient recovering from cardiac surgery,the nurse notes that ecchymosis is present aroundthe incision. What arethe physical findings of this condition? a) A purplish discoloration due to a collection of blood inthe subcutaneous tissues b) Small hemorrhagic spots caused by capillary bleeding c) Softening of tissue due to excessive moisture d) Accumulation of fluid inthe interstitial tissues A purplish discoloration due to a collection of blood inthe subcutaneous tissues  While performing a bedbath, you noted an area of tissue injury onthe patient's sacral area.the wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which ofthe following isthe correct name of this wound? a) Stage I pressure ulcer b) Stage IV pressure ulcer c) Stage II pressure ulcer d) Stage III pressure ulcer Stage II pressure ulcer  You are applying a saline-moistened dressing to a patient's wound.the patient asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which ofthe following responses is most appropriate? a) "Allowing a scab to form would prevent us from observingthe wound for signs of infection." b) "This wound is too large for a scab to form over it, so a moist dressing isthe best alternative." c) "Wounds heal better when a moist wound bed is maintained." d) "You may be correct. I will check with your primary healthcare provider." Wounds heal better when a moist wound bed is maintained  A nurse inspecting a patient's pressure ulcer documentsthe following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which ofthe following stages? a) Stage II b) Stage III c) Stage IV d) Stage I State III  A nurse bandagesthe knee of a client who has recently undergone a knee surgery. Which ofthe following isthe major purpose ofthe bandage? a) Reduces swelling and inflammation b) Supportsthe area aroundthe wound c) Maintains a moist environment d) Keepsthe wound clean Supportsthe area aroundthe knee  A nurse caring for a post-operative client observesthe drainage inthe client's closed wound drainage system.the drainage is thin with a pale pink-yellow color.the nurse documentsthe drainage as which ofthe following? a) Serosanguineous b) Serous c) Sanguineous d) Purulent Serosanguineous  A Penrose drain typically exits a patient's skin through a stab wound created bythe surgeon. a) True b) False True  What type of dressing hasthe advantages of remaining in place for 3 to 7 days, resulting in less interference with wound healing? a) Hydrogels b) Alginates c) Transparent films d) Hydrocolloid dressings Hydrocolloid dressings  An elderly client has edema ofthe right lower extremity with redness and clear drainage. This is most likely related to a) Venous insufficiency b) Age c) Beta-hemolytic streptococcus d) Hemangioma Venous insufficiency  Inthe elderly client, wrinkling is related to a) Loss of elasticity b) Loss of circulation c) Loss of fat d) Loss of protein loss of elasticity  The nurse is caring for a woman has a labile carbuncle. Which ofthe following interventions will most likely be included inthe plan of care? a) Soak in a warm bath for drainage b) Exposethe area to a heat lamp c) Cleanse labia with scented soap d) Apply an ice pack to relieve pain Soak in a warm bath for drainage  A postoperative client describesthe following during a transfer, "I feel like something just popped."the nurse immediately assesses for a) Herniation b) Dehiscence c) Evisceration d) Infection Dehiscence  Which ofthe following nutrients will prevent abnormal pigmentation? a) Vitamin D b) Vitamin E c) Fat d) Copper Vitamin E  The nurse would recognize which of these devices as an open drainage system? a) Jackson-Pratt drain b) Negative pressure dressing c) Hemovac d) Penrose drain Penrose drain  The wound care nurse evaluates a patient's wound after being consulted.the patient's wound healing has been slow. Upon assessment ofthe wound,the wound care nurse informsthe medical-surgical nurse thatthe wound healing is being delayed due to patient's state of dehydration and dehydrated tissues inthe wound that are crusty. What is another term for localized dehydration in a wound? a) Necrosis b) Maceration c) Evisceration d) Desiccation Desiccation  A client has a small wound with moderate drainage.the nurse should apply a) Hydrogels b) Collagens c) Hydrophilic polyurethane d) Silver dressings Hydrogels  Upon review of a postoperative patient's medication list,the nurse recognizes that which medication will delaythe healing ofthe operative wound? a) Antihypertensive drugs b) Corticosteroids c) Potassium supplements d) Laxatives Corticosteroids  A nurse applies an aquathermia pad onthe back of a patient with arthritis. What isthe expected action that will occur with this application of heat? a) Decreased blood flow tothe area b) Dilated peripheral blood vessels c) Decreased inflammatory response d) Increased venous congestion Dilated peripheral blood vessels  A nurse prepares to give a sitz bath to a client after perianal surgery. Which ofthe following would be most important forthe nurse to do? a) Assess for rapid pulse and facial pallor b) Keepthe feet and torso uncovered c) Encourage use of sitz bath for about an hour d) Maintainthe temperature of water at 100F Assess for a rapid pulse and facial pallor  You are caring for a patient who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removingthe old dressing, you note thatthe packing material is dry and adheres tothe wound bed. Which ofthe following modifications is most appropriate? a) Reducethe time interval between dressing changes. b) Use less packing material. c) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. d) Assure thatthe packing material is completely saturated when placed inthe wound. Reducethe time interval between dressing changes  It is customary forthe registered nurse to performthe initial postoperative dressing change. a) True b) False False  A nurse is treatingthe pressure ulcer onthe scapula of a bedridden patient. Which ofthe following must be used during this procedure? a) Sterile Technique b) Clean technique c) Transmission-Based Precautions d) Aseptic technique Clean Technique Chapter 29: Medications  A nurse is administering a subcutaneous injection to a client. What isthe common maximum volume of a subcutaneous injection? 1 mL  Drugs known to cause birth defects are called Teratogenic  What is involved inthe absorption, distribution, metabolism, and excretion of medication? Pharmacokinetics  A client is ordered to receive an intramuscular injection of medication. When preparing to administerthe injection,the nurse selectsthe ventrogluteal site based on which reason? free of major blood vessels and fat. It is consideredthe safest and least painful site  A nurse is providing care for a patient who has a history of dementia. Which ofthe following methods shouldthe nurse use in order to determinethe patient's identity prior to medication administration? Checkthe patient's identification band.  The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate forthe nurse to follow when administering a drug via this route? positionthe patient withthe head ofthe bed elevated, administeringthe medication at room temperature, flushingthe tube with water between each drug administered, and avoidingthe use of suction for 20 to 30 minutes afterthe drug is administered  A nurse is reviewing information about prescribed drug in a drug handbook in preparation for administration to a client. When reading aboutthe drug,the nurse identifies which name asthe generic name? Ampicillin sodium  A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which ofthe following responsibilities doesthe nurse have to complete when handling narcotic medications? Select all that apply • Maintain an accurate account ofthe use ofthe medication • Record each medication used fromthe stock supply • Count each narcotic medication atthe change of each shift  A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which ofthe following actions shouldthe nurse perform to prevent gastric reflux? Helpthe client into a Fowler's position  A nurse is caring for a client inthe nursing unit whenthe physician, duringthe rounds, prescribes a medication forthe client. What appropriate action shouldthe nurse take to ensurethe accuracy ofthe verbal medication order? askthe physician for a written order. When obtaining phone orders, it is important to repeatthe dosages of medications and to spell medication names for confirmation of accuracy  A nurse needs to administer a subcutaneous heparin injection to a client. Which ofthe following injection sites is most suitable for heparin? The abdomen, because of less pain intensity  You are preparing to administer a sublingual medication. Which ofthe following instructions tothe patient is correct? not to swallow whilethe pill dissolves  Which one ofthe following medications would most likely be administered via a transdermal patch? hormones, narcotic analgesics, cardiac medications, and nicotine  The primary reason forthe Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws  A nurse is explaining to a clientthe correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which ofthe following is a feature of a metered-dose inhaler? It is a canister that contains pressurized medication  A nurse atthe health care facility needs to instill eye medication in a client with conjunctivitis. What care shouldthe nurse take to avoid injury when instillingthe medication? Askthe client to blink his eye  You are preparing to administer a transdermal medication. How should this be accomplished? adsorbed throughthe skin  A nurse needs to use a moisturizer for an elderly client with dry skin. Why isthe onset ofthe medication action typical in an elderly client? Diminished subcutaneous fat  An elderly client with pneumonia has been prescribedthe use of a bronchodilator bythe physician. What shouldthe nurse monitor in a client taking an inhaled bronchodilator? heart rate and blood pressure ofthe elderly client who uses inhaled bronchodilators. It is important to monitorthe vital signs because these medications commonly cause tachycardia and hypertension. Either or both of these effects increasethe risks of complications, especially in elderly clients with underlying cardiovascular disease  A patient with chronic obstructive pulmonary disease has been prescribed an inhaled bronchodilator. Which ofthe following techniques shouldthe nurse implement in order to ensure safe and complete delivery ofthe prescribed medication? The use of an extender or spacer ensures thatthe patient receives as much ofthe inhaled medication as possible  Regarding medication administration, what must occur atthe change of shifts? perform a count of controlled medications at specified times (each shift) or when removed from an automated dispensing machine  The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which ofthe following represent these five rights? (1) Right medication is given tothe (2) right patient inthe (3) right dosage throughthe (4) right route atthe (5) right time  To which ofthe following patients wouldthe nurse be most likely to administer a PRN medication? A complaint of "breakthrough" pain, especially postsurgery  The nurse of a newly admitted patient notes a penicillin allergy, yetthe physician has just written an order for an antibiotic inthe same drug family; after reviewingthe patient's wound culture and sensitivity. How shouldthe nurse respond to this situation? Withholdthe medication untilthe potential drug allergy has been addressed bythe care team  What isthe term used forthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity? Therapeutic range  Children's medication dosages are most often calculated usingthe child's body surface area and Weight  A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which ofthe following isthe most suitable angle when administering an intradermal injection? holdthe syringe almost parallel to skin at a 10-degree angle withthe bevel pointing upward. This facilitates deliveringthe medication betweenthe layers ofthe skin and advancesthe needle tothe desired depth  A client with dry skin has been prescribed inunction. Which ofthe following shouldthe nurse do to promote absorption ofthe ointment? rubthe ointment intothe client's skin  The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? standing order, which is to be carried out as specified until it is cancelled by another order  Which organ isthe primary site for drug metabolism?  A nurse has to administer a subcutaneous injection to a client. For which ofthe following clients canthe nurse administer a subcutaneous injection at a 90-degree angle? in a normal-size or obese client who has a 2-inch tissue fold when it is bunched. For thin clients who have a 1-inch fold of tissue,the nurse insertsthe needle at a 45-degree  A nurse educator is teaching a student nurse how to choosethe correct needle for an injection. Which ofthe following guidelines for needle selection might they discuss? The largerthe gauge,the smallerthe needle  A nurse is using an 18-gauge needle to administer a medication to a client.the nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which ofthe following features? For most injections, 18- to 27-gauge needles are used;the smallerthe number,the largerthe diameter  Medications administered that are renal toxic should have frequent assessments of which blood values? BUN and creatinine  A nurse is bunchingthe tissue of a client when administering a subcutaneous injection.the nurse knows that which ofthe following isthe reason for bunching when injecting subcutaneously? Nurses bunch tissue betweenthe thumb and fingers before administeringthe injection to avoid instilling medication withinthe muscle  A nurse at a health care facility administers a prescribed drug to a client and does not record doing so inthe medical administration record.the nurse who comes duringthe next shift, assuming thatthe medication has not been administered, administersthe same drug tothe client again.the nurse onthe previous shift calls to informthe health care facility thatthe administration ofthe drug to this client inthe earlier shift was not recorded. What shouldthe nurse on duty do immediately upon detection ofthe medication error? immediately checkthe client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintainthe client's safety. As soon asthe nurse recognizes an error, he or she should checkthe client's condition and reportthe mistake tothe prescriber and supervising nurse immediately.  A nurse needs to administer an intramuscular injection to a thin and frail elderly client. Which ofthe following actions shouldthe nurse perform to avoid strikingthe bone when injecting? The muscular tissue should be pinched together to avoid strikingthe bone when administering an intramuscular injection ifthe older person has decreased subcutaneous fat  A nurse is caring for a client undergoing IV therapy.the nurse knows that intravenous administration of medication is appropriate in which ofthe following situations? when clients have disorders, such as severe burns, that affectthe absorption and metabolism of medications. IV therapy is also used in an emergency when a quick response is needed  A nurse is usingthe Z-track technique to administer an injection to a client. Which ofthe following injection routes utilizesthe Z-track technique? Intramuscular  A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which ofthe following precautions shouldthe nurse take when combining drugs? Withdraw exact amounts of each drug from each container  A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which ofthe following precautions shouldthe nurse take when storing narcotic medications? place narcotic drugs in a double-locked drawer. Narcotics are controlled substances, meaning that federal laws regulate their possession and administration  The process by which a drug moves throughthe body and is eventually eliminated is Pharmacokinetics isthe process by which a drug moves throughthe body and is eventually eliminated  A severe allergic reaction from a medication requires anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuingthe medication and administering epinephrine, IV fluids, and antihistamines  A nurse is assigned to a nursing unit where bar-coded identification systems are used for medication distribution. Which ofthe following shouldthe nurse do when administering medication to clients wearing bar-coded identification bracelets? • Scanthe client's identification bracelet • Tallythe bar code with packaged medication • Check for client confirmation bythe system  Which ofthe following patients receives a drug that requires parenteral route? drugs administered by intravenous, injections, & syringe  An acute care facility followsthe unit dose supply method to supply medication tothe clients. What is meant bythe unit dose supply method? self-contained packets hold one tablet or capsule for an individual client  A nurse is administering a prescribed intramuscular injection to a client bythe Z-track technique. Which ofthe following actions ensures thatthe medicine remains sealed? pullthe tissue laterally untilthe tissue is taut  A client has been prescribed nasal medication. What care shouldthe nurse take to avoid potential complications due tothe administration of this medication? Reviewthe client's medication, allergy, and medical history  A nurse is administering medication to a patient with a gastrointestinal tube. Which ofthe following is a recommended guideline for medication administration using this route? Medications should be crushed to a fine powder and mixed with 15 to 30 mL of water before delivery throughthe tube. Use liquid medications when possible, because they are readily absorbed and less likely to cause tube occlusions  A nurse needs to administer a prescribed injection to a toddler. Which ofthe following injection sites is most suitable forthe client? vastuslateralis site isthe most desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles  Ifthe dosage is inappropriate for a client, who is responsible? Whereas physicians and other healthcare providers prescribe and pharmacists dispense therapeutic agents, it isthe nurse's legal domain to administer medications in a safe and timely manner  The nurse is caring for a client who has problems coordinating his breathing withthe inhaler use. Therefore,the client is unable to receivethe full dose. Which ofthe following would help maximize drug absorption in this client? A spacer would help maximizethe absorption ofthe drug in a client who is having problems coordinating his breathing withthe inhaler use. A spacer provides a reservoir forthe aerosol medication. Asthe client takes additional breaths, he continues to inhalethe medication held inthe reservoir. This tends to maximizethe drug's absorption because it prevents drug loss  A nurse is using a volume control set to administer a dose of prescribed medication to a client.the nurse opensthe lower clamp untilthe tubing is filled with fluid and then reclamps it. Which ofthe following statements explainsthe nurse's action? purges air fromthe tubing  When instructing a client regarding sublingual application,the nurse should informthe client that which ofthe following is contraindicated when administeringthe drug? the client should avoid swallowing or chewingthe medication. Eating or smoking during administration is also contraindicated  A nurse should readthe instructions stated on a vial container before reconstituting it and administering it to a client. Which ofthe following instructions are stated onthe label of a vial container? Amount of diluent to be added  A nurse is administering a prescribed dose of medication to a client through a medication lock. How often shouldthe nurse flushthe medication lock to maintain patency? flush medication locks every 8 to 12 hours with saline or heparin  A nurse is administering an injection to a client at a 15-degree angle.the client has a venous access port. Which ofthe following injections can be administered at this angle? When giving an intradermal injection, instillsthe medication shallowly at a 10- to 15-degree angle of entry  Which ofthe following are recommended guidelines forthe nurse who is administering a piggyback intermittent intravenous infusion of medication? Attach infusion tubing tothe medication container by insertingthe tubing spike intothe port with a firm push and twisting motion  When administering heparin subcutaneously,the nurse should Never aspirate  If an elderly client is having difficulty comprehendingthe discharge instruction,the nurse should involve a second responsible person inthe instruction in order to ensure client safety A referral for skilled nurse visits is appropriate for homebound older adults who need additional instructions about medication routines after discharge  A nurse is caring for a client with difficulty breathing due to nasal congestion. What care shouldthe nurse take to preventthe client from inhaling large droplets ofthe medication whenthe nasal spray is being administered? instructthe client to breathe through her mouth. Placethe tip ofthe container just insidethe nostril confinesthe spray withinthe nasal passage. In order to facilitate depositingthe drug where its effect is desired,the nurse should helpthe client to a sitting or lying position with her head tilted backward or tothe side ifthe drug needs to reach one orthe other sinus  The nurse is preparing to administer meperidine (Demerol) as an intramuscular injection in an adult patient's deltoid site. Which ofthe following needles shouldthe nurse select for this injection? 1" with a 22 gauge  A nurse atthe health care facility needs to administer an otic application for a client with an earache. What shouldthe nurse do after instillingthe prescribed eardrops inthe client's ear? askthe client to maintainthe position untilthe solution travels towardthe eardrum. When instillingthe medication inthe client's ear,the nurse first manipulatesthe client's ear to straightenthe auditory canal. Tiltingthe client's head away,the nurse then administersthe prescribed number of drops of medication.the client remains in this position briefly asthe solution travels towardthe eardrum.the nurse then places a cotton ball loosely inthe ear to absorbthe excess medication.the nurse then waits for at least 15 minutes before administeringthe medication inthe opposite ear if prescribed  A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which ofthe following would bethe most effective method to administer this medication? a continuous subcutaneous infusion of morphine - longer rate of absorption  A nurse is caring for a client with an intravenous catheter. When administering medication throughthe intravenous port,the nurse pinchesthe tubing upstream fromthe port when instilling it withthe drug. Which ofthe following reasons explainsthe nurse's action? Ensure administration of medication. Pinching ensures thatthe tube does not get backfilled and thatthe drug gets administered tothe client  A nurse needs to administer a prescribed medication to a client using IV push. In which ofthe following ways isthe medication being administered tothe client? A bolus is a large amount of medication given all at once; bolus administration is described as a drug given by IV push, or rapid IV  The physiologic and biochemical effects of a drug Pharmacodynamics refers tothe physiologic and biochemical effects of a drug onthe body  Which ofthe following medication-administration systems protectsthe client by identifyingthe rights of medication administration? The Barcode Medication Administration system will warn of a potential error  A nurse is applying a vaginal cream to a patient with a vaginal infection. Which ofthe following is a recommended guideline for this application? Cleanse area at vaginal orifice with wash cloth and warm water  After teaching a group of nursing students about pharmacokinetics,the instructor determines thatthe teaching was successful whenthe students identify which ofthe following asthe process by whichthe medication is delivered tothe target cells and tissues? distribution, absorption isthe process by which a medication entersthe bloodstream  A nurse caring for a client with diarrhea needs to establish an intravenous (IV) access to administer fluids and medication. When explaining intravenous access tothe client, which ofthe following wouldthe nurse most likely incorporate intothe description? Insertion of a needle into a peripheral vein  A client suffers from infectious diarrhea. Based on his loss of fluid, his protein level is below normal. What blood product willthe physician order to restore intravascular volume? Albumin  The maintenance of client safety with medication administration is of primary importance in healthcare.the most commonly used system for billing and record keeping is the Automated dispensing system - keeps an account of all medication used for billing, controlled substance & record keeping. Access by using a password or by fingerprint.the medication is delivered in a unit-dose package.  A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which ofthe following actions shouldthe nurse perform when administering oral medication tothe client? never administer medications prepared by another nurse. Prepare and bring oral medications tothe client's bedside in a paper or plastic cup, not in a glass container or ceramic cup, in order to avoid accidents and spills. Checkthe label ofthe medication container three times when preparing it  During a visit tothe clinic,the physician prescrbes an intramuscular injection of a medication for an 8-month old. When administering this medication tothe child, which ofthe following sites wouldthe nurse be least likely to select? The dorsogluteal is not used in infants and toddlers. Muscles in this site are not well developed until children begin to walk  A nurse is administering intermittent IV medication to an active adolescent. Which ofthe following IV systems could be used to allowthe patient more freedom? A peripheral venous access device allowsthe patient more freedom.the patient is connected tothe IV line when it is time to receivethe medication and disconnected whenthe medication is completed.the device is kept patent (working) by flushing with small amounts of saline pushed throughthe device on a routine basis  A nurse is administering medication to a patient via a gastric tube and finds thatthe medicine entersthe tube and thenthe tube becomes clogged. What isthe appropriate intervention in this situation? When medication becomes clogged inthe tube, you should attach a 10-mL syringe ontothe end ofthe tube, pull back, and then lightly apply pressure tothe plunger in a repetitive motion  A nurse needs to administer an insulin injection to a client with diabetes. Which ofthe following actions shouldthe nurse perform to prevent bruising ofthe injection site? Select all that apply. • Changethe needle before injecting • Rotatethe injection sites with each injection • Avoid aspiratingthe plunger after placingthe needle  A nurse needs to administer medications to a client through an IV port. Which ofthe following actions should she perform to ascertain thatthe IV catheter is inthe vein? The nurse should observe for blood inthe tubing nearthe IV catheter or insertion device because blood validates thatthe IV catheter is inthe vein  A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which ofthe following actions should she perform to ensure that allthe medication is equally distributed when withdrawing? Tappingthe top ofthe ampule distributes allthe medication tothe lower portion ofthe ampule  A nurse is caring for a client who is being tube fed. What care shouldthe nurse take when administering medications through an enteral tube? avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption  A nurse is administering enoxaparin, (blood thinner) to a patient with DVT, viathe subcutaneous route. Which ofthe following is a recommended guideline when administering a subcutaneous injection? Subcutaneous injections are administered intothe adipose tissue layer just belowthe epidermis and dermis  A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to Provide access forthe administration of insulin  Which parenteral route of administration hasthe longest absorption time? Intradermal injections administered intothe dermis, just belowthe epidermis, this route hasthe longest absorption time  A post-surgical patient's MAR provides for PRN administration of a number of analgesics by various routes. Which ofthe following routes will likely providethe most rapid pain relief forthe patient? Intravenous drugs, because they are introduced directly intothe circulatory system  A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline.the nurse understand that this type of infusion is used for which situation? Medications that need to be infused over 20 to 60 minutes  Which ofthe following actions are included inthe required "checks" for safe medication administration? Select all that apply. • Readthe medication label when reaching forthe unit dose package. • Readthe medication label after retrievingthe medication fromthe drawer. • Readthe medication label just before administering a unit dose medication tothe patient.  A nurse is administering pain medication to an 80-year-old woman. What altered drug response might be expected due tothe patient's age? Increased possibility of toxicity due to higher drug plasma concentrations & a decreased number of protein-binding sites  The nurse is administering a hepatitis B shot intramuscularly. What would bethe appropriate site for administration? the deltoid, children are administered atthe vastuslateralis  What is an venous access port? for patients who require long-term IV medication.the port is usually placed just underthe skin onthe upper part ofthe chest  Subcutaneous injections administered intothe adipose tissue layer The nurse is unable to palpatethe dorsalis pedis pulse on an older adult client. Which ofthe following would be most appropriate forthe nurse to do next? Use Doppler ultrasonography to locatethe pulse. A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable.the nurse would need to attempt to assessthe pulse, and ifthe pulse could not be obtained via Doppler, then it would be appropriate to documentthe absence ofthe pulse and include attempts to assess it, such as via palpation and Doppler ultrasound. Asking another nurse to assessthe pulse would be helpful in confirmingthe finding, especially if no pulse was obtained via Doppler. Auscultating with a stethoscope would not be helpful.  When analyzingthe nursing history recently taken on a client, which factor would alertthe nurse to a significantly increased risk for chronic arterial insufficiency? Cigarette smoking The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency.the risk increases according tothe length of time a person smokes and amount of tobacco smoked. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage tothe blood vessels. Alcohol intake is unrelated tothe development of chronic arterial insufficiency.  A nurse observes a decrease in hair onthe lower extremities of an elderly client. What is an appropriate action bythe nurse in regards to this finding? Elevatethe legs and observe forthe onset of pallor. Loss of hair can be a normal finding inthe elderly client, butthe nurse should perform further assessment before making this judgment. Loss of hair is seen with arterial insufficiency. Ulcers onthe medial aspect ofthe ankle are a sign of venous stasis as isthe presence of edema. Pallor, or loss of color, is seen in arterial insufficiency, especially whenthe legs are elevated.  Which ofthe following assessment findings is most congruent with chronic arterial insufficiency? Cool foot temperature and ulceration onthe client's great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.  The nurse documents a 2+ radial pulse. What assessment data indicated this result? brisk, expected (normal) pulse  A client reports pain inthe legs that begins with walking but is relieved by rest. Which condition shouldthe nurse assessthe client for? Peripheral vascular problems The nurse should assessthe client for peripheral vascular problems in boththe legs. Intermittent claudication is a condition that indicates vascular deficiencies inthe peripheral vascular system. In case of an acute obstruction,the leg pain would persist even whenthe client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.  When assessingthe lymph system of a 52-year-old patient,the nurse notes thatthe epitrochlear nodes are nonpalpable. What does this indicate? Normal finding Normally,the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpableepitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence  A nurse is unable to palpate a client's radial and ulnar pulses. Which ofthe following wouldthe nurse do next? Palpatethe brachial pulse. When unable to palpate a peripheral pulse,the pulse area immediately proximal to it should be palpated. In this case,the brachial pulse is indicated. Inability to palpatethe client's pulses suggests arterial insufficiency.  Walking contractsthe calf muscles and forces blood away fromthe heart. False  While performing a routine check-up on an 81-year-old retired grain farmer inthe vascular surgery clinic,the nurse notes that he has a history of chronic arterial insufficiency. Which ofthe following physical examination findings ofthe lower extremities would be expected with this disease? Thin, shiny, atrophic skin Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiencythe skin often has a brown pigmentation and may be thickened.  Which ofthe following wounds is most likely attributable to neuropathy? A painless wound onthe sole ofthe client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such asthe sole ofthe foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.  If palpable, superficial inguinal nodes are expected to be: Nontender, mobile, and 1 cm in diameter Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.  A client asksthe nurse aboutthe function thatthe lymph system plays inthe body. Which ofthe following would be most appropriate forthe nurse to include when responding tothe client? It filters harmful substances fromthe body. Explanation:the lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them tothe venous system.the system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced bythe immune system.  Which ofthe following clients is most likely atthe greatest risk of acute compartment syndrome? A 17-year-old who has just been fitted with an arm cast following a fracture of his radius Application of a cast that is too tight is a central risk factor forthe development of compartment syndrome. Immobility and smoking are not key tothe development of compartment syndrome, while pregnancy and IV drug use constitute a risk of thrombosis.  A nurse cares for a client who is postoperative cholecystectomy. Which action bythe nurse is appropriate to help preventthe occurrence of venous stasis? Assistthe client to walk as soon and as often as possible. Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as havingthe client ambulate as soon as possible will stimulate circulation and venous return. This reducesthe possibility of clot formation. Raisingthe foot ofthe bed, vigorous massage, and active range of motion ofthe upper body may not prevent venous stasis.  The nurse is palpatingthe pulse just underthe inguinal ligament.the nurse is assessing which pulse? Femoral The femoral pulse is palpated inthe groin (inguinal area) by compressingthe femoral artery between skin and bone.the temporal pulse is located onthe head.the brachial pulse is palpated medial tothe biceps tendon in and abovethe bend inthe elbow.the popliteal pulse is palpated behindthe knee.  A finding on palpation that suggests venous insufficiency is: Diminished dorsalis pedis pulse in an edematous foot Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be onthe sides ofthe foot and temperature is usually normal. Sensation does not tend to diminish.  A 57-year-old maintenance worker comes tothe office for evaluation of pain in his legs. He is a two-pack per day smoker sincethe age of 16, but he is otherwise healthy.the nurse is concerned thatthe client may have peripheral vascular disease. Which ofthe following is part of common or concerning symptoms forthe peripheral vascular system? Intermittent claudication Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.  The veins from where drain intothe superior vena cava? (Mark all that apply.) • Upper torso • Head • Upper extremities The veins ofthe upper extremities, upper torso, head, and neck drain intothe superior vena cava and thenthe right atrium.  When administering heparin subcutaneously,the nurse should Never aspirate When administering heparin subcutaneously, never aspirate before administration  A nurse is administering a hepatitis B shot intramuscularly. What would bethe appropriate site for administration? Deltoid The deltoid isthe best site for this medication. Biologicals for infants and young children are administered atthe vastuslateralis.the ventrogluteal site is used for depot formulations and irritating mediations.the scapula is a site for an intradermal injection.  A nurse is performing a sensitivity test on a patient. What would bethe best type of injection to use for this procedure? Intradermal Intradermal injections are administered intothe dermis, just belowthe epidermis.the intradermal route hasthe longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia.the advantage ofthe intradermal route for these tests is thatthe body's reaction to substances is easily visible, and degrees of reaction are discernible by comparative study.  A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO.the drug is available as 125 mcg tablets. How many ofthe tablets willthe nurse administer? 0.5 125 mcg = 0.125 mg. 0.0625 mg 0.125 mg = 0.5 tablets  A nurse needs to administer a prescribed injection to a toddler. Which ofthe following injection sites is most suitable forthe client? Vastuslateralis site Thevastuslateralis site isthe most desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles.the dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed; whereas,the ventrogluteal site is safe for children.the deltoid site isthe least-used intramuscular injection site because it is a smaller muscle thanthe others. It is used only for adults becausethe muscle is not sufficiently developed in infants and children.  Drugs known to cause birth defects are called Teratogenic Drugs know to cause birth defects are called teratogenic.  Ifthe dosage is inappropriate for a client, who is responsible? Nurse Whereas physicians and other healthcare providers prescribe and pharmacists dispense therapeutic agents, it isthe nurse's legal domain to administer medications in a safe and timely manner.  A nurse at a health care facility has to instill ear drops in a client.the nurse knows that which ofthe following techniques varies for an adult and child client? Manipulation ofthe client's ear to straightenthe auditory canal The nurse should be aware thatthe method of manipulation ofthe client's ear to straightenthe auditory canal varies between an adult and child client. In a young client,the nurse pullsthe ear down; in an adult client,the nurse pullsthe ear up and back.the medication is not diluted;the number of medication drops instilled is as perthe physician's prescription and does not depend onthe client's age.the position in whichthe client remains untilthe medication reachesthe eardrum andthe amount of time before instilling medication inthe client's opposite ear does not differ withthe age ofthe client.  A nurse is providing care for a patient who has a history of dementia. Which ofthe following methods shouldthe nurse use in order to determinethe patient's identity prior to medication administration? Checkthe patient's identification band. For all patients,the preferred method of confirming identity is to readthe patient's identification band.  The primary reason forthe Controlled Substances Act is To prevent drug abuse The primary reason forthe Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws.  The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? Standing order This is an example of a standing order, which is to be carried out as specified until it is cancelled by another order.  Whenthe client demonstrates a rash 30 minutes after she has taken a dose of penicillin,the nurse recognizes thatthe client is likely demonstrating which type of drug reaction? Allergy Explanation: Allergic reactions result from an immunologic response to a substance to whichthe client is sensitized.  A nurse needs to use a moisturizer for an elderly client with dry skin. Why isthe onset ofthe medication action atypical in an elderly client? Diminished subcutaneous fat Explanation:the onset of medication action is atypical for topical medications due to diminished subcutaneous fat, resulting in quicker absorption. Decreased appetite, diminished physical mobility, and decreased body temperature may not lead to atypical action with relation tothe application of topical medication.  Which medication system allows for client independence? Self-administered medication system Explanation:the self-administered system allowsthe client independence and responsibility while simultaneously allowing nursing supervision, teaching, and evaluation for client compliance and safety medication management prior to facility discharge.  A nurse is caring for a client with severe lower back pain.the doctor orders administration of an analgesic as a stat dose. When shouldthe nurse administerthe medication? Immediately Explanation:the nurse should givethe medication immediately. A stat order is a single order for a medication that must be given immediately. An administration order for a specified number of days is a standing order. A medication order that is given only once is a one-time order. PRN medications are given as needed bythe client.  Medications administered that are renal toxic should have frequent assessments of which blood values? BUN and creatinine Explanation: If medications are known to cause kidney dysfunction, kidney function tests (serum creatinine, blood urea nitrogen).  A severe allergic reaction from a medication requires Epinephrine Explanation: A severe allergic reaction, called an anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuingthe medication and administering epinephrine, IV fluids, and antihistamines.  A client with dry skin has been prescribed inunction. Which ofthe following shouldthe nurse do to promote absorption ofthe ointment? Rubbingthe ointment intothe skin Explanation: In order to promote absorption,the nurse should rubthe ointment intothe client's skin. Shakingthe contents would mixthe contents uniformly, whereas applyingthe with a cotton ball would distributethe substance over a wide area. Warmingthe ointment before application would provide comfort.  Which ofthe following medication-administration systems protectsthe client by identifyingthe rights of medication administration? Barcode Medication Administration Explanation:the Barcode Medication Administration system will warn of a potential error ifthe action does not meetthe rights of medication administration.  What isthe term used forthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity? Therapeutic range Explanation: Therapeutic range isthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity. Peak level isthe highest plasma concentration. Trough level isthe point whenthe drug is atthe lowest concentration. Half-life isthe amount of time it takes for 50% ofthe blood concentration of a drug to be eliminated fromthe body.  Which ofthe following accurately describes a recommended guideline when administering oral medications to patients? If a child refuses to take medication,the medication can be crushed and added to a small amount of food. Explanation: Medication can be added to small amounts of food, but should not be added to liquids. If it is questionable whetherthe medication was swallowed, checkthe patient's mouth and cheeks. If a pill is dropped, it should be discarded, and if a patient vomits, notifythe physician to see ifthe medication should be readministered.  A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which ofthe following responsibilities doesthe nurse have to complete when handling narcotic medications? Select all that apply. • Count each narcotic medication atthe change of each shift • Record each medication used fromthe stock supply • Maintain an accurate account ofthe use ofthe medication Explanation: When handling narcotic medications,the nurse should have an accurate account ofthe use ofthe medications, a record of each medication used fromthe stock supply, andthe nurse should count each narcotic atthe change of each shift. Narcotic medications are controlled substances, meaning that federal laws regulate their possession and administration.the nurse should not placethe medication inthe container with other prescribed medications or placethe medication along with other medications onthe nursing unit. An individual supply is placed in a container with enough ofthe prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains onthe nursing unit for use in an emergency or so that a nurse can give a medication without delay.  A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer? 0.7 cc Explanation:the nurse will administer Demerol 35 mg or 0.7 cc.  A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which ofthe following actions shouldthe nurse perform to prevent gastric reflux? Helpthe client into a Fowler's position. Explanation: Assuming Fowler's position can help prevent gastric reflux when medications are administered through an enteral tube.the nurse checksthe client's medical history for drug allergies to avoid potential complications. Adding diluted medication tothe syringe as it becomes nearly empty prevents instilling air intothe syringe. Administeringthe medication over several minutes has no effect on reflux.  A client has been prescribed nasal medication. What care shouldthe nurse take to avoid potential complications due tothe administration of this medication? Reviewthe client's medication, allergy, and medical history Explanation: To avoid any potential complications,the nurse should reviewthe client's medication, allergy, and medical history.the nurse should read and comparethe label onthe medication withthe medical record at least three timesbefore, during, and after preparingthe medicationto ensure thatthe right medication is given atthe right time bythe right route. Administeringthe medication within 30 to 60 minutes ofthe scheduled time demonstrates timely administration and compliance withthe medical order. Allowing sufficient time to preparethe medication with minimal distraction promotesthe safe preparation of medications.  A nurse needs to administer an intradermal injection to a client. Which ofthe following isthe most common site for administering an intradermal injection? Forearm Explanation:the most common site for an intradermal injection isthe inner aspect ofthe forearm. Intradermal injections are commonly used for diagnostic purposes. Examples include tuberculin tests and allergy testing. Small volumes, usually 0.01 to 0.05 mL, are injected because ofthe small tissue space. Other areas that may be used arethe back and upper chest, notthe stomach.  A nurse is administering a subcutaneous injection to a client. What isthe common maximum volume of a subcutaneous injection? 1 mL Explanation:the volume of a subcutaneous injection is usually up to 1 mL. An intramuscular injection isthe administration of up to 3 mL of medication into one muscle or muscle group. Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL. Answer Key Question 1: (see full question) A nurse is administering a subcutaneous injection to a client. What isthe common maximum volume of a subcutaneous injection? You selected: Correct Explanation: The volume of a subcutaneous injection is usually up to 1 mL. An intramuscular injection isthe administration of up to 3 mL of medication into one muscle or muscle group. Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778. Chapter 28: Medications - Page 778 ________________________________________ Question 2: (see full question) A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO.the drug is available as 125 mcg tablets. How many ofthe tablets willthe nurse administer? You selected: Correct Explanation: 125 mcg = 0.125 mg. 0.0625 mg 0.125 mg = 0.5 tablets Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, pp. 765-766. Chapter 28: Medications - Page 765 ________________________________________ Question 3: (see full question) What isthe term used forthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity? You selected: Correct Explanation: Therapeutic range isthe concentration of drug inthe blood serum that producesthe desired effect without causing toxicity. Peak level isthe highest plasma concentration. Trough level isthe point whenthe drug is atthe lowest concentration. Half-life isthe amount of time it takes for 50% ofthe blood concentration of a drug to be eliminated fromthe body. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 835. Chapter 28: Medications - Page 835 ________________________________________ Question 4: (see full question) A nurse educator is teaching a student nurse how to choosethe correct needle for an injection. Which ofthe following guidelines for needle selection might they discuss? You selected: Correct Explanation: The largerthe gauge,the smallerthe needle.the first number on a needle package isthe gauge or diameter ofthe needle andthe second number isthe length in inches. When giving an injection,the viscosity ofthe medication directsthe choice of gauge.the size ofthe syringe is directed bythe amount ofthe medication to be given. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 774. Chapter 28: Medications - Page 774 ________________________________________ Question 5: (see full question) A severe allergic reaction from a medication requires You selected: Correct Explanation: A severe allergic reaction, called an anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuingthe medication and administering epinephrine, IV fluids, and antihistamines. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756. Chapter 28: Medications - Page 756 ________________________________________ Question 6: (see full question) A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to You selected: Correct Explanation: A client with acute diabetic ketoacidosis requires intravenous access forthe administration of insulin. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 785. Chapter 28: Medications - Page 785 ________________________________________ Question 7: (see full question) Regarding medication administration, what must occur atthe change of shifts? You selected: The medications forthe division are counted Incorrect Correct response: Explanation: Healthcare facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine). Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 768. Chapter 28: Medications - Page 768 ________________________________________ Question 8: (see full question) A nurse needs to administer a subcutaneous heparin injection to a client. Which ofthe following injection sites is most suitable for heparin? You selected: Correct Explanation: The abdomen area isthe preferred site for a subcutaneous heparin injection because of less pain intensity.the forearm, back, and upper chest are common sites for an intradermal injection, not a subcutaneous injection. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778. Chapter 28: Medications - Page 778 ________________________________________ Question 9: (see full question) A nurse is explaining to a clientthe correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which ofthe following is a feature of a metered-dose inhaler? You selected: Correct Explanation: A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used thanthe turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 792. Chapter 28: Medications - Page 792 ________________________________________ Question 10: (see full question) Which ofthe following are included inthe "five rights for medication administration"? Select all that apply. You selected: Correct Explanation: You should observethe patient take medications and should not leave them atthe bedside. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778. Chapter 28: Medications - Page 778 ________________________________________ Question 11: (see full question) A nurse is caring for a client with typhoid at a health care facility.the nurse checksthe medication order inthe client's chart forthe drugs prescribed tothe client. Which ofthe following is a required component ofthe medication order? You selected: Correct Explanation: The client's name is an important component ofthe medication order; without it,the nurse should withholdthe administration ofthe drug.the client's age, diagnosis, and signature are not components ofthe medication order. Other components ofthe medication order includethe date and timethe order is written,the drug name,the dose to be administered,the route of administration,the frequency of administration, andthe signature ofthe person orderingthe drug. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 762. Chapter 28: Medications - Page 762 ________________________________________ Question 12: (see full question) After administering medication to a client subcutaneously,the nurse removesthe needle atthe same angle at which it was inserted. Which ofthe following explainsthe nurse's action? You selected: Correct Explanation: Removingthe needle atthe same angle at which it was inserted to administer medication minimizes tissue trauma and discomfort tothe client. To verify correct injection ofthe drug,the nurse pushesthe plunger and watches for a small wheal. To prevent needle-stick injuries,the nurse coversthe needle with a protective cap. Holdingthe client's arm and stretchingthe skin taut helps to control placement ofthe needle. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 779. Chapter 28: Medications - Page 779 ________________________________________ Question 13: (see full question) A nurse is using a volume control set to administer a dose of prescribed medication to a client.the nurse opensthe lower clamp untilthe tubing is filled with fluid and then reclamps it. Which ofthe following statements explainsthe nurse's action? You selected: Correct Explanation: The nurse opensthe lower clamp untilthe tubing is filled with fluid and then reclamps it because doing so purges air fromthe tubing. In order to provide diluent forthe medication,the nurse opensthe clamp abovethe calibrated container, fillsthe chamber with desired volume of fluid, and reclamps. To remove colonizing microorganisms,the nurse swabsthe injection port onthe calibrated container. To mixthe medication thoroughly withthe fluid,the nurse rotatesthe fluid chamber back and forth. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 838. Chapter 28: Medications - Page 838 ________________________________________ Question 14: (see full question) A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer? You selected: Correct Explanation: The nurse will administer Demerol 35 mg or 0.7 cc. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 758. Chapter 28: Medications - Page 758 ________________________________________ Question 15: (see full question) A nurse needs to use a moisturizer for an older adult client with dry skin. Why isthe onset ofthe medication action atypical in an older adult client? You selected: Correct Explanation: The onset of medication action is atypical for topical medications due to diminished subcutaneous fat, resulting in quicker absorption. Decreased appetite, diminished physical mobility, and decreased body temperature may not lead to atypical action with relation tothe application of topical medication. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778. Chapter 28: Medications - Page 778 ________________________________________ Question 16: (see full question) Drugs known to cause birth defects are called You selected: Correct Explanation: Drugs know to cause birth defects are called teratogenic. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756. Chapter 28: Medications - Page 756 ________________________________________ Question 17: (see full question) A nurse is administering a hepatitis B immunization injection to an adult patient. Which site wouldthe nurse choose for this injection? You selected: Correct Explanation: Hepatitis B virus vaccine is one medication that should be given inthe deltoid muscle in adults to induce adequate levels ofthe antibody.the vastuslateralis muscle andthe ventrogluteal muscle can be used for other intramuscular injections.the dorsogluteal muscle is no longer a preferred site for intramuscular injections. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 28, Medications, p. 783 ________________________________________ Question 18: (see full question) The primary reason forthe Controlled Substances Act is You selected: Correct Explanation: The primary reason forthe Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, pp. 767-768. Chapter 28: Medications - Page 767 ________________________________________ Question 19: (see full question) The nurse is beginning to administer oral medications to a client.the client states, "I haven't taken that pill before. Are you sure it's correct?" You recheckthe CMAR/MAR and find thatthe medication is scheduled to be administered. Which ofthe following responses is most appropriate? You selected: Correct Explanation: This action indicates adherence tothe five rights of medication administration. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 767. Chapter 28: Medications - Page 767 ________________________________________ Question 20: (see full question) Whenthe client demonstrates a rash 30 minutes after she has taken a dose of penicillin,the nurse recognizes thatthe client is likely demonstrating which type of drug reaction? You selected: Correct Explanation: Allergic reactions result from an immunologic response to a substance to whichthe client is sensitized. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756. Chapter 28: Medications - Page 756 Answer Key Vital Signs Chapter Question 1: (see full question) A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which ofthe following statements accurately describes a recommended guideline for using this type of equipment? You selected: For patients who are comatose or anesthetized, use a rectal probe to monitor core body temperature. Incorrect Correct response: Explanation: The nurse should positionthe blanket underthe patient so thatthe top edge ofthe pad is aligned withthe patient's neck; use an esophageal probe for patients who are comatose or anesthetized; coverthe hypothermia blanket with a thin sheet or bath blanket; and apply lanolin or a mixture of lanolin and cold cream tothe patient's skin where it will be in contact withthe blanket. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 585. Chapter 24: Vital Signs - Page 585 ________________________________________ Question 2: (see full question) A nurse is calculatingthe cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/minute. What number wouldthe nurse document for this assessment? You selected: Correct Explanation: Cardiac output is determined by multiplyingthe stroke volume bythe heart rate/minute, which equals 5,850 mL. Cardiac output and peripheral resistance determine both systolic and diastolic pressures. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 594 ________________________________________ Question 3: (see full question) What isthe ideal method for monitoring response to treatment for high blood pressure (BP)? You selected: Correct Explanation: HBPM readings arethe ideal method for monitoring response to treatment for high BP.the client’s BP may require medications to be controlled. HBPM readings tend to be lower and provide for a more consistent view ofthe clients BP over longer periods rather than justthe BP reading during an annual health screening. Although important,the client’s report of feeling better is notthe ideal method for monitoring of response to treatment. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604. Chapter 24: Vital Signs - Page 604 ________________________________________ Question 4: (see full question) The nurse is taking a rectal temperature on a patient who reports feeling lightheaded duringthe procedure. What would bethe nurse’s priority action in this situation? You selected: Correct Explanation: Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can causethe pulse and blood pressure to drop significantly causingthe patient to feel light-headed; thereforethe thermometer should be removed immediately andthe pulse and blood pressure assessed.the physician can be called after assessingthe patient.the temperature is notthe priority at this time. Assistance for CPR would be determined ifthe patient’s condition worsens. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 588-589 ________________________________________ Question 5: (see full question) A nurse is obtaining vital signs from patients usingthe tympanic method for measuring temperature. Which ofthe following guidelines should be followed when taking a tympanic temperature? You selected: Do not take a tympanic temperature ifthe patient has an ear infection. Incorrect Correct response: Explanation: If a patient has an earache,the nurse should not usethe affected ear to take a tympanic temperature, becausethe movement ofthe tragus may cause severe discomfort.the nurse should assessthe patient for significant ear drainage or a scarred tympanic membrane, because these conditions can provide inaccurate results and could cause problems forthe patient. However, an ear infection orthe presence of earwax inthe canal will not significantly affect a tympanic thermometer reading. Ifthe patient has been sleeping withthe head turned to one side,the nurse should take a tympanic temperature inthe other ear. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 587. Chapter 24: Vital Signs - Page 587 ________________________________________ Question 6: (see full question) An ultrasonic Doppler is used for You selected: Correct Explanation: A Doppler device can be used to detect a pulse that is not easily palpable. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 590. Chapter 24: Vital Signs - Page 590 ________________________________________ Question 7: (see full question) A nurse applies a cuff ofthe automated blood pressure device aroundthe client's arm in preparation for serial blood pressure recordings.the nurse checksthe cuff frequently based on which rationale? You selected: Correct Explanation: When using electronic automated blood pressure devices for serial blood pressure recording, frequently checkingthe cuffed limb ensures adequate arterial perfusion and venous drainage between measurements.the nurse does not checkthe cuffed limb to see if it is warm or cold, but to ensure that there is adequate arterial perfusion and venous drainage between measurements. Elevatingthe arm abovethe head between cuff measurements automatically speeds venous return tothe heart. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599. Chapter 24: Vital Signs - Page 599 ________________________________________ Question 8: (see full question) Based upon circadian rhythms, when wouldthe nurse notethe highest temperature during a 24-hour period? You selected: Correct Explanation: Body temperature fluctuates throughoutthe day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582. Chapter 24: Vital Signs - Page 582 ________________________________________ Question 9: (see full question) An obese patient has developed peripheral edema as a consequence of heart failure, making it very difficult forthe student nurse to accurately palpatethe patient's peripheral pulses. How shouldthe nurse proceed with this assessment? You selected: Palpatethe patient's apical pulse Incorrect Correct response: Explanation: When peripheral pulses are difficult to palpate, it is appropriate to auscultatethe patient's apex. This is preferable to auscultating a peripheral site, such asthe brachial artery, and more accurate than attempting to palpatethe apical pulse. Cardiac monitoring is not necessarily indicated in this case. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, pp. 590-591. Chapter 24: Vital Signs - Page 590 ________________________________________ Question 10: (see full question) A nurse is assessingthe blood pressure of a client usingthe Korotkoff sound technique.the nurse notes thatthe phase I sound disappears for 2 seconds. What shouldthe nurse document onthe progress record? You selected: Correct Explanation: An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening inthe diameter ofthe artery takes place inthe phase II ofthe Korotkoff sound technique. An adult diastolic pressure takes place inthe phase IV ofthe Korotkoff sound technique. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 601. Chapter 24: Vital Signs - Page 601 1. A nurse takes a patient's vital signs. Which ofthe following is considered a vital sign? A) mental status B) visual acuity C) blood pressure D) urinary output c  2. Which ofthe following patients should have their vital signs monitored at least every 4 hours? A) a patient in a critical care unit B) a patient hospitalized for high blood pressure C) a resident in a long-term care facility D) a long-term care resident on Medicare A b  3. In which ofthe following situations is it protocol forthe nurse to take a patient's vital signs? Select all that apply. A) upon admitting a patient to a hospital B) at a healthcare screening C) when medications are given for a cardiac arrhythmia D) following a diagnostic procedure E) prior to an invasive procedure F) when daily medications are dispensed a,b,c,d,e  4. A nurse has an order to takethe core temperature of a patient. At which ofthe following sites would a core body temperature be measured? A) tympanic B) oral C) axillary D) skin surface a  5. Which ofthe following isthe primary source of heat inthe body? A) hormones B) metabolism C) blood circulation D) muscles b  6. A nurse places a fan inthe room of a patient who is overheated. This is an example of heat loss related to which ofthe following mechanisms of heat transfer? A) evaporation B) radiation C) conduction D) convection d  7. Which ofthe following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C a  8. What anatomic site regulatesthe pulse rate and force? A) thermoregulatory center C) cardiac atria and valves B) cardiac sinoatrial node D) peripheral chemoreceptors b  9. A patient is constipated and trying to have a bowel movement. How does holdingthe breath and pushing down (the Valsalva maneuver) affectthe pulse? A) left ventricle pumps more forcefully; pulse is stronger B) stimulatesthe vagus nerve to increasethe rate C) stimulatesthe vagus nerve to decreasethe rate D) right ventricle is less efficient; pulse is thready c  10.the arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations wouldthe nurse expect to assess based on these findings? A) absent and infrequent C) rapid and deep B) shallow and slow D) noisy and difficult c  11. A nurse walks into a patient's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What shouldthe nurse do next? A) Take vital signs again in 15 to 30 minutes. B) Documentthe data and report it later. C) Askthe patient if he is anxious or afraid. D) Report findings tothe physician immediately. d  12. Which ofthe following pathologic conditions would result in release of ADH bythe posterior pituitary? A) hemorrhage B) allergies C) obesity D) asthma a  13. A student is readingthe medical record of an assigned patient and notesthe patient has been afebrile forthe past 12 hours. What doesthe term "afebrile" indicate? A) normal body temperature C) increased body temperature B) decreased body temperature D) fluctuating body temperature a  14. A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) bradycardia B) tachycardia C) dysrhythmia D) bigeminal b  15. While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes thatthe patient's respiratory rate is 8 breaths/min. How willthe nurse interpret this finding? A) bradypnea is uncommon in patient with IICP B) IICP most commonly results in tachypnea C) bradypnea is a response to IICP D) this is a normal respiratory rate c  16. A nurse is conducting a health history for a patient with a chronic respiratory problem. What question mightthe nurse ask to assess for orthopnea? A) "Do you have problems breathing when you walk up stairs?" B) "Does your medication help you breathe better?" C) "How many pillows do you sleep on at night to breathe better?" D) "Tell me about your breathing difficulties since you stopped smoking." c  17. What population is at greatest risk for hypertension? A) Hispanic B) White C) Asian D) African American d  18. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for? A) stroke B) anemia C) cancer D) infection a  19. A nurse educator is teaching a patient about a healthy diet. What information would be included to reducethe risk of hypertension? A) "Eat a diet high in fruits and vegetables." B) "Remember to drink 8 to 10 glasses of water a day." C) "It is important to have increased fats in your diet." D) "Put awaythe salt shaker and eat low-salt foods." d  20. A nurse is caring for a patient who is ambulating forthe first time after surgery. Upon standing,the patient complains of dizziness and faintness.the patient's blood pressure is 90/50. What isthe name for this condition? A) orthostatic hypotension C) ambulatory bradycardia B) orthostatic hypertension D) ambulatory tachycardia a  21. What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious? A) rectal B) tympanic C) oral D) axillary c  22. A patient has been diagnosed with peripheral vascular disease ofthe lower extremities. What site wouldthe nurse use to assess circulation ofthe legs? A) radial artery B) dorsalis pedis artery C) temporal artery D) carotid artery b  23. A nurse is taking a patient's temperature and wantsthe most accurate measurement, based on core body temperature. What site should be used? A) rectal B) oral C) axillary D) forehead a  24. A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used forthe top number (140)? A) systolic pressure B) diastolic pressure C) pulse pressure D) hypotension a  25. A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy? A) It is an embarrassing and painful assessment. B) Thermometer insertion stimulatesthe vagus nerve. C) It is less expensive to take oral temperatures. D) It is to avoid perforatingthe wall ofthe rectum. b  26. As adults age,the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affectthe blood pressure? A)the blood pressure does not change. C)the blood pressure decreases. B)the blood pressure is erratic. D)the blood pressure increases. d  27. What equipment is needed to take an apical pulse? A) sphygmomanometer C) stethoscope B) electronic thermometer D) no specific equipment c  28. Two nurses collaborate in assessing an apical-radial pulse on a patient.the pulse deficit is 16 beats/min. What does this indicate? A)the radial pulse is more rapid thanthe apical pulse. B) This is a normal finding and should be ignored. C)the patient's arteries are very compliant. D) Not all ofthe heartbeats are reachingthe periphery. d  29. A nurse is assessingthe blood pressure on an obese woman. What error might occur ifthe cuff used is too narrow? A) reading is erroneously high B) reading is erroneously low C) pressure onthe cuff with be painful D) it will be difficult to pump upthe bladder a  30. Various sounds are heard when assessing a blood pressure. What doesthe first sound heard throughthe stethoscope represent? A) systolic pressure C) auscultatory gap B) diastolic pressure D) pulse pressure a  31. An adult patient is assessed as having an apical pulse of 140. How wouldthe nurse document this finding? A) bradycardia B) tachycardia C) dysrhythmia D) normal pulse b  32. A patient in a physician's office has a single blood pressure (BP) reading of 150/92. Shouldthe patient be taught about hypertension? A) It depends onthe time of daythe BP was taken. B) It depends on whetherthe patient is male or female. C) No, a single BP reading should not be used. D) Yes, this reading is high enough to be significant. c  All ofthe following patients have a body temperature of 38°C (100.4°F). About which patient would a nurse be most concerned? A) an older adult C) a junior high football player B) a pregnant adolescent D) a 2-month-old infant d  34. A home healthcare nurse notices that his assigned patient uses a mercury thermometer. He asksthe nurse what to do if it breaks. Which ofthe following is not correct? A) "Just flushthe glass and mercury downthe toilet." B) "Do not vacuumthe area where it breaks." C) "Openthe windows and close offthe room for an hour." D) "Throw away any clothing exposed tothe mercury." a CHAPTER 33 4. A nurse performing range-of-motion exercises on a bedfast patient movesthe patient's chin down ontothe chest and then back to an upright position.the nurse then tiltsthe head as far as possible to each shoulder. What therapeutic movement isthe nurse achieving with this exercise? Select all that apply. A) flexion B) adduction C) extension D) dorsiflexion E) pronation F) abduction a,c  5. While performing range-of-motion exercises on a patient, a nurse bends a patient's foot so thatthe toes are brought up, as though to point them atthe knee. What isthe term for this type of movement? A) dorsiflexion B) inversion C) rotation D) eversion a  6. What term is used to describethe correction or prevention of disorders of body structures used in locomotion? A) pediatrics B) obstetrics C) geriatrics D) orthopedics d  7. A nurse is assessingthe activity level of a 5-month-old baby. What normal findings would be assessed? A) ability to sit and head control B) ability to pick up small objects C) progress toward running and jumping D) progress toward unassisted walking a  8. Which ofthe following activities are normally acquired inthe toddler years? Select all that apply A) rolling over B) pulling to a standing position C) walking D) running E) jumping F) climbing stairs c,d,e  9. A nurse is teaching an older adult about activity. What information would be included inthe teaching plan? A)the requirement of frequent inactivity B)the recognition that exercise is not important C)the importance of regular exercise D)the possibility of exercise-induced fractures c  10. A nurse is assessingthe muscles of an older adult. What will be assessed? A) temperature, turgor, moisture C) degree of flexion, associated pain B) mass, tone, strength D) reflexes, range of motion b  Which ofthe following postural deformities might be assessed in a teenager? A) kyphosis B) rickets C) osteoporosis D) scoliosis d  12. A nurse is providing home care for an older woman with severe osteoporosis. What complication of this disease process mustthe nurse consider inthe plan of care? A) diarrhea B) fractures C) visual deficits D) skin disorders b  13. A nurse is teaching an older woman how to move and lift her disabled husband.the woman has osteoarthritis ofthe hips and knees. What isthe goal ofthe nurse's teaching plan? A) minimize stress onthe wife's joints C) increase socialization with neighbors B) provide exercise forthe husband D) maintain self-esteem ofthe wife a  Why is it important forthe nurse to teach and role model proper body mechanics? A) to ensure knowledgeable patient care B) to promote health and prevent illness C) to prevent unnecessary insurance claims D) to demonstrate knowledge and skills b  15. Bedrest, with resultant immobility, affectsthe whole body. What is one effect onthe musculoskeletal system? A) impaired gas exchange C) increased risk for contractures B) increased risk for venous thrombosis D) decreased sensory stimulation c  16. A middle-aged man walks 2 miles each day. What type of exercise is he getting by this activity? A) isotonic B) isometric C) isokinetic D) isostretching a  17. What body system benefitsthe most from aerobic exercises? A) musculoskeletal B) neurologic C) respiratory D) cardiovascular d  18. A nurse recommends a regular exercise program for a patient who has difficulty sleeping.the patient asks how this will help. How wouldthe nurse respond? A) "The fresh air will stimulate your metabolism." B) "Improved sleep is one benefit of regular exercise." C) "Exercise can help you control your weight." D) "Take my word for it. It sure helped me." b  19. A nurse is assessingthe vital signs of a patient who has exercised regularly for several years. What vital sign findings would be expected? A) increased body temperature and respirations B) increased pulse and blood pressure C) decreased pulse and blood pressure D) exercise has no effect on vital signs c  20. A patient at a community health center is discussing a planned exercise program.the patient is being treated for cardiovascular disease. What wouldthe nurse recommend? A) "Beginthe exercise program immediately." B) "It would be best if you did not exercise." C) "Be sure to take your pulse before you begin." D) "See your doctor and have a checkup first." d  21. Ofthe following guidelines, which would not be recommended to a person who has sustained an orthopedic injury during exercise? A) ice B) warmth C) rest D) elevation b  22. Immobility affectsthe body in many ways. What is one serious effect of immobility onthe cardiovascular system? A) increased cardiac workload C) increased venous return B) decreased cardiac workload D) increased peripheral resistance a  23. An immobile person has decreased movement of respiratory secretions. What condition is a greater risk as a result? A) respiratory tract infection C) greater thoracic expansion B) increased gas exchange D) increased respiratory rate a  24. Laboratory results for a patient on prolonged bedrest include a high level of urinary calcium. What risk does this pose forthe patient? A) urinary calcium is not a concern C) increased urinary output B) renal calculi (kidney stones) D) imbalanced intake/output b  25. At what time would a nurse assessthe gait of an ambulatory patient? A) afterthe neurologic assessment B) atthe end ofthe physical examination C) whilethe patient is lying supine onthe examining table D) whenthe patient walks intothe room d  26. What term is used to document impaired muscle strength or weakness? A) paralysis B) paresis C) spasticity D) flaccidity b  27. A patient has chronic obstructive pulmonary disease and is unable to perform basic self-care activities or activities of daily living. Which ofthe following would be an appropriate nursing diagnosis? A) Risk for Injury: Pathologic Fractures C) Altered Tissue Perfusion B) Activity Intolerance D) Altered Thought Processes b  28. A nurse is caring for a comatose patient. What can happen tothe feet if they are unsupported inthe dorsiflexed position? A) heel extension and pain C) plantar extension and arch loss B) toe contractures and numbness D) plantar flexion and footdrop d  29. A nurse is placing a patient in Fowler's position. What should she teachthe family about this position? A) "Use at least two big pillows to supportthe head." B) "Crossthe arms overthe patient's abdomen." C) "Do not raisethe knees withthe knee gatch." D) "Keepthe hands lower thanthe rest ofthe body." c  30. A nurse is ambulating a patient who has had a stroke.the patient has paresis onthe right side ofthe upper body. Where wouldthe nurse stand to walkthe patient? A) onthe weak side C) in front ofthe patient B) onthe strong side D) in back ofthe patient a  31. A college student fell and sprained his right ankle.the student health physician recommendsthe student use crutches to facilitate healing. Which ofthe following wouldthe nurse teachthe student? A)the crutches should be as long asthe student is tall. B)the support ofthe body should be inthe axilla. C)the support ofthe body should bethe hands and arms. D) Walk fast and use long steps when usingthe crutches. c  32. A nurse is following a plan of care for passive range-of-motion (ROM) exercises. What specifics will be included onthe plan? A) Askthe patient to demonstrate ROM at 9 a.m. each day. B) Do ROM exercises two times a day, each exercise two to five times. C) Request family be available twice a day to perform ROM. D) Move each joint untilthe patient complains of pain. b What are vital signs? Temperature, pulse, respiration, and blood pressure.  What isthe fifth vital sign? Pain  What temperature is highest, ranging around 36.0 C (97.0 F) to 37.5 C (99.5 F) Core body temperature  Where are core temperatures measured? Tympanic or rectal sites. Also esophagus, pulmonary areterty. or bladder by invasive monitoring devices.  Where are surface body temperatures measured at? oral (sublingual) axillary, and skin surface sites.  What maintainsthe thermoregulatory set point hypothalamus.  What hormones are released to to maintain balance with additional heat? epi and norepi. (anterior hypothalamus or pituitary) T3 and T4 (thyroid)  What connections inthe body remain open to allow heat to dissipate tothe skin and then tothe external environment (Or close to retain heat inthe body?) arteriovenous shunts (arterioles andthe venules)  How is heat transferable? radiation, convection, evaporation, and conduction.  A 24 hour cycle is known as Circadian Rhythms.  What isthe the typical variance in body temperature amounginvdividuals. 0.3 to 0.6 C (0.5-1 F)  Febrile fever  How does a fever occur (agent) cytokines produced by pyrogens (microorganisms or substances that cause fever)  Tissue injury can cause fever. Name some injuries that would cause this MI, pulmonary emboli, cancer, trauma, and surgery.  Older adults often have a lower baseline body temp, and a fever elevation (even a slight elevation) may be indicative of what? serious infection.  What mechanisms are initiates whenthe set point is increased from a bacterial or viral infection? shivering, piloerection, vasoconstriction, and increased metabolism.  Most fevers are what? self-limiting.  Hyperthermia whenthe set point forthe body is not changed, but occurs in extreme conditions of heat.  Neurogenic fever result of damage tothe hypothalamus from interacranial trauma, intracranial bleeding , or increased intracranial pressure.  What type of fever does not respond to antipyretic medication? Neurogenic fever.  What is an FUO A fever of 101 F that lasts for 3 weeks or longer without an identified cause.  potentially dangerous complications of fever Fluid, electrolyte and acid-base imbalances  What drug should not be given to children and teenagers with chickenpox or flu because of possible association with Reye's syndrome? Aspirin  When using a hypothermia blanket to lower body temperature, how do you monitory body temp? monitorthe rectal temperature every 15 min and all vital signs every 30 minutes.  What temperature do you start a hypothermia blanket at? 37 C and decrease it 2 to 3 degrees every 15 minutes untilthe temp that is ordered or that is agency policy is reached.  When hypothermia blanket treatment is discontinued, how often doesthe nurse monitorthe temp ofthe patient? every 2 hours for 24 hours. Answer Key Question 1: (see full question) A client monitoring his BP at home notices that his BP is higher in one arm thanthe other so he calls his health care provider for guidance. What isthe most appropriate information forthe nurse to give this client? You selected: Correct Explanation: It has been found that most people have differences in BP between arms and that he should usethe arm that gives himthe highest reading for accurate results. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 600. Chapter 24: Vital Signs - Page 600 ________________________________________ Question 2: (see full question) The nurse is assessingthe apical pulse of a patient using auscultation. What action wouldthe nurse perform after placingthe diaphragm overthe apex ofthe heart? You selected: Correct Explanation: The apex ofthe heart is found after palpating betweenthe fifth and sixth ribs, then movingthe stethoscopethe left midclavicular line.the apical rate is typically assessed for 1 minute. Each “lub-dub” sound counts as one beat. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 592 ________________________________________ Question 3: (see full question) A nurse is caring for an adult with fever.the nurse determines that which site is most ideal for obtainingthe client's core body temperature? You selected: Ear Incorrect Correct response: Explanation: The rectal temperature, a core temperature, is considered to be one ofthe most accurate routes. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 587. Chapter 24: Vital Signs - Page 587 ________________________________________ Question 4: (see full question) During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. usedthe standard size of blood pressure cuff available onthe unit, despitethe fact thatthe patient's upper arms have a high circumference. What arethe potential consequences of Nurse R.'s action? You selected: Correct Explanation: If a blood pressure cuff is too narrow,the reading could be erroneously high becausethe pressure is not evenly transmitted tothe artery. This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflatethe cuff and brachial occlusion is not a significant risk. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599. Chapter 24: Vital Signs - Page 599 ________________________________________ Question 5: (see full question) Which ofthe following terms indicates a potentially serious patient condition? You selected: Correct Explanation: Pyrexia means an increase above normal in body temperature. Pulse pressure is an objective term related tothe pulse. Eupnea means a normal breathing pattern. Afebrile means thatthe body temperature is not elevated. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, ________________________________________ Question 6: (see full question) The nurse is providing discharge teaching for a patient diagnosed with hypertension. Which teaching points about monitoring blood pressure shouldthe nurse include inthe plan? (Select all that apply.) You selected: Correct Explanation: Takingthe blood pressure atthe same time each day will providethe patient with a more accurate comparison of blood pressure measurements becausethe blood pressure may fluctuate during different times ofthe day. Appropriate cuff size directly affectsthe accuracy ofthe blood pressure measurement.the patient should not be encouraged to use BP devices in public places as these may be inaccurate and may bethe wrong cuff size, leading to further inaccuracy. Keepingthe wrist at heart level ensures that this type of BP measurement is accurate. It is difficult for patients to use manual cuffs at home; home electronic devices are generally accurate and should be checked againstthe health care provider’s manual BP reading every 1 to 2 years.the blood pressure measurement inthe lower extremities produces a systolic pressure approximately 10 to 40 mm Hg higher than inthe arm. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 620 ________________________________________ Question 7: (see full question) A nurse attempts to countthe respiratory rate for a client via inspection and finds thatthe client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determiningthe respiratory rate for this client? You selected: Correct Explanation: Sometimes it is easier to count respirations by auscultatingthe lung sounds for 30 seconds and multiplyingthe result by 2. Palpatingthe posterior thorax excursion detects vibrations inthe lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 615. Chapter 24: Vital Signs - Page 615 ________________________________________ Question 8: (see full question) A nurse is assessingthe blood pressure of a team of healthy athletes atthe heath care facility. Which ofthe following observations can be made bythe nurse and athletes by measuringthe blood pressure? You selected: Correct Explanation: Measuringthe blood pressure helps to assessthe efficiency ofthe client's circulatory system. Blood pressure measurements reflectthe ability ofthe arteries to stretch,the volume of circulating blood, andthe amount of resistancethe heart must overcome when it pumps blood. Measuringthe blood pressure does not help in assessingthe thickness of blood, oxygen level inthe blood, orthe volume of air enteringthe lungs. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597. Chapter 24: Vital Signs - Page 597 ________________________________________ Question 9: (see full question) A patient has been diagnosed with peripheral vascular disease ofthe lower extremities. What site wouldthe nurse use to assess circulation ofthe legs? You selected: Correct Explanation: The nurse would assess circulation inthe lower extremities by palpatingthe dorsalis pedis artery.the other arteries listed would not be used to assess circulation tothe legs. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591. Chapter 24: Vital Signs - Page 591 ________________________________________ Question 10: (see full question) A 62-year-old female client being treated for hypertension did not take her daily BP medication overthe weekend because she was out of medication andthe pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She callsthe on-call nurse for her health care provider. What isthe most appropriate thing for this nurse to advise this client? You selected: Correct Explanation: HBPM readings arethe ideal method for monitoring response to treatment for high BP. This client’s average BP after not taking her medication is 138/87 and is NOT 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM that they should callthe health care provider ifthe averages of HBPM readings increase/decrease by 10, or if she has any concerns.the client should not be told to take doublethe dose of medication or to takethe doses she missed; this is unsafe advice without consulting a health care provider. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604. Chapter 24: Vital Signs - Page 604 ________________________________________ Question 11: (see full question) The temperature is 102°F (39 deg C); during a heat wave.the nurse can expect admissions tothe emergency room to present with You selected: Correct Explanation: Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 583. Chapter 24: Vital Signs - Page 583 ________________________________________ Question 12: (see full question) When assessing an infant's axillary temperature, it will be You selected: Correct Explanation: Rectal temperatures may be one degree higher than oral temperatures, and axillary temperatures are one degree lower than oral temperatures. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 588. Chapter 24: Vital Signs - Page 588 ________________________________________ Question 13: (see full question) An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She calledthe nurse concerned about her BP. What isthe most appropriate information forthe nurse to give this client? You selected: Correct Explanation: Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure fromthe sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 597. Chapter 24: Vital Signs - Page 597 ________________________________________ Question 14: (see full question) A nurse is assessingthe pulse volume of a client with influenza.the nurse notes thatthe client has a thready pulse. Which ofthe following is a description of a thready pulse? You selected: Correct Explanation: Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 589. Chapter 24: Vital Signs - Page 589 ________________________________________ Question 15: (see full question) A pulse deficit isthe difference between ... You selected: Correct Explanation: When a pulse deficit is present,the radial pulse is always lower thanthe apical pulse rate. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591. Chapter 24: Vital Signs - Page 591 ________________________________________ Question 16: (see full question) A nurse is assessingthe pulse rate of a client for one full minute. Which ofthe following clients' pulse rates need to be assessed for one full minute? Select all that apply. You selected: • Clients with irregular pulse rates • Clients with fast pulse rates • Clients recovering from anesthesia • Clients with abnormally slow pulse rates Incorrect Correct response: Explanation: The nurse assesses clients with irregular or abnormally slow or fast pulse rates for one full minute.the time interval used to assessthe pulse depends onthe client's condition andthe agency's norms. Clients with regular rhythms and normal rates may be assessed for a shorter time. Intervals of 15 seconds may be used for clients with regular rhythms when reassessingthe pulse frequently, as during recovery from anesthesia. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, pp. 588-589. Chapter 24: Vital Signs - Page 588 ________________________________________ Question 17: (see full question) Which patient wouldthe nurse consider at risk for low blood pressure? You selected: Correct Explanation: Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity ofthe arteriole walls would potentially cause increased blood pressure. A strong pumping action ofthe heart may not affectthe blood pressure, or it may causethe blood pressure to increase. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 597 ________________________________________ Question 18: (see full question) A nurse is takingthe vital signs of a 9-year old child who is anxious aboutthe procedures. Which nursing action would be appropriate when assessing this child? You selected: Correct Explanation: The blood pressure reading isthe most invasive procedure performed when measuring vital signs. Ifthe nurse were to perform it first it may upsetthe child further and prevent obtainingthe remainder ofthe vital signs. Allowingthe child to touchthe assessment equipment often helpsthe child be more relaxed forthe remainder ofthe assessment. Lying onthe exam table is not necessary for vital signs and will likely call more anxiety. Being quick with a serious demeanor does not help decreasethe child’s anxiety. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 616 ________________________________________ Question 19: (see full question) The nurse is teachingthe parents of an infant with an irregular heartbeat how to checkthe pulse rate.the infant’s pulse is very high and irregular. What willthe nurse have to do in order to teach these parents how to monitor their infant’s pulse rate? You selected: Correct Explanation: If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid,the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is alsothe preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor,the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant’s pulse accurately. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 590. Chapter 24: Vital Signs - Page 590 ________________________________________ Question 20: (see full question) A nurse is assessing an apical pulse on a cardiac client.the client is taking digoxin, which is a cardiac medication.the nurse can anticipate thatthe digoxin will do what? You selected: Correct Explanation: Some cardiac medications, such as digoxin, whose action is specific tothe work ofthe heart, slowthe heart rate while also strengtheningthe force of contraction to increase cardiac output. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 589. Chapter 24: Vital Signs - Page 589 Question 1: (see full question)A 57-year-old male client is admitted tothe medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique wouldthe nurse perform last?Youselected:PalpationCorrectExplanation: The sequence of techniques used to assessthe abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659. Chapter 25: Health Assessment - Page 659 ________________________________________ Question 2: (see full question)The nurse is asking admission interview questions andthe client has explainedthe reason for seeking care. Which ofthe following isthe most appropriate way to documentthe response?Youselected:Client states, "I feel winded all ofthe time and yesterday I started spitting up a lot of phlegm."CorrectExplanation: The client's reason for seeking care should always be stated inthe client's own words. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628. Chapter 25: Health Assessment - Page 628 ________________________________________ Question 3: (see full question)The nurse is preparing to perform an examination ofthe abdomen of a 23-year-old male client admitted 3 days ago with gastroenteritis. What sequence of techniques willthe nurse use to assessthe abdomen of this client?Youselected:Inspection, auscultation, percussion, palpationCorrectExplanation: The sequence of techniques used to assessthe abdomen is inspection, auscultation, percussion, and palpation. Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658. Chapter 25: Health Assessment - Page 658 ________________________________________ Question 4: (see full question)Which ofthe following statements accurately represents a characteristic ofthe third or fourth heart sound?You selected:S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.CorrectExplanation: S3,the third heart sound, is considered normal in children and young adults and abnormal in middle-aged and older adults. This sound is best heard withthe stethoscope bell atthe mitral area, withthe patient lying onthe left side. S4 is represented by “dee-lub-dub” and is considered normal in older adults but abnormal in children and adults. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 5: (see full question)The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration.the nurse bringsthe client his breakfast tray and notes thatthe client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?Youselected:Checkthe client’s ear canals for cerumen.CorrectExplanation: Ear wax (cerumen) becomes drier inthe elderly and can blockthe ear canal and cause decreased hearing. Askingthe client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating withthe hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking tothe elderly who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic forthe elderly. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646. Chapter 25: Health Assessment - Page 646 ________________________________________ Question 6: (see full question)The nurse inthe emergency department observes a client experiencing a generalized tonic–clonic seizure. What isthe priority intervention forthe nurse to take?Youselected:Assess and maintainthe client's airway.CorrectExplanation: Risk for aspiration is a concern during a seizure becausethe client will have copious oral secretions that will need to be suctioned and allowed to drain out ofthe mouth.the nurse should assessthe client's airway and maintain it by placingthe client in a side-lying position, which will allowthe oral secretions to drain from his mouth and not accumulate in his throat and compromisethe airway. It is contraindicated to place anything inthe mouth of a person who is actively convulsing. Reorientingthe client and documentingthe seizure are important actions afterthe postictal phase, but client safety isthe priority intervention during a seizure. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 ________________________________________ Question 7: (see full question)The nurse is caring for a client who just informed her that he noticed some blood inthe toilet after a bowel movement.the nurse assessesthe client's anal area and notes a deep linear separation inthe skin that extends intothe dermis.the nurse recognizes that this skin lesion is characteristic of which ofthe following?Youselected:FissureCorrectExplanation: A fissure is characterized as a deep linear separation inthe skin that extends intothe dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) onthe skin. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4. Chapter 25: Health Assessment - Page 641 ________________________________________ Question 8: (see full question)The nurse is caring for a 72-year-old female client who recently arrived from El Salvador for cancer treatments.the nurse informsthe client that she has to sign a consent forthe treatments that are scheduled to startthe next day.the client tellsthe nurse that she is expecting her family to arrive later and wants to wait to signthe consent when they are present. What action bythe nurse isthe most appropriate?Youselected:Askthe client if she has any questions aboutthe cancer treatments.IncorrectCorrectresponse:Tellthe client to callthe nurse when her family arrives.Explanation: In Hispanic culturesthe family plays a major role inthe social organization ofthe family.the nurse should be sensitive to cultural diversity. Being available whenthe family arrives is showing respect forthe client’s wishes and cultural sensitivity. Askingthe client to signthe consent withoutthe presence of her family, notifyingthe physician, or asking her if she has questions does not addressthe client’s cultural diversity. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 671. Chapter 25: Health Assessment - Page 671 ________________________________________ Question 9: (see full question)You are assessing a patient's thorax and lungs. Which ofthe following findings would indicatethe need for further assessment?Youselected:Auscultation of short, high-pitched popping sounds during inspirationCorrectExplanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 ________________________________________ Question 10: (see full question)The nurse is assessing an older adult’s near vision. Which assessment finding aboutthe client's near vision shouldthe nurse anticipate? You selected:BlurryCorrectExplanation: A common finding inthe older adult is impaired near vision (presbyopia), which makes near vision blurry. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648. Chapter 25: Health Assessment - Page 648 Answer Key Question 1: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 2: (see full question) A nurse is assessingthe lungs of a patient and auscultates soft, low-pitched sounds overthe base ofthe lungs during inspiration. What would bethe nurse’s next action? You selected: Suspect an inflamed pleura rubbing againstthe chest wall Incorrect Correct response: Explanation: Soft, low-pitched, whispering sounds are normal sounds heard over most ofthe lung fields. Inflammation ofthe pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not inthe nurse’s scope of practice. Asthma usually results in wheezing. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 651 ________________________________________ Question 3: (see full question) A nurse is performing eye assessments at a community clinic. Which assessment wouldthe nurse document as normal? You selected: Correct Explanation: The pupils should be black, equal in size, and round and smooth. When an object moves towardsthe patient’s nose,the eyes should converge towardsthe object. Pale and cloudy pupils are indication of a problem such as cataracts.the patient’s pupils should constrict when looking at a near object and dilate when looking at a distant object. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluw Answer Key Question 1: (see full question) The acute care nurse is assessing a newly admitted client's abdomen. Which ofthe following findings would indicatethe need to contactthe primary care provider? You selected: Correct Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654. Chapter 25: Health Assessment - Page 654 ________________________________________ Question 2: (see full question) A nurse is assessingthe lungs of a patient and auscultates soft, low-pitched sounds overthe base ofthe lungs during inspiration. What would bethe nurse’s next action? You selected: Suspect an inflamed pleura rubbing againstthe chest wall Incorrect Correct response: Explanation: Soft, low-pitched, whispering sounds are normal sounds heard over most ofthe lung fields. Inflammation ofthe pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not inthe nurse’s scope of practice. Asthma usually results in wheezing. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 651 ________________________________________ Question 3: (see full question) A nurse is performing eye assessments at a community clinic. Which assessment wouldthe nurse document as normal? You selected: Correct Explanation: The pupils should be black, equal in size, and round and smooth. When an object moves towardsthe patient’s nose,the eyes should converge towardsthe object. Pale and cloudy pupils are indication of a problem such as cataracts.the patient’s pupils should constrict when looking at a near object and dilate when looking at a distant object. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluw You selected: Correct Explanation: The tympanic membrane should be intact, translucent, shiny, and gray.the ear canal should be smooth and pink. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 645-646 ________________________________________ Question 7: (see full question) A nurse performs an integumentary assessment of a client and documentsthe following: 5/27/12: Examined skin of Mr. Williams. Client is a white, 56-year-old male who reports a history of emphysema. Skin coloring is bluish gray. What isthe term for this change in skin color? You selected: Correct Explanation: Cyanosis is a bluish or grayish tinge caused by inadequate oxygenation. Jaundice is a yellow color resulting from liver and gallbladder disease. Erythema is a reddish color associa ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 638. Chapter 25: Health Assessment - Page 638 ________________________________________ Question 8: (see full question) During which ofthe following assessments shouldthe nurse usethe bell ofthe stethoscope during auscultation? You selected: Correct Explanation: The bell ofthe stethoscope is used to listen to low-pitched sounds, such as heart murmurs.the diaphragm ofthe stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 632, 654. Chapter 25: Health Assessment - Page 632 ________________________________________ Question 9: (see full question) A grating feel and noise with joint movement, particularly inthe temporomandibular joint, is called what? You selected: Correct Correct Explanation: Problems withthe temporomandibular joint include pain or a grating feeling called crepitus. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 662. Chapter 25: Health Assessment - Page 662 ________________________________________ Question 10: (see full question) A new client is admitted tothe hospital and requires a comprehensive admission assessment. What shouldthe nurse include in this assessment? (Select all that apply.) You selected: • Goals with outcome criteria • Collection of subjective data • Complete set of vital signs Incorrect Correct response: Explanation: Collecting subjective data, vital signs, and functional ability should be included inthe initial admission assessment and will helpthe nurse plan care forthe client.the development ofthe care plan, which includes goals with outcome criteria and client teaching, are done afterthe admission assessment. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625. Chapter 25: Health Assessment - Page 625 A nurse is assessing a newborn atthe health care facility whenthe mother ofthe child asksthe nurse whythe body temperature of her baby is unstable. Which response bythe nurse would be most appropriate? a) "It is because ofthe immature ability to regulate temperature in general." b) "It is common for newborns to have body temperatures less than 36.4C" c) "The baby is showing how it is adapting tothe environmental temperature. d) "It is because ofthe closely woven, dark fabric wrapped aroundthe baby" a) "It is because ofthe immature ability to regulate temperature in general."  Which ofthe following is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound? a) If using a mercury manometer, check to see thatthe manometer is inthe horizontal position and thatthe mercury is withinthe zero level. b) Centerthe bladder ofthe cuff overthe artery, lining upthe artery marker onthe cuff withthe artery itself. c) Using your nondominant hand, placethe Doppler tip inthe gel and adjustthe volume as needed; movethe Doppler tip around until you hearthe pulse. d) Takethe measurement withthe client in a standing position withthe appropriate limb exposed. b) Centerthe bladder ofthe cuff overthe artery, lining upthe artery marker onthe cuff withthe artery itself  You are preparing to measure an adult's orthostatic blood pressure. Placethe following steps ofthe procedure inthe correct order. 1. Assistthe client into a supine position 2. Assistthe client to a standing position. 3. Assistthe client tothe sitting position with legs dangling. 4. Wait one to three minutes, then measurethe client's blood pressure. 5. Wait 2 to 3 minutes, then measurethe patient's blood pressure. 6. Wait three to 10 minutes, then measurethe client's blood pressure. 1. Assistthe client into a supine position 6. Wait three to 10 minutes, then measurethe client's blood pressure. 3. Assistthe client tothe sitting position with legs dangling. 4. Wait one to three minutes, then measurethe client's blood pressure. 2. Assistthe client to a standing position. 5. Wait 2 to 3 minutes, then measurethe patient's blood pressure.  Assessment ofthe pulse amplitude is accomplished by which ofthe following? a) Palpatingthe area ofthe left ventricle b) Auscultatingthe area ofthe left ventricle c) Palpatingthe flow of blood through an artery d) Auscultatingthe flow of blood through an artery c) Palpatingthe flow of blood through an artery  Upon assessing a client who is hemorrhaging,the nurse is most likely to assess which compensatory change in vital signs? a) Decreased pulse rate b) Increased temperature c) Decreased temperature d) Increased pulse d) Increased pulse  Clients demonstrating apnea have what? a) Increased rate and depth of respirations b) Normal respiratory rate of 20 c) Usually have a temporary cessation of breathing d) Decreased rate and depth of respirations c) Usually have a temporary cessation of breathing  Which peripheral pulse site is generally used in emergency situations? a) Apical b) Temporal c) Carotid d) Radial c) Carotid  The nurse places a client experiencing labored breathing in an upright position.the nurse notes thatthe client is able to breathe more easily in this upright position and documents this condition onthe chart as which ofthe following? a) Tachypnea b) Bradypnea c) Orthopnea d) Apnea c) Orthopnea  A nurse needs to measurethe blood pressure of a client who has just undergone a bilateral mastectomy. How shouldthe nurse measurethe blood pressure? a) Radial artery b) Overthe lower arm c) Brachial artery d) Overthe client's thigh d) Overthe client's thigh  A nurse is assigned to take vital signs in a pediatric unit. Which ofthe following sites would be most appropriate for takingthe blood pressure of children? a) Temporal b) Popliteal c) Brachial d) Radial b) Popliteal  During a routine vital sign assessment, you notethe client's blood pressure is 212/110. Why is this finding particularly significant? a) It allowsthe nurse to have a baseline value. b) It is due tothe factthe client is fearful. c) It is related to a tumor ofthe adrenal. d) It deviates from normal and is significant. d) It deviates from normal and is significant.  While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes thatthe client's respiratory rate is 8 breaths/minute. How willthe nurse interpret this finding? a) Bradypnea is a response to IICP. b) Bradypnea is uncommon in a client with IICP. c) This is a normal respiratory rate. d) IICP most commonly results in tachypnea. a) Bradypnea is a response to IICP.  The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? a) 60% ofthe circumference ofthe limb to be used b) 70% ofthe circumference ofthe limb to be used c) 40% ofthe circumference ofthe limb to be used d) 50% ofthe circumference ofthe limb to be used c) 40% ofthe circumference ofthe limb to be used  A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which ofthe following health problems shouldthe nurse consider when client falls occur? a) Secondary hypertension b) Dyspnea c) Primary hypertension d) Orthostatic hypotension d) Orthostatic hypotension  A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess pulse in this client? a) Brachial b) Radial c) Dorsalis pedis d) Apical d) Apical  The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC).the client states, "I just finished my coffee right before you came in. Can I have another cup?" Which ofthe following responses bythe nurse is most appropriate? a) "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." b) "You will need to remain NPO until I notify your primary health care provider about your increased temperature." c) "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." d) "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." a) "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."  A nurse attempts to countthe respiratory rate for a client via inspection and finds thatthe client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determiningthe respiratory rate for this client? a) Use a pulse oximeter to countthe respirations for one minute. b) Palpatethe posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. c) Monitor arterial blood gas results for one minute. d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.  Which ofthe following terms describes a heart rate that is belowthe expected norm? a) Apnea b) Tachycardia c) Hypotension d) Bradycardia d) Bradycardia  A nurse who provides care on a hospital unit has taken a client's temperature this morning, yielding a reading of 37.6C (99.7F). How shouldthe nurse best interpret this assessment finding? a)the client is at risk of experiencing seizure activity. b) This body temperature may temporarily enhancethe client's immune function. c)the client is experiencing dysfunction ofthe thermoregulatory center. d) This is likely a reflection of normal circadian variations in body temperature. ________________________________________ Question 9: (see full question) When performing fall risk assessments,the nurse understands that which of these clients is most at risk for falls? You selected: An 80-year-old female with a history of falling last year and breaking a hip Incorrect Correct response: Explanation: Risk factors for falls include age older than 65 years, documented history of falls, impaired vision or sense of balance, altered gait or posture, a medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics, postural hypotension, slowed reaction time, confusion or disorientation, impaired mobility, weakness and physical frailty, and/or an unfamiliar environment.the 70-year-old female that has postural hypotension and wears eyeglasses, but has no history of falls, has three of these risk factors: age, impaired vision, and postural hypotension. Therefore, she is most at risk. All ofthe other clients only have two risk factors. (less) Question 6: (see full question) The community nurse knows that which population of Americans is particularly vulnerable tothe aftermath of a disaster? You selected: Children Incorrect Correct response: Older adults Explanation: Older adults, especially overthe age of 85, are particularly vulnerable tothe aftermath of a disaster due to their increased presence of altered mobility, altered perception, long-term illnesses, and dependency on equipment. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 713-714. Chapter 26: Safety, Security, and Emergency Preparedness - Page 713 congrats! Congratulations! You've reached Mastery Level 3 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 7 70% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 2 Quizzes taken My Mastery Level: 3.00 Class Average: 3.23 Chapter 26: Safety, Security, and Emergency Preparedness 4 Quizzes taken My Mastery Level: 4.00 Class Average: 2.82 Answer Key Question 1: (see full question) A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient? You selected: “Have you had any unusual symptoms after blowing up balloons?” Correct Explanation: Awareness of a latex allergy is important for safe home care. Nurses need to ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 548. Chapter 23: Asepsis and Infection Control - Page 548 ________________________________________ Question 2: (see full question) A child football player has been diagnosed with an uncomplicated concussion and is being discharged home on cognitive rest. When preparing this child’s teaching plan, what shouldthe nurse include that will helpthe family understand what is meant by cognitive rest? You selected: Reading, watching television, and playing games of any kind should be avoided until he is cleared. Correct Explanation: The treatment for an uncomplicated concussion is physical and cognitive rest. Reading, watching television, and playing games of any kind are examples of cognitive activities that should be avoided untilthe athlete is cleared. Lifting objects and playing football are examples of physical activities only, andthe need for 8 hours of sleep does not directthe family inthe limitations of cognitive activity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 3: (see full question) The nurse is applying wrist restraints on a client and notes thatthe client is unable to move his right arm. What isthe appropriate action bythe nurse? You selected: Apply onlythe left wrist restraint. Correct Explanation: The nurse should apply onlythe left wrist restraint. Asthe client is unable to movethe right arm, this arm does not need restraining. Vest restraints and wrist restraints are typically utilized to meet different client needs, so they are not usually interchanged for one another. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 722. Chapter 26: Safety, Security, and Emergency Preparedness - Page 722 ________________________________________ Question 4: (see full question) Which ofthe following practices is a correct application of infection control practices? You selected: A nurse dons a pair of gloves prior to any patient contact. Incorrect Correct response: A nurse performs handwashing each time she removes a pair of gloves. Explanation: Handwashing should be performed afterthe removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 5: (see full question) A school nurse is teaching a group of adolescents about safe driving. What behaviors shouldthe nurse encourage in order to help prevent motor vehicle accidents? (Select all that apply.) You selected: • Never text while driving. • Limitthe number of other adolescents inthe car. • Obeythe speed limit. Incorrect Correct response: • Always wear a seat belt. • Limitthe number of other adolescents inthe car. • Never text while driving. • Obeythe speed limit. Explanation: Safe driving behaviors include always wearing a seat belt, limitingthe number of other adolescents inthe car, never texting while driving, and obeyingthe speed limit. Driving at night should be limited, not encouraged. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 6: (see full question) The nurse overhears an older client's son talking to her in a very aggressive and violent way. Whenthe nurse walks intothe room,the son changes and speaks kindly to his mother andthe health care providers. What shouldthe nurse do about this observation? You selected: Ask to examinethe client alone in order to speak to her privately. Correct Explanation: In 90% of elder abuse cases that are reported,the person doingthe abusing is a family member.the best thing to do would be forthe nurse to getthe client alone so that she can discussthe relationship that was observed. Documentingthe behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury tothe client.the nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 706. Chapter 26: Safety, Security, and Emergency Preparedness - Page 706 ________________________________________ Question 7: (see full question) You have completed an intervention with a patient. There is no visible soiling on your hands. Which ofthe following techniques is recommended bythe Centers for Disease Control (CDC) for hand hygiene? You selected: Decontaminate hands using an alcohol-based hand rub. Correct Explanation: Alcohol-based hand rubs can be used if hands are not visibly soiled. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 8: (see full question) To eliminate needlesticks as potential hazards to nurses,the nurse should You selected: Immediately deposit uncapped needles into puncture-proof plastic container Correct Explanation: All uncapped needles should be placed in puncture-proof plastic units immediately after use. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 9: (see full question) A lead nurse is removing her personal protective equipment after dressingthe infected wounds of a client. Which ofthe following isthe highest priority nursing action? You selected: Make contact between two contaminated surfaces. Incorrect Correct response: Handwashing before leavingthe client's room. Explanation: The most important nursing action is to perform a thorough handwashing before leavingthe client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them.the procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses removethe garments that are most contaminated first, preservingthe clean uniform underneath. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 542, 561. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 10: (see full question) The nurse needs to planthe interventions necessary to reduce fall risks forthe older adult clients at her facility. Which isthe strongest indicator that a client is at risk for falls? You selected: The client has fallen before. Correct Explanation: Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls. Cardiovascular medications, being forgetful, or using an assistive device do not necessarily predispose a client to falling. (less) Quiz Results Quiz Stats Quiz completed in: 5 min Total Questions: 10 Questions answered: 10 Number correct: 8 80% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 3 Quizzes taken My Mastery Level: 3.00 Class Average: 3.23 Answer Key Question 1: (see full question) A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. Which ofthe following is an accurate guideline for using this technique? You selected: Considerthe outer 3-inch edge of a sterile field to be contaminated. Incorrect Correct response: Hold sterile objects above waist level to prevent accidental contamination. Explanation: Holding a sterile object above waist level ensuresthe object is kept in sight and prevents accidental contamination.the outside ofthe sterile package andthe outer one inch of a sterile field are contaminated. Sterile packages should be opened so thatthe first edge ofthe wrapper is directed away fromthe nurse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 ________________________________________ Question 2: (see full question) The nurse planning to insert an indwelling urinary catheter into a client should utilize which ofthe following techniques? You selected: Medical asepsis Incorrect Correct response: Surgical asepsis Explanation: Surgical asepsis, also known as sterile technique, is utilized to keep objects and areas free from microorganisms when performing surgery and procedures such as inserting an indwelling urinary catheter or IV catheter. Medical asepsis reducesthe number and transfer of pathogens. Universal precautions and contact precautions help to decreasethe risk of transmitting infection. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 538. Chapter 23: Asepsis and Infection Control - Page 538 ________________________________________ Question 3: (see full question) A nurse changingthe linens of a patient bed is exposed to urine and performs hand hygiene. Which ofthe following is a guideline for performing this skill properly following this patient encounter? You selected: Keep hands lower than elbows to allow water to flow toward fingertips. Correct Explanation: Handwashing, as opposed to hand hygiene with an alcohol-based rub, is required when hands are exposed to body fluids. Jewelry should be removed, if possible, and secured in a safe place, but a plain wedding band may remain in place. Wetthe hands and wrist area, and keep hands lower than elbows to allow water to flow toward fingertips and pat hands dry with a paper towel, beginning withthe fingers and moving upward toward forearms. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 559. Chapter 23: Asepsis and Infection Control - Page 559 ________________________________________ Question 4: (see full question) Which ofthe following is an accurate guideline forthe use of PPE? You selected: Replace gloves if they are visibly soiled. Correct Explanation: If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before enteringthe client's room and glasses should not be substituted for protective eyewear. Work should progress from “clean” areas to “dirty” areas. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 570-572. Chapter 23: Asepsis and Infection Control - Page 570 ________________________________________ Question 5: (see full question) When preparing to take a client’s blood pressure,the nurse notes thatthe sphygmomanometer is visibly soiled. What isthe correct action bythe nurse? You selected: Cleanse and disinfectthe sphygmomanometer Correct Explanation: The nurse should cleanse and disinfectthe sphygmomanometer. A sphygmomanometer is another name for a blood pressure cuff. As this equipment is used onthe outside ofthe arm versus entering a sterile body part, there is no need to havethe equipment sterilized. It would be inappropriate forthe nurse to usethe visibly soiled blood pressure cuff or to throw it inthe trash. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 546. Chapter 23: Asepsis and Infection Control - Page 546 ________________________________________ Question 6: (see full question) The nurse caring for clients at an outpatient clinic determines which ofthe following clients is at greatest risk for infection? You selected: An 80-year-old woman Correct Explanation: Age, race, sex, and heredity all influence susceptibility to infection. Neonates and older adults tend to be most vulnerabe to infection, sothe 80-year-old woman isthe client most at risk for infection. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 537. Chapter 23: Asepsis and Infection Control - Page 537 ________________________________________ Question 7: (see full question) When is hand hygiene with an alcohol-based rub appropriate, as opposed to using handwashing? You selected: When hands are not visibly soiled Correct Explanation: Alcohol-based hand rubs may be used if hands are not visibly soiled, or have not come in contact with blood or body fluids. They should be used before and after each client contact, or when in contact with surfaces inthe client's environment. Handwashing is required before eating or after usingthe restroom. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 543. Chapter 23: Asepsis and Infection Control - Page 543 ________________________________________ Question 8: (see full question) A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus infection. What isthe most important factor to prevent this infection? You selected: Surgical asepsis Correct Explanation: Clients are at risk for nosocomial infections whenthe healthcare staff does not follow safety guidelines. Medical and surgical asepsis isthe primary safety intervention for preventing disease inthe healthcare environment. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 540. Chapter 23: Asepsis and Infection Control - Page 540 ________________________________________ Question 9: (see full question) A nurse is taking care of a client with tuberculosis who has developed resistance tothe ordered antibiotic. Which type of client is most likely at increased risk for infection? You selected: Older adult Correct Explanation: Long-term care residents and older adult hospitalized clients are at increased risk for antibiotic-resistant infections. Pneumonia, influenza, urinary tract and skin infections, and TB are common in older people, especially residents of long-term care facilities. These infectious diseases are not commonly seen in young adults, children, or pregnant women admitted to health care facilities. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 536-537. Chapter 23: Asepsis and Infection Control - Page 536 ________________________________________ Question 10: (see full question) Which ofthe following patients presentsthe most significant risk factors forthe development of Clostridium difficileinfection? You selected: An 81-year-old patient who has been receiving multiple antibiotics forthe treatment of sepsis Correct Explanation: Old age and recent, long-term antibiotic therapy are significant risk factors for C. difficile infection. These supersedethe risks posed by recent HIV infection, skin grafts, and hemodialysis. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 543. Chapter 23: Asepsis and Infection Control - Page 543 congrats! Congratulations! You've reached Mastery Level 4 for Chapter 23: Asepsis and Infection Control! Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 9 90% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 23: Asepsis and Infection Control 4 Quizzes taken My Mastery Level: 4.00 Class Average: 3.23 Answer Key Question 1: (see full question) The nurse determines that which ofthe following clients is at greatest risk for a wound infection? You selected: A two-day postoperative client Correct Explanation: The client at greatest risk for a wound infection isthe two-day postoperative client, asthe surgery disruptedthe integrity ofthe skin, thereby increasingthe risk for wound infection. Although elderly clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk thanthe postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 557. Chapter 23: Asepsis and Infection Control - Page 557 ________________________________________ Question 2: (see full question) A nurse is caring for a patient who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based onthe QSEN competency of safety? You selected: The nurse placesthe patient in a private room with monitored negative air pressure. Correct Explanation: When a client is diagnosed with tuberculosis it is important forthe nurse to remember thatthe client should be placed in a private room with monitored negative air pressure.the client should not be placed in a room withthe door open.the nurse must wearthe appropriate respirator when caring forthe client, but visitors must wear masks. Simply being 3 feet away will not keepthe visitor from being exposed tothe client.the nurse would use airborne precautions, not droplet precautions when caring for a client diagnosed with tuberculosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 551. Chapter 23: Asepsis and Infection Control - Page 551 ________________________________________ Question 3: (see full question) The nurse is setting up a sterile field to perform a catheterization whenthe patient touchesthe end ofthe sterile field. What would bethe nurse’s next appropriate action? You selected: Discardthe sterile field andthe supplies and start over. Correct Explanation: The nurse’s next appropriate action would be to discardthe sterile field andthe supplies and start over.the client touchingthe end ofthe sterile field contaminatedthe field andthe items onthe field.the nurse cannot reusethe sterile equipment becausethe items are no longer sterile.the nurse cannot proceed withthe procedure sincethe items have been contaminated. Calling for help and asking for new supplies is notthe best answer.the field has been contaminated also. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 544. Chapter 23: Asepsis and Infection Control - Page 544 ________________________________________ Question 4: (see full question) Which action shouldthe nurse perform first after an exposure to a client’s body fluids? You selected: Washthe exposed area with soap and water Correct Explanation: The first action bythe nurse should be to washthe exposed area immediately with warm water and soap. While being tested for HIV and hepatitis and/or taking post-exposure prophylaxis may be appropriate, they would not bethe firstaction bythe nurse. (less) Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 552. Chapter 23: Asepsis and Infection Control - Page 552 ________________________________________ Question 5: (see full question) Surgical asepsis is defined as You selected: Absence of all microorganisms Correct Explanation: Surgical asepsis refers to sterile technique and indicates procedures used to eliminate any microorganisms. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 539. Chapter 23: Asepsis and Infection Control - Page 539 ________________________________________ Question 6: (see full question) A nurse is caring for a client with ringworm. Which ofthe following microorganisms causes ringworm in a client? You selected: Fungi Correct Explanation: Ringworm is caused by a fungal infection. Fungi include yeasts and molds, which cause infections inthe skin, mucous membranes, hair, and nails. Rickettsiae are microorganisms that resemble bacteria but cannot survive outside of another living species. They are responsible for Lyme disease. Protozoans are single-celled animals classified according to their ability to move. They do not cause ringworm. Helminths are infectious worms that may or may not be microscopic. They include roundworms, tapeworms, and flukes. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 533. Chapter 23: Asepsis and Infection Control - Page 533 ________________________________________ Question 7: (see full question) A lead nurse is removing her personal protective equipment after dressingthe infected wounds of a client. Which ofthe following isthe highest priority nursing action? You selected: Handwashing before leavingthe client's room. Correct Explanation: The most important nursing action is to perform a thorough handwashing before leavingthe client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them.the procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses removethe garments that are most contaminated first, preservingthe clean uniform underneath. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 542, 561. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 8: (see full question) The nurse performs hand hygiene using soap and water before and after providing patient care. Which nursing action is performed correctly according tothe procedure? You selected: The nurse uses about 2 teaspoons of liquid soap to wash hands. Incorrect Correct response: The nurse washes at least one inch abovethe area of contamination if present. Explanation: the nurse must wash at last one inch abovethe area of contamination to properly performed hand hygiene.the nurse should use warm to hot water to wash hands.the amount of liquid soap varies depending onthe concentration ofthe soap.the nurse rinses with water flowing towardthe fingertips. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 559. Chapter 23: Asepsis and Infection Control - Page 559 ________________________________________ Question 9: (see full question) Which ofthe following practices is a correct application of infection control practices? You selected: A nurse performs handwashing each time she removes a pair of gloves. Correct Explanation: Handwashing should be performed afterthe removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542. Chapter 23: Asepsis and Infection Control - Page 542 ________________________________________ Question 10: (see full question) A patient is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? You selected: Surgical asepsis technique Correct Explanation: Surgical asepsis technique isthe technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly inthe operating room, labor and delivery areas, and certain diagnostic testing areas, are also used bythe nurse atthe patient’s bedside. Procedures that involvethe insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reducethe number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique wherethe client is protected fromthe nurse, other health care providers, and visitors. A client that has immune system disorders wherethe client might not be able to fight off an organism would be kept in an environment to minimize exposure tothe organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn to not carrythe organism via droplet from exposed client to others. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 23: Asepsis and Infection Control, p. 553. Chapter 23: Asepsis and Infection Control - Page 553 congrats! Congratulations! You've reached Mastery Level 5 for Chapter 26: Safety, Security, and Emergency Preparedness! Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 8 80% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 26: Safety, Security, and Emergency Preparedness 5 Quizzes taken My Mastery Level: 5.00 Class Average: 2.82 Answer Key Question 1: (see full question) The nurse is creating a plan of care forthe older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What isthe most appropriate nursing diagnosis to include in this client's plan of care? You selected: Risk for poisoning related to poor eyesight andthe inability to read medication labels Correct Explanation: Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in readingthe labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 705-706. Chapter 26: Safety, Security, and Emergency Preparedness - Page 705 ________________________________________ Question 2: (see full question) What is an appropriate nursing intervention to include inthe plan of care for a client with smallpox? You selected: Droplet precautions Incorrect Correct response: Strict contact and airborne precautions forthe duration ofthe illness Explanation: Clients with smallpox should receive strict contact and airborne precautions for duration of illness and supportive care. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 715. Chapter 26: Safety, Security, and Emergency Preparedness - Page 715 ________________________________________ Question 3: (see full question) When educating families on fire safety inthe home, which information is important forthe nurse to emphasize? You selected: Have a meeting place outsidethe home in case of fire. Correct Explanation: The whole family should regularly practice a fire escape plan, such as crawling onthe floor, using escape routes, and having a meeting place outsidethe home in case of fire. Attempting to account for all family members before exitingthe burning structure is dangerous and may result inthe loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in a area with access and not a closet. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 694. Chapter 26: Safety, Security, and Emergency Preparedness - Page 694 ________________________________________ Question 4: (see full question) A child is playing soccer and is involved in a head collision with another player. Which assessment findings shouldthe nurse be alert to that may indicate a concussion? (Select all that apply.) You selected: • Drowsiness • Vomiting • Headache Correct Explanation: Concussions are a frequently seen sports injury in school age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present. Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702. Chapter 26: Safety, Security, and Emergency Preparedness - Page 702 ________________________________________ Question 5: (see full question) A nurse in a psychiatric care unit finds that a client with psychosis has become violent and is harmingthe other patients inthe unit. What action shouldthe nurse take in this case? You selected: Restrainthe client, as he is harmful tothe other patients. Correct Explanation: The nurse should restrainthe client because he is potentially harmful to other patients inthe psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however.the nurse should informthe physician aboutthe client, but sometimes it may not be logical to wait for orders to restrain a violent client. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 707-710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 707 ________________________________________ Question 6: (see full question) Which nursing assessment finding while screening a family with an 11-month-old infant who is beginning to pull to stand should be most concerning? You selected: The older siblings play ball inthe back yard that is not fenced in. Incorrect Correct response: The mother loves to drink coffee all day. Explanation: As infants begin to become mobile and more active, they havethe tendency to pull up on objects and climb on furniture because they are curious. Since this 11-month-old is becoming mobile and is pulling up,the risk is great that he may pull over a cup ofthe mother’s hot coffee that she drinks all day. Therefore, this should be concerning tothe nurse. At leastthe father who smokes is smoking outside, and this child is not able to ride a tricycle yet if he is just pulling up, sothe parents have time to purchase a helmet.the older siblings inthe back yard have no direct affect on this child yet. When he gets older and begins to run and play,the risk of running afterthe stray ball fromthe backyard becomes a concern. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 697-701. Chapter 26: Safety, Security, and Emergency Preparedness - Page 697 ________________________________________ Question 7: (see full question) The nurse is caring for a client in a posey vest restraint.the restraint was ordered at 0800.the last nursing client assessment and need for restraint was documented at 1000. It is now 1200. What isthe appropriate action bythe nurse? You selected: Assessthe client and document findings immediately. Correct Explanation: Assessment and documentation of a client in restraints should occur at least every hour. Although it has been longer than an hour sincethe last documented assessment,the nurse should immediately assessthe client and documentthe findings.the nurse should never falsify documentation by documenting that an assessment was done at at time when it was not completed.the restraints should not be discontinue unless it is appropriate to do so, and there is no need to contactthe physician at this time. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 709. Chapter 26: Safety, Security, and Emergency Preparedness - Page 709 ________________________________________ Question 8: (see full question) What isthe most important safety concept that a nurse should include inthe teaching plan for a family with a newborn infant inthe household? You selected: Avoid stuffed animals and blankets inthe crib. Correct Explanation: Suffocation is a hazard for infants, especially beforethe age of 4 months. Toddlers and older children are more at risk for falls, and adolescents tend to engage in risky behaviors. Therefore, education about and awareness of these behaviors is important in this age group, but not for an infant. Seat-belt safety is more appropriate to teach older children and adults. Car seat safety would be important for families with a newborn infant. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, pp. 687, 689. Chapter 26: Safety, Security, and Emergency Preparedness - Page 687 ________________________________________ Question 9: (see full question) A nurse smells smoke and subsequently discovers a fire in a garbage can in a common area onthe hospital unit. What isthe nurse's priority action in this situation? You selected: Rescue anyone who is in immediate danger. Correct Explanation: The acronym "RACE" can be used as a guide tothe immediate response to fire. This involves Rescuing anyone in immediate danger; Activatingthe fire code system and notifyingthe appropriate person; Confiningthe fire by closing doors and windows; Evacuating clients and other people to a safe area. Extinguishingthe fire is not part ofthe immediate response. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 ________________________________________ Question 10: (see full question) The unlicensed personnel tellsthe nurse that a client is very confused and trying to get out of bed without assistance. What isthe appropriate action bythe nurse? You selected: Initiate use of a bed alarm. Correct Explanation: The nurse should attempt to preventthe client confused client from getting out of bed by themselves to prevent a fall usingthe least restrictive action first. In this case, it would be to initiatethe use of a bed alarm. Putting up all 4four siderails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort whenthe client is in danger of harming themselves or others. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710. Chapter 26: Safety, Security, and Emergency Preparedness - Page 710 Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 9 90% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 34: Comfort and Pain Management 1 Quiz taken My Mastery Level: 1.00 Class Average: 3.05 Answer Key Question 1: (see full question) A nurse attempts to relievethe pain of a patient by using cutaneous stimulation. Which ofthe following accurately describes usage of this technique? You selected: A nurse applies intermittent heat and cold to a patient's leg. Correct Explanation: Cutaneous stimulation isthe intermittent application of heat or cold, or both. Heat acceleratesthe inflammatory response to promote healing, reduces muscle tension to promote relaxation, and helps to relieve muscle spasms and joint stiffness. Cold reduces muscle spasm, alters tissue sensitivity, and promotes comfort by slowingthe transmission of pain stimuli. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1171. Chapter 34: Comfort and Pain Management - Page 1171 ________________________________________ Question 2: (see full question) Which ofthe following isthe priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump? You selected: Respiratory Correct Explanation: The priority assessment forthe nurse caring for a client with a PCA pump is respiratory, with particular attention tothe respiratory rate and pattern. Too much narcotic or a displaced catheter may allowthe medication to have a depressant effect onthe brainstem center, causing life-threatening respiratory depression. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1180. Chapter 34: Comfort and Pain Management - Page 1180 ________________________________________ Question 3: (see full question) Which ofthe following would bethe most appropriate nursing action to managethe pain of a Navajo Indian after surgery? You selected: Offer pain medication to client at routine intervals. Correct Explanation: The nurse should offerthe pain medication tothe client at routine intervals, as Navajo Indians do not usually openly express their pain or request pain medication. By offeringthe medication,the nurse will enablethe client to acceptthe pain medication in a manner that is culturally acceptable tothe client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1159. Chapter 34: Comfort and Pain Management - Page 1159 ________________________________________ Question 4: (see full question) Which ofthe following is considered to bethe most potent neuromodulators? You selected: Endorphins Correct Explanation: Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 5: (see full question) A physician orders a placebo for a client. What is a placebo? You selected: An inactive substance given in place of a drug Correct Explanation: A placebo is an inactive substance given to satisfy a person's demand for a drug.the use of placebos raises serious ethical questions, andthe nurse has firm legal and ethical grounds for refusing to administer a placebo. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1184. Chapter 34: Comfort and Pain Management - Page 1184 ________________________________________ Question 6: (see full question) A client reports after a back massage that his lower back pain has decreased from 8 to 3 onthe pain scale. What opioid neuromodulator doesthe nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort? You selected: Endorphins Correct Explanation: Endorphins and enkephalins are opioid neuromodulators that are powerful pain-blocking chemicals, which have prolonged analgesic effects and produce euphoria. It is thought that cer ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 34: Comfort and Pain management, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 7: (see full question) A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. What drug hasthe potential to reversethe respiratory-depressant effect of an opioid? You selected: Naloxone Correct Explanation: Naloxone (Narcan) is an opioid antagonist that reversesthe respiratory-depressant effect of an opioid. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1174. Chapter 34: Comfort and Pain Management - Page 1174 ________________________________________ Question 8: (see full question) The nurse is preparing to administer an NSAID to a client for pain relief.the nurse notices thatthe client is diagnosed with a bleeding disorder. What shouldthe nurse do? You selected: Contactthe physician. Correct Explanation: The nurse should contactthe physician regardingthe diagnosis of a bleeding disorder andthe order forthe NSAID. NSAIDs are contraindicated in clients with bleeding disorders, asthe action ofthe NSAID can interfere withthe client's platelet function. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1176. Chapter 34: Comfort and Pain Management - Page 1176 ________________________________________ Question 9: (see full question) Which ofthe following statements accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain? You selected: A PCA pump must be used and monitored in a health care facility. Incorrect Correct response: The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. Explanation: The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval. This approach can be used with oral analgesic agents as well as with infusions of opioid analgesic agents by intravenous, subcutaneous, epidural, and perineural routes. This drug delivery system may be used to manage acute and chronic pain in a health care facility orthe home. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1180. Chapter 34: Comfort and Pain Management - Page 1180 ________________________________________ Question 10: (see full question) A nurse assesses a client who is being given an opioid analgesic and findsthe client unresponsive to shaking or other stimuli. What drug might be ordered to reverse this state? You selected: Naloxone Correct Explanation: If stimulation is ineffective in arousing a client using opioids, naloxone (Narcan), an opioid antagonist that reversesthe respiratory-depressant effects of opioids, can be used. Whenthe client is alert andthe respiratory rate is greater than 9 breaths/min,the opioids may be resumed. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1175. Chapter 34: Comfort and Pain Management - Page 1175 Question 1: (see full question) A nurse is administering prescribed medicine to a client who experienced acute pain inthe lower back after a motor vehicle accident.the client tellsthe nurse that compared tothe previous week, his pain had reduced considerably. Which phase of pain isthe client experiencing? You selected: Correct Explanation: The client is inthe modulation phase of pain, during whichthe brain interacts withthe spinal nerves in a downward fashion to subsequently alterthe pain experience.the client is not inthe transduction, transmission, or perception phase of pain. Transduction phase refers tothe conversion of chemical information atthe cellular level into electrical impulses that move towardthe spinal cord. In transmission phase,the stimuli move fromthe peripheral nervous system towardthe brain, andthe perception phase occurs whenthe pain threshold is reached. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 2: (see full question) A male college student age 20 years has been experiencing increasingly sharp pain inthe right, lower quadrant of his abdomen overthe last 12 hours. A visit tothe emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain isthe client most likely experiencing? You selected: Correct Explanation: Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed. Appendicitis is characterized by inflammation ofthe vermiform appendix. Cutaneous pain is superficial. Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed nearthe location of his appendix. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1155. Chapter 34: Comfort and Pain Management - Page 1155 ________________________________________ Question 3: (see full question) The nurse recognizes which ofthe following statements is true of chronic pain? You selected: Correct Explanation: Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because ofthe unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 4: (see full question) The nurse is caring for several clients experiencing acute pain. Which ofthe following would bethe most appropriate task to delegate tothe unlicensed assistive personnel? You selected: Correct Explanation: The most appropriate task forthe nurse to delegate tothe unlicensed personnel is to givethe client a back massage. It is not appropriate to delegate administration of oral and/or intravenous medication tothe client. It is also not appropriate forthe unlicensed personnel to provide spiritual counseling. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, pp. 1188-1191. Chapter 34: Comfort and Pain Management - Page 1188 ________________________________________ Question 5: (see full question) The nurse has completed a preoperative education session with a client who will receive morphine via a patient-controlled analgesia pump (PCA) after surgery. Which ofthe following statements bythe client indicatesthe need for further teaching? You selected: Correct Explanation: Sedation that preventsthe client from delivering a dose of opioid contributes tothe safety of intravenous PCA drug administration. Ifthe client is too sleepy to pushthe button (or asks that it be pushed),the button should not be pushed. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1180. Chapter 34: Comfort and Pain Management - Page 1180 ________________________________________ Question 6: (see full question) A nurse is assessing a client's pain.the nurse notes which ofthe following database findings that is indicative of acute pain? You selected: Correct Explanation: The increase in blood pressure that may accompany acute pain is believed to be due to overactivity ofthe sympathetic nervous system. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1162. Chapter 34: Comfort and Pain Management - Page 1162 ________________________________________ Question 7: (see full question) Which ofthe following nonpharmacologic pain relief measures has been found to be effective for soothing agitated newborns and comatose clients? You selected: Correct Explanation: Listening to music can relax, soothe, decrease pain, and provide distraction. It has proven effective for soothing agitated newborns and comatose clients. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1170. Chapter 34: Comfort and Pain Management - Page 1170 ________________________________________ Question 8: (see full question) Three days after surgery, a patient continues to have moderate to severe incisional pain. Based onthe gate control theory, what action shouldthe nurse take? You selected: Correct Explanation: The nurse would repositionthe client and gently massagethe client’s back usingthe gate control theory of pain.the gate control theory providesthe most practical model regardingthe concept of pain. It describesthe transmission of painful stimuli and recognizes a relation between pain and emotions. Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to closethe gate, thus blocking pain impulses from that area. Decreasingthe dosage ofthe pain medication, but givingthe doses more frequently does not follow this theory. Decreasing external stimuli inthe room during painful episodes would not addressthe gate control theory. Advisethe client to sleep following administration of pain medication does not addressthe gate control theory. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 9: (see full question) Which ofthe following means of pain control is based onthe gate control theory? You selected: Correct Explanation: Acupuncture is a means of pain control that is based onthe gate control theory. Biofeedback, distraction, and hypnosis are alternative and complementary therapies that are nonpharmacological means of pain control. They are not based onthe gate control theory. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p. 1172. Chapter 34: Comfort and Pain Management - Page 1172 ________________________________________ Question 10: (see full question) A nurse administers pain medication to patients on a med-surg ward. Which patient would benefit from a PRN drug regimen as an effective method of pain control? You selected: A patient experiencing acute pain Incorrect Correct response: Explanation: A PRN (as needed) medication would be most appropriate for a client inthe postoperative stage with occasional pain. A client inthe early postoperative period would benefit fromthe dosage of pain medication with aroundthe clock dosing. A client experiencing chronic pain would benefit fromthe dosage of pain medication with aroundthe clock dosing. A client experiencing acute pain would benefit fromthe dosage of pain medication with aroundthe clock dosing. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p. 1177. Chapter 34: Comfort and Pain Management - Page 1177 congrats! Congratulations! You've reached Mastery Level 3 for Chapter 34: Comfort and Pain Management! Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 9 90% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 34: Comfort and Pain Management 3 Quizzes taken My Mastery Level: 3.00 Class Average: 3.05 Answer Key Question 1: (see full question) The nurse is providing education to a client aboutthe role of endogenous opioids inthe transmission of pain. Which information aboutthe release of endogenous opioids is most accurate? You selected: They bind to opioid receptor sites throughoutthe CNS. Correct Explanation: When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughoutthe central nervous system (C ... (more) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1154. Chapter 34: Comfort and Pain Management - Page 1154 ________________________________________ Question 2: (see full question) A client is ordered pain medication every 4 to 6 hours as needed. Whenthe nurse entersthe client's room to administerthe medication,the client is laughing with visitors.the client's pulse rate is 64, respirations 16, and blood pressure 120/80.the client states that they are in pain and wantsthe medication. What isthe most appropriate action bythe nurse? You selected: Administerthe pain medication. Correct Explanation: Pain is present wheneverthe client perceives that they are in pain.the client is orderedthe medication,the client's vital signs are within acceptable range, andthe client stat ... (more) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1152. Chapter 34: Comfort and Pain Management - Page 1152 ________________________________________ Question 3: (see full question) A nurse is caring for a client with an amputated limb.the client tellsthe nurse that he has a burning sensation in his amputated limb. How shouldthe nurse document this pain? You selected: Phantom pain Correct Explanation: The nurse should documentthe pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months afterthe source ofthe pain has been treated a ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1156. Chapter 34: Comfort and Pain Management - Page 1156 ________________________________________ Question 4: (see full question) A client asksthe nurse which vitamins should be taken daily for feelings of fatigue, anxiety, and depression 1 week before menses. Which ofthe following isthe correct response bythe nurse? You selected: Vitamin B6 Correct Explanation: The nurse should encourage taking Vitamin B6 daily, as it may be effective at relieving symptoms of irritability, fatigue, and depression related tothe premenstrual period. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1187. Chapter 34: Comfort and Pain Management - Page 1187 ________________________________________ Question 5: (see full question) A client in pain believes that their pain is a punishment from God, and feels angry and resentful. Which ofthe following isthe most appropriate action bythe nurse? You selected: Encourage client to confer with a spiritual advisor. Correct Explanation: The most appropriate action bythe nurse would be to encouragethe client to confer with a spritual advisor to work through feelings of anger and resentment as it relates to God and their pain experience. Consulting a psychiatric nurse practitioner may helpthe client work through feelings of anger and resentment, but may not addressthe underlying feelings/beliefs related to God andthe client's experience of pain. Encouragingthe client to pray or to have visitors pray forthe client may not helpthe client work through feelings of anger and resentment related to God and their experience of pain. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1160. Chapter 34: Comfort and Pain Management - Page 1160 ________________________________________ Question 6: (see full question) Which ofthe following principles shouldthe nurse integrate intothe pain assessment and pain management of pediatric clients? You selected: Pain assessment may require multiple methods in order to ensure accurate pain data. Correct Explanation: It is often necessary to use more than one technique for pain assessment in children. Though their neurological system is indeed developing, children feel pain acutely, and it is inappropriate to withhold analgesics until they are a "last resort." It is simplistic to specify a numeric pain scale for all clients above a certain age;the assessment tool should reflectthe client's specific circumstances, abilities, and development. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1178-1179. Chapter 34: Comfort and Pain Management - Page 1178 ________________________________________ Question 7: (see full question) After sedating a patient,the nurse assesses thatthe patient is frequently drowsy and drifts off during conversations. What number onthe sedation scale wouldthe nurse document for this patient? You selected: 3 Correct Explanation: The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows: 1 = awake and alert; no action necessary, 2 = occasionally drowsy but easy to arouse; requires no action, 3 = frequently drowsy and drifts off to sleep during conversation; decreasethe opioid dose, 4 = somnolent with minimal or no response to stimuli; discontinuethe opioid and consider use of naloxone. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p. 1174. Chapter 34: Comfort and Pain Management - Page 1174 ________________________________________ Question 8: (see full question) The wife of a patient with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief.the nurse would recognize thatthe patient is likely showingthe effects of which ofthe following? You selected: Tolerance. Correct Explanation: This patient is likely developing drug tolerance, which occurs whenthe body becomes accustomed tothe opioid and needs a larger dose each time for pain relief. This is not a pathological finding and does not necessarily indicate physical dependence. Tolerance does not indicate addiction or a heightened risk of addiction.the phenomenon noted is not indicative of a drug interaction. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1175. Chapter 34: Comfort and Pain Management - Page 1175 ________________________________________ Question 9: (see full question) Which ofthe following guidelines regarding pain should be included inthe nurse's education plan for a group of parents with infants and toddlers? You selected: Pain can be a source of fear and threat tothe toddler's security. Correct Explanation: Duringthe toddler and preschool years, children are achieving a sense of autonomy. Because pain can be a source of fear and threat to security, children respond with crying, anger, physical resistance, or withdrawal. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1164. Chapter 34: Comfort and Pain Management - Page 1164 ________________________________________ Question 10: (see full question) The nurse is developing a plan of care for a client in acute pain. Which ofthe following shouldthe nurse include? (Select all that apply.) You selected: • Promote a restful environment. • Encourage deep breathing. Incorrect Correct response: • Encourage deep breathing. • Playthe client's favorite music. • Promote a restful environment. Explanation: Anxiety, lack of sleep, and muscle tension may all increasethe client's perceived intensity of pain. Therefore,the client's plan of care should include measures to promote sleep and decrease anxiety and muscle tension. These include relaxation techniques, such as deep breathing, favorite music, and restful environment. Use of a sitter, someone to be paid to stay withthe client inthe room at all times, is not indicated and may causethe client's anxiety level to increase. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1160. Chapter 34: Comfort and Pain Management - Page 1160 Chapter 30: Hygiene - Page 921 ________________________________________ Question 8: (see full question) A client is being discharged today fromthe hospital.the nurse delegates morning care tothe unlicensed assistive personnel (UAP).the assessment finds thatthe client is able to stand and ambulate independently without weakness or dizziness.the nurse will delegate what type of care to be provided based onthe assessment findings? You selected: Correct Explanation: Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowingthe client to shower independently would be appropriate.the client is not unstable enough to prohibit hygiene measures. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 30: Hygiene, pp. 903-904. Chapter 30: Hygiene - Page 903 ________________________________________ Question 9: (see full question) The nurse is assisting a 56-year-old female, who has undergone a mastectomy, with her morning care. Which action bythe client requires further teaching bythe nurse? You selected: Correct Explanation: Clients who have undergone surgery for a mastectomy should avoidthe use of deodorants or antiperspirants post-operatively because they act to close sweat glands and can cause skin irritations. In others,the use of these products may be contraindicated due to personal or cultural values. Independence with hygiene measures is encouraged and cosmetics may be used for multiple reasons, including self-image enhancement in women. There are several bath preparations and a bag bath is convenient and beneficial tothe client's skin. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 928. Chapter 30: Hygiene - Page 928 ________________________________________ Question 10: (see full question) A nurse is washing a patient's hair using a shampoo cap. Which ofthe following is an accurate step in this procedure? You selected: Correct Explanation: Steps inthe procedure include: Place a towel acrossthe patient's chest. Placethe shampoo cap onthe patient's head. Massagethe scalp and hair throughthe cap to latherthe shampoo. Continue to massage according tothe time frame specified bythe manufacturer's directions. Remove and discardthe shampoo cap. Drythe patient's hair with a towel. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 922. Chapter 30: Hygiene - Page 922 congrats! Congratulations! You've reached Mastery Level 4 for Chapter 30: Hygiene! Quiz Results Quiz Stats Quiz completed in: 11 min Total Questions: 10 Questions answered: 10 Number correct: 8 80% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 30: Hygiene 3 Quizzes taken My Mastery Level: 4.00 Class Average: 3.40 Answer Key Question 1: (see full question) A nurse is performing an admission assessment on a client. What is an appropriate question to ask when assessingthe client’s self-care hygiene measures? You selected: “Do you feel you will have difficulty performing self-care while inthe hospital?” Correct Explanation: When assessing a client’s self-care patterns and feelings, it is important to understandthe client’s perceptions regarding bathing and elicit personal care preferences. Although it is important to incorporate preferences, it may not be possible to allow clients to bring products from home if they are in specialty care environments. Asking questions about body odor may sound judgmental and may causethe client to feel judged, which may prohibitthe ability to form a trusting relationship withthe nurse. A clear threat to health must be present before a nurse can decide a client's hygiene practices are inadequate. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 912. Chapter 30: Hygiene - Page 912 ________________________________________ Question 2: (see full question) A nurse caring forthe skin of patients of different age groups should consider which accurately described condition? You selected: An adolescent’s skin ordinarily has enlarged sebaceous glands and increased glandular secretions. Correct Explanation: Adolescents have enlarges sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining tothe mucous mem ... (more) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 30, Hygiene, p. 900 ________________________________________ Question 3: (see full question) When bathing a patient,the nurse notices thatthe patient has a rash on her arms. What would be an appropriate nursing intervention? You selected: Do not use over-the-counter products on unknown rashes. Incorrect Correct response: Use a tepid bath to relieve inflammation and itching. Explanation: Try tepid baths will most likely help relieve inflammation and itching.the area should be washed thoroughly with a mild cleansing agent and rinsed well. Over-the-counter products can be used on unknown rashes if approved bythe health care provider. A moisturizing lotion is recommended to use on a dry rash and a drying agent on a wet rash to prevent itching and promote healing. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 30, Hygiene, p. 906 ________________________________________ Question 4: (see full question) A school nurse is dealing with an outbreak of pediculosis in an elementary school. Which ofthe following teaching points shouldthe nurse prioritize when educatingthe parents of students who have lice and nits? You selected: The importance of completely finishingthe prescribed treatment Correct Explanation: When educating about pediculosis,the nurse must stressthe importance of finishingthe treatment. Many timesthe client will shampoothe hair once and not follow through with a second washing. Pediculosis requires treatment and is not self-limiting. It is not necessarily a reflection of inadequate hygiene. It is also not necessary to destroythe child's clothing and bedding. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 908. Chapter 30: Hygiene - Page 908 ________________________________________ Question 5: (see full question) A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An outcome measure wasthe client will participate in self-care measures bythe end ofthe week. Which documentation bythe nurse showsthe outcome was met? You selected: Client demonstrated bathing independently seated inthe bathroom. Client experienced no difficulty withthe procedure and experienced no pain. Correct Explanation: Bathing/hygiene self-care deficits resulting from hospitalizations and complications require return of strength and motor abilities. An appropriate goal is forthe client to actively and independently participate in hygiene and self-care. In order forthe nurse to document thatthe outcome was met,the nurse must seethe client performthe activity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 30: Hygiene, p. 910. Chapter 30: Hygiene - Page 910 ________________________________________ Question 6: (see full question) When providing oral care, which ofthe following doesthe nurse recognize asthe most important component ofthe oral care process? You selected: A thorough mechanical cleaning Correct Explanation: Followingthe steps for cleaningthe mouth thoroughly is more important thanthe agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning ofthe oral cavity. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 917. Chapter 30: Hygiene - Page 917 ________________________________________ Question 7: (see full question) Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers? You selected: Adolescents Correct Explanation: As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a person ages, bathing frequently decreases, and older people may not use deodorant due to excessive drying ofthe skin. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 903. Chapter 30: Hygiene - Page 903 ________________________________________ Question 8: (see full question) A nurse is preparing to help a client with a skin infection have a tub bath. In which ofthe following ways canthe nurse ensurethe client's safety? You selected: Check thatthe bathroom has a non-skid floor. Correct Explanation: The nurse can ensurethe client's safety by checking for non-skid strips onthe floors of bathtubs and showers, along with strategically placed handles and grab bars that reducethe risk of falls for elderly adults when bathing. Grab bars should be placed not at shoulder level but at arm level and within reach ofthe dominant arm. Asthe client has a skin infection, providing him with a damp towel will add to his problem. Oils are not used in showers or bathtubs as they increasethe risk of falls. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 913. Chapter 30: Hygiene - Page 913 ________________________________________ Question 9: (see full question) A nurse is evaluatingthe effectiveness of health promotion teaching related to hygiene at a community workshop. Which statements bythe one ofthe participants requires further teaching to ensure understanding? Select all that apply. You selected: • "Hygiene measures have no affect on skin." • "Hygiene does not contribute to my well-being so I can choose to not perform hygiene." • "It is important to brush your teeth regularly but flossing is not necessary since it can damagethe gums." Correct Explanation: Health promotion teaching for hygiene should include proper diet and exercise to promote healthy skin; brushing and flossing teeth regularly and visitingthe dentist every six months; keeping hair neat, combed, and brushed regularly; using caution with certain hair care products that can damagethe hair; keeping nails clean and neatly trimmed by clipping them straight across and shaping and smoothing with an emery board; bathing and cleansingthe skin regularly using lotions and creams while ensuring good cleansing ofthe axilla and application of deodorant and antiperspirants; and cleaningthe perineal areas. Hygiene also promotes a sense of well-being and positive self-image. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 904-906. Chapter 30: Hygiene - Page 904 ________________________________________ Question 10: (see full question) An Indian client is admitted to a facility for treatment of pneumonia. Since admission, she has been unwilling to participate in care offered bythe nursing staff but is too weak to provide her own care.the nurse is planning care for this client with a diagnosis of bathing/hygiene: self-care deficit. What wouldthe priority nursing intervention be? You selected: Incorporatethe patient’s preferences while providing care. Incorrect Correct response: Assessthe client’s cultural views regarding hygiene and self-care. Explanation: In accordance withthe nursing process, assessment ofthe client's cultural views regarding hygiene will be necessary in order to plan care accordingly. Assessment ofthe skin usingthe Braden scale is a daily intervention for skin integrity. Incorporatethe patient's preferences intothe plan of care which will be identified during assessment ofthe cultural views. Bathing is a task that can be delegated to a UAP. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 903. Chapter 30: Hygiene - Page 903 congrats! Congratulations! You've reached Mastery Level 6 for Chapter 32: Activity! Quiz Results Quiz Stats Quiz completed in: 5 min Total Questions: 10 Questions answered: 10 Number correct: 8 80% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 32: Activity 5 Quizzes taken My Mastery Level: 6.00 Class Average: 3.67 Answer Key Question 1: (see full question) A nurse is promoting body movements for a patient during range-of-motion exercises. Which movements provide for flexion? (Select all that apply.) You selected: • Bendingthe hand or foot backward and forward • Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position. • Curlingthe toes downward and then straightening them out Incorrect Correct response: • Bendingthe hand or foot backward and forward • Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position. • Movingthe head from side to side, then bringingthe chin toward each shoulder Explanation: Flexion isthe state of being bent. Bendingthe hand or foot backward and forward would be an example of flexion. Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position would be an example of flexion. Movingthe head from side to side, then bringingthe chin toward each shoulder would includethe movement of flexion. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041. Chapter 32: Activity - Page 1041 ________________________________________ Question 2: (see full question) The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? You selected: Scoliosis Correct Explanation: Numerous factors, including growth and development, influence a person’s posture, movement, and daily activity level.the adolescent should be assessed for scoliosis (curvature ofthe spine). Kyphosis is increased convexity nthe thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (inthe adult) that occurs because ofthe developing fetus. Older adults have an increased need for calcium and vitamin D related tothe risk for osteoporosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 3: (see full question) Which type of mobility aids would be most appropriate for a client who has poor balance? You selected: A cane with four prongs onthe end (quad cane) Correct Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness becausethe handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 32: Activity, p. 1078. Chapter 32: Activity - Page 1078 ________________________________________ Question 4: (see full question) The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would causethe nursethe most concern? You selected: Shortness of breath after walking up five stairs Correct Explanation: Activity Intolerance may result from any condition that interferes withthe transport of oxygenated blood to tissue.the altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic ofthe nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1081. Chapter 32: Activity - Page 1081 ________________________________________ Question 5: (see full question) The nursing assistant is preparing to helpthe client make a lateral transfer fromthe bed to a stretcher.the client informsthe nurse that he is able to move ontothe stretcher without her help. What isthe nurse's best response? You selected: "You are free to move ontothe stretcher without assistance, but I will supervise for your safety." Correct Explanation: Ifthe client is fully able to assist inthe transfer,the nurse should allowthe client to completethe movement independently, with supervision for safety. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1071-1072. Chapter 32: Activity - Page 1071 ________________________________________ Question 6: (see full question) A home care nurse visits a client with Parkinson's disease.the nurse observes thatthe client has rhythmic, repetitive movements ofthe hands.the home care nurse documents this as which ofthe following? You selected: Tremor Correct Explanation: Tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. A tremor usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation. Athetosis is movement characterized by slow, irregular, twisting motions. Dystonia is similar to athetosis but usually involves larger areas ofthe body. Ataxia is a general term used to describe impaired muscle coordination. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1047. Chapter 32: Activity - Page 1047 ________________________________________ Question 7: (see full question) The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? You selected: Safety Correct Explanation: When moving a client,the nurse’s key concerns are safety and client comfort. Privacy should be provided, as with any other nursing action, but this is not a key concern. Assisting a client with activity strengthensthe nurse/client relationship. Confidentiality is not a major concern with activity. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1059-1060. Chapter 32: Activity - Page 1059 ________________________________________ Question 8: (see full question) The nurse would like to assist a client to get out of bed to a chair.the client is uncooperative, has a leg cast, and can bear weight onthe unaffected leg. Which equipment or assistive device shouldthe nurse use? You selected: Lateral assist device Incorrect Correct response: Powered full-body lift Explanation: Many devices are available to aid in transferring, repositioning, and lifting clients. It is important to usethe right equipment and appropriate device based on client assessment and desired movement. Although this client can bear weight onthe unaffected side is uncooperative. A powered full-body lift device should be used. A lateral assist device is used during side-to-side transfers to make transfers safer and more comfortable forthe client. A friction-reducing device can be used under clients to prevent skin shearing when moving clients in bed and when assisting with lateral transfers. A powered stand-assist can be used with clients who can bear weight on at least one leg, can follow directions, and are cooperative. Although able to bear weight on one leg, this client is uncooperative and thus may not be able to follow directions. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 8: p. 1065. ________________________________________ Question 9: (see full question) How should an injured muscle associated with exercise be treated? (Select all that apply.) You selected: • Apply an elastic bandage tothe injured area. • Keepthe injured elevated. Correct Explanation: Elevation of an injured area will help to reduce edema. An elastic bandage for compression will help to reduce edema. Ice should be applied to minimize pain and edema. Ice, not heat, should be applied to minimize pain and edema. A physician (or health care provider) should be contacted immediately to diagnosethe extent ofthe injury. Exercising should be discontinued untilthe injury is healed. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1051. Chapter 32: Activity - Page 1051 ________________________________________ Question 10: (see full question) The nurse has been teachingthe client about how to use a walker safely.the nurse knowsthe teaching has been effective whenthe client: You selected: steps intothe walker when walking. Correct Explanation: A walker is mechanical aide that enhancesthe client's balance and ability to bear weight. Teaching is usually done by physical medicine or physical therapy, butthe nurse should continue to assessthe client’s ability to use it properly.the client should step intothe walker when walking, rather than walking behind it. When rising from a seated position,the arms ofthe chair should be used for support, notthe walker.the client should be cautioned to avoid pushingthe walker out too far in front. Also,the client should avoid leaning overthe walker, but should stay upright as he/she moves. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1077-1078. Chapter 32: Activity - Page 1077 Quiz Results Quiz Stats Quiz completed in: 6 min Total Questions: 10 Questions answered: 10 Number correct: 10 100% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 32: Activity 6 Quizzes taken My Mastery Level: 6.00 Class Average: 3.67 Answer Key Question 1: (see full question) An immobile client who weighs over 250 pounds is discharged to his daughter's home.the nurse should instructthe family to arrange for which ofthe following? You selected: Bariatric lift Correct Explanation: A bariatric lift is a type of hydraulic lift that is a mechanical device, which permits a client to be transferred fromthe bed to a chair effortlessly.the others would not be beneficial forthe daughter and would not be appropriate if used with this type of client. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1063. Chapter 32: Activity - Page 1063 ________________________________________ Question 2: (see full question) A nurse is teaching a patient how to walk with crutches. Which teaching points are recommended guidelines for this activity? (Select all that apply.) You selected: • Usethe four-point gait for patients who may bear weight on both feet. • Prevent crutches from getting closer than 3 inches tothe feet. • Keep elbows close to sides. Correct Explanation: The client should keepthe elbows close to their sides.the crutches should not be any closer than 12 inches fromthe feet.the client should usethe four-point gait if they can bear weight on both feet. When climbing stairs,the client should advancethe unaffected leg pastthe crutches, then place weight onthe unaffected leg. Thenthe client should advancethe affected leg and thenthe crutches tothe step.the swing-to gait is for individuals who can bear weight on both feet. This technique cannot be used with individuals who can bear weight on only one foot.the two-point gait is used with individuals who can bear weight on both feet. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1079. Chapter 32: Activity - Page 1079 ________________________________________ Question 3: (see full question) The adult client in good health has just started a walking exercise program and tellsthe nurse that he has to urinate more often and asks why this is happening. What would bethe nurse's best response? You selected: “Exercise improves circulation tothe kidneys so you may urinate more often.” Correct Explanation: Exercise has many effects onthe major body systems. Kidney function is affected where blood flow tothe kidneys is increased resulting in improved circulation tothe kidneys and excretion of body wastes; urine output would be increased. Although it is true that increased urination is a response to increased activity and exercise, tellingthe client that this is a common response to exercise does not addressthe client’s question. Urinary tract infections can be caused by urinary stasis which is an effect of immobility, not exercise, would have onthe kidneys.the development of kidney stones is an effect immobility would have onthe kidneys in which there is decreased urinary volume and increased urinary calcium. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1051 & 1053. Chapter 32: Activity - Page 1051 ________________________________________ Question 4: (see full question) The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would bethe nurse's next action? You selected: Movethe client to edge ofthe bed oppositethe side that client will be turning. Correct Explanation: When turning a client in bed,the nurse would use a friction-reducing sheet to pullthe client tothe edge ofthe bed that is oppositethe sidethe client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending onthe individual client. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1095-1098. Chapter 32: Activity - Page 1095 ________________________________________ Question 5: (see full question) A 65-year-old woman suffers from a condition where bone destruction exceeds bone formation and in whichthe resultant thin, porous bones fracture easily. This client is most likely diagnosed with which disorder? You selected: Osteoporosis Correct Explanation: Osteoporosis is a condition where bone destruction exceeds bone formation and in whichthe resultant thin, porous bones fracture easily. Achondroplasia is a congenital problem in which premature bone ossification (bone tissue formation) leads to dwarfism. Vitamin D deficiency is a nutrition-related problem, which results in deformities ofthe growing skeleton (rickets.) Osteogenisisimperfecta is a disease characterized by excessively brittle bones and multiple fracture both at birth and later in life. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1046. Chapter 32: Activity - Page 1046 ________________________________________ Question 6: (see full question) A nurse applies padded boots to maintainthe foot in dorsiflexion on a client who is comatose.the nurse is protectingthe client from what? You selected: Foot drop Correct Explanation: A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in whichthe foot is fixed in plantar flexion. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1066. Chapter 32: Activity - Page 1066 ________________________________________ Question 7: (see full question) When developing a plan of care for a client who has been inthe (protective) prone position,the nurse recognizes that it is essential to monitorthe client for: You selected: plantar flexion ofthe feet. Correct Explanation: It is important to be aware of client positioning and nursing actions required to prevent complications.the client who is inthe prone position is at risk for footdrop (plantar flexion ofthe feet) becausethe pull of gravity onthe feet unlessthe legs and feet are positioned carefully.the client inthe prone position is not at risk for flexion contracture ofthe neck becausethe body is straight asthe shoulders, head, and neck are in an erect position.the client would be at risk for flexion contractures ofthe hips when inthe supine or fowler’s position.the client inthe prone position is lying onthe abdomen so would be at risk for skin breakdown ofthe sacrum.the client inthe fowler’s position would be at risk for skin breakdown ofthe sacrum. When inthe prone position,the hips are prevented from flexing or hyperextending. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1069-1070. Chapter 32: Activity - Page 1069 ________________________________________ Question 8: (see full question) The nurse is orienting a new graduate nurse applying graduated compression stockings tothe client.the nurse should intervene immediately whenthe new graduate nurse: You selected: massagesthe client’s legs duringthe morning care. Correct Explanation: Massagingthe client’s legs is contraindicated because it will dislodge any potential clots that may be present.the clot may move away fromthe vessel wall and circulate inthe bloodstream. Graduated compression stockings should be applied inthe morning beforethe client gets out of bed. Otherwise,the client’s legs should be elevated for at least 15 minutes. This will prevent congestion of blood inthe leg vessels, reducingthe effectiveness ofthe stockings. Application of compression stockings requires a physician’s order.the stockings should be removed once a day to bathethe legs and feet. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1070. Chapter 32: Activity - Page 1070 ________________________________________ Question 9: (see full question) A client has been bedridden for a week.the daughter ofthe client asksthe nurse why her mother needs to sit onthe bedside before getting out of bed.the nurse’s best response is: You selected: “Your mother might get dizzy when she gets up so she needs to sit onthe side ofthe bed first.” Correct Explanation: Clients who are walking forthe first time after prolonged bed rest often feel faint or weak. Placingthe client inthe sitting position in bed for a few minutes will accustomthe client to this position and help prevent feelings of faintness, lightheadedness, dizziness, nausea, tachycardia, or pallor that are signs of orthostatic hypotension.the nurse should plan for ambulation for a short distance forthe first few times after periods of prolonged bed rest, gradually increasingthe distance as tolerated.the nurse should remain withthe patient and be ready to placethe back to a lying position if he or she feels faint, to preventthe client from falling out of bed. Although clients should have slippers or non-skid footwear on before ambulating, this is notthe reason for dangling a client onthe side ofthe bed before ambulating. Actually, slippers could essentially be placed onthe client before even getting out of bed. Ifthe client experiences shortness of breath,the client may not be stable enough or ready for increased activity at this time. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1075. Chapter 32: Activity - Page 1075 ________________________________________ Question 10: (see full question) A nurse is performing range-of-motion exercises on a patient who is on bedrest. What would bethe nurse’s best action whenthe patient complains: “I’m just too tired to do these exercises today.” You selected: Stopthe exercises and reevaluatethe nursing plan of care. Correct Explanation: While you are performing range-of-motion exercises, andthe client complains of feeling tired, stopthe activity for that time and re-evaluatethe nursing plan of care. Consider spacingthe exercises out at different times ofthe day. Schedule exercise times forthe parts ofthe daythe client is typically feeling more rested.the nurse would not encouragethe client to finishthe exercises and then reevaluatethe nursing plan.the nurse would not finishthe exercises and reportthe incident tothe primary care provider.the nurse would not modifythe number of repetitions for each exercise and then modifythe plan. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1113. Chapter 32: Activity - Page 1113 congrats! Congratulations! You've reached Mastery Level 7 for Chapter 32: Activity! Quiz Results Quiz Stats Quiz completed in: 5 min Total Questions: 10 Questions answered: 10 Number correct: 6 60% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 32: Activity 7 Quizzes taken My Mastery Level: 7.00 Class Average: 3.67 Answer Key Question 1: (see full question) Which body system effects wouldthe nurse state as occurring due to immobility? (Select all that apply.) You selected: • Increased cardiac workload • Increased risk for renal calculi • Increased rate of respiration • Increased risk for electrolyte imbalance Incorrect Correct response: • Increased cardiac workload • Increased risk for renal calculi • Increased risk for electrolyte imbalance Explanation: Increased cardiac workload, increased risk for renal calculi, and increased risk for electrolyte imbalance occur from immobility.the client would have decreased depth of respiration, decreased rate of respiration, and increase in urinary stasis with immobility. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1052. Chapter 32: Activity - Page 1052 ________________________________________ Question 2: (see full question) When turning a patient in bed, what muscle groups wouldthe nurse use to pullthe patient tothe opposite side ofthe bed? You selected: Arm Incorrect Correct response: Leg Explanation: The nurse would tighten gluteal and abdominal muscles, flexthe knees, and usethe leg muscles to dothe pulling. This saves strain onthe nurse’s lower back. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1095-1098. Chapter 32: Activity - Page 1095 ________________________________________ Question 3: (see full question) The nurse would like to assist a client to get out of bed to a chair.the client is uncooperative, has a leg cast, and can bear weight onthe unaffected leg. Which equipment or assistive device shouldthe nurse use? You selected: Powered full-body lift Correct Explanation: Many devices are available to aid in transferring, repositioning, and lifting clients. It is important to usethe right equipment and appropriate device based on client assessment and desired movement. Although this client can bear weight onthe unaffected side is uncooperative. A powered full-body lift device should be used. A lateral assist device is used during side-to-side transfers to make transfers safer and more comfortable forthe client. A friction-reducing device can be used under clients to prevent skin shearing when moving clients in bed and when assisting with lateral transfers. A powered stand-assist can be used with clients who can bear weight on at least one leg, can follow directions, and are cooperative. Although able to bear weight on one leg, this client is uncooperative and thus may not be able to follow directions. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 8: p. 1065. ________________________________________ Question 4: (see full question) Which exercises wouldthe nurse recommend when planning isometric exercise for a patient? (Select all that apply.) You selected: • Contracting and releasingthe gluteal muscles • Kegel exercises • Contractingthe quadriceps Correct Explanation: Contractingthe quadriceps, Kegel exercises, and contracting and releasingthe gluteal muscles are isometric exercises thatthe nurse might recommend to a client. Jogging, range-of-motion exercises, and bicycling are not isometric exercises, rather isotonic exercises. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1050. Chapter 32: Activity - Page 1050 ________________________________________ Question 5: (see full question) The nurse is assessingthe client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement.the nurse documents this finding as: You selected: hypertrophy. Incorrect Correct response: spasticity. Explanation: Adequate skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Spasticity, or hypertonicity, is defined as increased tone that interferes with movement. Spasticity is caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling ofthe muscle. Hypertrophy refers to increased muscles mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Flaccidity, or hypotonicity, results from disuse or neurologic impairments, and is described as a weakness of paralysis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1057-1058. Chapter 32: Activity - Page 1057 ________________________________________ Question 6: (see full question) In planning care for clients who need to be ambulated,the nurse knows that a gait belt should be used on which clients? (Select all that apply.) You selected: • Clients who require minimal assist • Cooperative clients Correct Explanation: Gait belts should be used with clients who are cooperative and require minimal assistance. Clients who have had lung surgery will have a thoracic incision and gait belts should not be used. Clients with weak legs are not candidates for a gait belt. Clients who have had abdominal surgery will have an abdominal incision and are not appropriate for a gait belt. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1064. Chapter 32: Activity - Page 1064 ________________________________________ Question 7: (see full question) A nurse is recommending aerobic exercise for a patient who is overweight. Which exercise mightthe nurse suggest? You selected: Swimming Correct Explanation: The exercise that is aerobic in this question is swimming. Aerobic exercise is also known as cardio exercise.the other options listed are anaerobic exercise. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1082 ________________________________________ Question 8: (see full question) A nurse is teaching a patient aboutthe beneficial effects of exercise on his body. Which teaching point wouldthe nurse include inthe plan? (Select all that apply.) You selected: • Exercise increases blood flow to kidneys. • Exercise increases intestinal tone. • Exercise increases efficiency of metabolic system. Correct Explanation: The benefits of exercise include increasing intestinal tone, increasing efficiency ofthe metabolic system, and increasing blood flow tothe kidneys. Exercise decreases resting heart and blood pressure. Exercise increases appetite. Exercise increasesthe rate of carbon dioxide excretion. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1050. Chapter 32: Activity - Page 1050 ________________________________________ Question 9: (see full question) The nurse would likethe client to perform some exercises that use muscle shortening and active movement that will help build bone and improve cardiac and respiratory functioning. Which exercise shouldthe nurse encouragethe client to do? (Select all that apply.) You selected: • Swimming • Lifting weights • Bicycling • Walking Incorrect Correct response: • Walking • Swimming • Bicycling Explanation: Exercises can be divided into two major groups. One is based onthe type of muscle contraction occurring duringthe exercise. Isotonic exercises shorten muscles and involve active movement. Isotonic exercises provide many benefits, including increased cardiac and respiratory function and builds bones. Walking, swimming, and bicycling are examples of isotonic exercises. Yoga exercises are an example of isometric exercises that involve muscle contraction without shortening (i.e. there is no movement or only a minimum of shortening of muscle fibers.) Although it is true that some ofthe same benefits such as improved circulation and bone building occur with isometric exercises. Lifting weights is an example of isokinetic exercise that involves muscle contractions with resistance provided at a constant rate by an external device. There is also capacity for variable resistance. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1049-1050. Chapter 32: Activity - Page 1049 ________________________________________ Question 10: (see full question) The nurse is assisting a patient fromthe bed into a wheelchair. Which ofthe following is a recommended guideline for this procedure? You selected: Raisethe head ofthe bed to a sitting position. Correct Explanation: When assisting a client fromthe bed into a wheelchair,the nurse would placethe bed inthe lowest position and raisethe head ofthe bed to a sitting position.the nurse would make surethe bed brakes are locked and putthe wheelchair next tothe bed, lockingthe brakes ofthe chair. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1102-1105. Chapter 32: Activity - Page 1102 Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 8 80% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 32: Activity 8 Quizzes taken My Mastery Level: 7.00 Class Average: 3.67 Answer Key Question 1: (see full question) The nurse is assessingthe developmental level of children in a pediatric clinic.the nurse would be most concerned about which client? You selected: The 24-month-old child who is unable to walk unassisted Correct Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raisethe head, but this is not expected at this age for all 3-month olds. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month olds. Stacking blocks is accomplished by most 3-year olds, although 18 months is early. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 2: (see full question) After positioning a client to move fromthe bed into a wheelchair, how wouldthe nurse stand when helpingthe client to sit up onthe side ofthe bed? You selected: Nearthe client's hip, with legs shoulder-width apart and one foot nearthe head ofthe bed Correct Explanation: When assistingthe client fromthe bed into a wheelchair,the nurse would take position nearthe client's hip, with legs shoulder-width apart and one foot nearthe head ofthe bed. This ensures thatthe nurse's center of gravity is placed nearthe client's greatest weight, to assistthe client to a sitting position safely. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1102-1105. Chapter 32: Activity - Page 1102 ________________________________________ Question 3: (see full question) Which nursing actions wouldthe nurse perform when assisting patients with passive ROM exercises? (Select all that apply.) You selected: • Move each joint in a smooth, rhythmic manner. • Use a flat palm to support joints during ROM exercises. • Begin ROM exercises atthe patient’s head and move down one side ofthe body at a time. • Adjustthe bed tothe flat position or as low asthe patient can tolerate. Incorrect Correct response: • Adjustthe bed tothe flat position or as low asthe patient can tolerate. • Begin ROM exercises atthe patient’s head and move down one side ofthe body at a time. • Move each joint in a smooth, rhythmic manner. Explanation: The nurse would adjustthe bed tothe flat position or as low asthe client can tolerate.the nurse would begin ROM exercises atthe client’s head and move down one side ofthe body at a time.the nurse would move each joint in a smooth, rhythmic manner.the nurse would not raisethe bed tothe highest position, but at a position that is waist high tothe nurse.the nurse would not perform each exercise 10 to 15 times, rather 2 to 5 times.the nurse would not use a flat palm, rather a cupping hold to support joints during ROM exercises. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1105. Chapter 32: Activity - Page 1105 ________________________________________ Question 4: (see full question) A nurse is logrolling a patient who has a spinal injury. Which nursing action followsthe recommended guidelines for this procedure? You selected: Have two nurses stand onthe side ofthe bed inthe directionthe patient will be turned. Incorrect Correct response: Enlistthe assistance of two or three other nurses to performthe procedure. Explanation: When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keepthe body in straight alignment when turningthe client. Two or three nurses can accomplish this safely by logrolling a patient. Do not try to logrollthe client without enough help. Do not twistthe client’s head, spine, shoulders, knees, or hips while logrolling. A friction-reducing sheet is used for other transfers, but not withthe logrolling technique.the nurse would have a client cross their arms on their chest with other transfers, but not withthe logrolling technique. A nurse should be on both sides ofthe bed of a client who is being logrolled, not just onthe side thatthe client is being turned. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1072. Chapter 32: Activity - Page 1072 ________________________________________ Question 5: (see full question) During range-of-motion exercises,the nurse turnsthe sole of a patient's foot towardthe midline and then turnsthe sole ofthe foot outward. Which type of movement is this nurse promoting by these actions? You selected: Inversion and eversion ofthe ankle Correct Explanation: Inversion and eversion are movements ofthe ankle. Inversion isthe movement ofthe sole ofthe foot inward. Eversion isthe movement ofthe sole ofthe foot outward. Internal rotation isthe turning of a body part on its axis towardthe midline ofthe body. External rotation isthe turning of a body part on its axis away fromthe midline ofthe body. Dorsiflexion isthe backward bending ofthe hand or foot. Plantar flexion is flexion ofthe foot. Flexion isthe state of being bent. Extension isthe state of being in a straight line. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041. Chapter 32: Activity - Page 1041 ________________________________________ Question 6: (see full question) When assessingthe physical activity of clients,the nurse would be most concerned about which client? You selected: The middle aged computer programmer Correct Explanation: Although further assessments should be done to avoid assumptions and stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive.the nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work.the mother of small children would be involved in housecleaning and chasing afterthe 2- and 4-year old. Walking is a commonly prescribed exercise and going tothe mall provides a safe environment where walking would be available. A Native American who hunts is engaging in culturally related physical activity. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1054. Chapter 32: Activity - Page 1054 ________________________________________ Question 7: (see full question) The 55 year-old client who is newly diagnosed with osteoarthritis ofthe hips asksthe nurse why it hurts when walking. What isthe nurse's best response? You selected: “You have lostthe padding in your joints andthe friction causes pain.” Correct Explanation: Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints particularly weight-bearing joints, characterized bythe deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction betweenthe moving parts ofthe joint. Ifthe client experienced a fall and subsequent hip fracture, mobility would be more impaired.the client would have difficulty walking. Also, this does not addressthe client’s question of why pain accompanies osteoarthritis. Although it is true that osteoarthritis is painful and common as people age, this response does not answerthe client’s question of why there is pain. Further, although it is also true that loss of muscle tone is common as people age, it may cause weakness, but not cause pain with walking. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 8: (see full question) When working with a client who has a fractured wrist,the nurse applies what knowledge aboutthe bones inthe body? You selected: Short bones contribute to movement. Correct Explanation: Short bones contribute to movement and are located inthe wrist and ankle.the wrist is classified as a short bone. Long bones, such asthe femur and humerus, are located inthe upper and lower extremities and contribute to height and length.the flat bones are relatively thin and contribute to shape.the flat bones are found inthe ribs and several ofthe skull bones and contribute to shape (structural contour). (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1038. Chapter 32: Activity - Page 1038 ________________________________________ Question 9: (see full question) The nurse moves a person’s arm from an outstretched position to a position atthe side ofthe patient’s body. What isthe term used to describe this type of body movement? You selected: Adduction Correct Explanation: Adduction is a lateral movement of a body part towardthe midline ofthe body. An example of adduction is when a person’s arm is moved from an outstretched position to a position alongsidethe body. Abduction is a lateral movement of a body part away fromthe midline ofthe body. An example of abduction is when a person’s arm is moved away fromthe body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement isthe circling ofthe arm atthe shoulder, as in bowling or a serve in tennis. Extension isthe state of being in a straight line. An example of extension is when a person’s cervical spine is extended,the head is held straight onthe spinal column. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041. Chapter 32: Activity - Page 1041 Quiz Results Quiz Stats Quiz completed in: 4 min Total Questions: 10 Questions answered: 10 Number correct: 9 90% Next Take another quiz to work towards a higher mastery level. See your overall performance. Performance by Chapter Chapter Mastery 1 2 3 4 5 6 7 8 Chapter 32: Activity 9 Quizzes taken My Mastery Level: 7.00 Class Average: 3.67 Answer Key Question 1: (see full question) The nurse is assessing a patient who is bedridden. For which condition wouldthe nurse consider this patient to be at risk? You selected: Predisposition to renal calculi Correct Explanation: In a bedridden client,the kidneys and ureters are level, and urine remains inthe renal pelvis for a longer period of time before gravity causes it to move intothe ureters and bladder. Urinary stasis favorsthe growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increasethe risk for urinary tract infection in an immobile patient. Immobility also predisposesthe patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone;the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume.the client would be at risk for decreased movement of secretion inthe respiratory tract, due to lack of lung expansion.the client would suffer from decreased metabolic rate due to being bedridden.the client would not have an increase in circulating fibrinolysin. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1053. Chapter 32: Activity - Page 1053 ________________________________________ Question 2: (see full question) A client with a hip fracture is returning tothe orthopedic unit, andthe orders indicate thatthe client should be turned by logrolling. What statement is correct regarding logrolling? You selected: Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. Correct Explanation: Logrolling requiresthe assistance of two or three nurses. Logrolling will maintain straight alignment whenthe client is being turned.the nurse should avoid twistingthe client's head, spine, shoulders, knees, or hips while logrolling.the nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1072-1073. Chapter 32: Activity - Page 1072 ________________________________________ Question 3: (see full question) When transferring a client fromthe bed to a stretcher, it is important forthe nurse to: You selected: leavethe friction-reducing sheet in place oncethe client is transferred. Correct Explanation: Safe patient handling and transfers involvethe use of client assessment criteria, algorithms for client handling decisions and proper use of client handling equipment.the client should be kept in good alignment and protected from injury while being moved. Oncethe client is transferred,the friction-reducing sheet should be left in place forthe return transfer. In preparation forthe transfer, a bath blanket should be placed overthe client andthe top covers removed from underneath.the client should be instructed to foldthe arms againstthe chest and movethe chin to chest. This provides assistance inthe transfer and prevents hyperextension ofthe neck.the nurse onthe side ofthe bed withoutthe stretcher should graspthe friction-reducing sheet atthe head and chest areas ofthe client.the nurse onthe stretcher side ofthe bed should graspthe friction-reducing sheet atthe head and chest, andthe nurse onthe other side should graspthe friction-reducing sheet atthe chest and leg areas ofthe client. This allows for even support ofthe client. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1061-1063. Chapter 32: Activity - Page 1061 ________________________________________ Question 4: (see full question) The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? You selected: Scoliosis Correct Explanation: Numerous factors, including growth and development, influence a person’s posture, movement, and daily activity level.the adolescent should be assessed for scoliosis (curvature ofthe spine). Kyphosis is increased convexity nthe thoracic spine from disk shrinkage and decreased height, common in older adults. A shifted center of gravity occurs during pregnancy (inthe adult) that occurs because ofthe developing fetus. Older adults have an increased need for calcium and vitamin D related tothe risk for osteoporosis. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045. Chapter 32: Activity - Page 1045 ________________________________________ Question 5: (see full question) The nurse would likethe client to perform some exercises that use muscle shortening and active movement that will help build bone and improve cardiac and respiratory functioning. Which exercise shouldthe nurse encouragethe client to do? (Select all that apply.) You selected: • Swimming • Bicycling • Walking Correct Explanation: Exercises can be divided into two major groups. One is based onthe type of muscle contraction occurring duringthe exercise. Isotonic exercises shorten muscles and involve active movement. Isotonic exercises provide many benefits, including increased cardiac and respiratory function and builds bones. Walking, swimming, and bicycling are examples of isotonic exercises. Yoga exercises are an example of isometric exercises that involve muscle contraction without shortening (i.e. there is no movement or only a minimum of shortening of muscle fibers.) Although it is true that some ofthe same benefits such as improved circulation and bone building occur with isometric exercises. Lifting weights is an example of isokinetic exercise that involves muscle contractions with resistance provided at a constant rate by an external device. There is also capacity for variable resistance. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1049-1050. Chapter 32: Activity - Page 1049 ________________________________________ Question 6: (see full question) When assisting a client fromthe bed into a wheelchair,the nurse assessesthe client for signs of dizziness upon standing. For what adverse condition isthe nurse assessingthe client? You selected: Orthostatic hypotension Correct Explanation: The nurse would stand in front ofthe client and assess for any balance problems or complaints of dizziness upon standing, due to orthostatic hypotension. Standing in front ofthe ... (more) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1075. Chapter 32: Activity - Page 1075 ________________________________________ Question 7: (see full question) The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would causethe nursethe most concern? You selected: Shortness of breath after walking up five stairs Correct Explanation: Activity Intolerance may result from any condition that interferes withthe transport of oxygenated blood to tissue.the altered response to activity includes exertional dyspnea, s ... (more) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1081. Chapter 32: Activity - Page 1081 ________________________________________ Question 8: (see full question) A patient will be ambulating forthe first time since his cardiac surgery. What shouldthe nurse consider when assisting this patient? You selected: Patients who can lift their legs only 1 to 2 inches offthe bed do not have sufficient muscle power to permit walking. Incorrect Correct response: If an ambulating patient whom a nurse is assisting begins to fall,the nurse should slidethe patient down his or her own body tothe floor, carefully protectingthe patient’s head. Explanation: The nurse would usethe gait belt to easethe client backward against one’s own body and gently easethe client tothe floor while protectingthe client’s head.the client should not look at their feet, but rather out at eye level at their surroundings.the nurse should consultthe plan of care forthe client, butthe nurse regularly ambulates a client without a physical therapist present.the evaluation of a client’s muscle power to permit walking cannot be measured by their ability to lift their legs offthe bed. (less) Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1076. Chapter 32: Activity - Page 1076 ________________________________________ Question 9: (see full question) Which type of mobility aids would be most appropriate for a client who has poor balance? You selected: A cane with four prongs onthe end (quad cane) Correct Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness becausethe handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 32: Activity, p. 1078. Chapter 32: Activity - Page 1078 ________________________________________ Question 10: (see full question) A home care nurse visits a client with Parkinson's disease.the nurse observes thatthe client has rhythmic, repetitive movements ofthe hands.the home care nurse documents this as which ofthe following? You selected: Tremor Correct Explanation: Tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. A tremor usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation. Athetosis is movement characterized by slow, irregular, twisting motions. Dystonia is similar to athetosis but usually involves larger areas ofthe body. Ataxia is a general term used to describe impaired muscle coordination. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1047. Chapter 32: Activity - Page 1047 Question 7: (see full question) Which characteristics or examples help to define a cartilaginous joint? (Select all that apply.) You selected: • Freely movable • No joint cavity • Cartilage betweenthe bones Incorrect Correct response: Explanation: The pubis symphysis is an example of a cartilaginous joint.the cartilaginous joint has cartilage between bones. There is no joint cavity in a cartilaginous joint. A freely movable joint is a synovial joint,the cartilaginous joint is slightly movable. A fibrous joint has fibrous connective tissue betweenthe bones.the sutures betweenthe bones ofthe skull are an example of a fibrous joint. (less) ________________________________________ Question 4: (see full question) The nurse is assessing an ambulatory patient for gait. Which documentation describes this mobility status? You selected: Adequate muscle mass, tone, and strength are available to accomplish movement. Incorrect Correct response: Explanation: The patient’s movements while walking should be coordinated andthe posture well balanced.the arms should swing freely in a rhythm alternating withthe legs. Mobility would not be described bythe drawing of a straight line fromthe ear throughthe shoulder and hip. This does not explain howthe client moves.the documentation of full range-of-motion does not describethe client’s mobility.the documentation of adequate muscle mass, tone, and strength could be important to include inthe general documentation, but this description does not explainthe client’s mobility status. (less) Question 8: (see full question) A nurse assesses a patient's alignment and documents which data as a normal finding? You selected: The knees are slightly bent. Incorrect Correct response: The base of support is onthe soles ofthe feet. Explanation: Documentation of a normal finding of a client’s alignment would be thatthe base of support is onthe soles ofthe feet, and weight is distributed throughthe soles and heels.the chest would be held upward, but not backward.the abdominal muscles would be held upward, not downward.the buttocks would be held upward.the knees are extended in a slightly flexed position— not bent or hyperextended inthe knee-locked position. (less) Question 3: (see full question) The nurse should intervene immediately when observingthe nursing assistive personnel (NAP) performing which activity with a stable client? You selected: Applying graduated compression stockings Incorrect Correct response: Teaching a client range of motion exercises Explanation: Client teaching regarding range-of-motion (ROM) exercises cannot be delegated tothe NAP, although reinforcement or implementation of ROM exercises may be delegated. Transferring a client fromthe bed to a stretcher may be delegated tothe NAP. Transferring a client fromthe bed to a chair may be delegated tothe NAP. Applying and removing graduated compressions stocking may be delegated tothe NAP. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1057. Chapter 32: Activity - Page 1057 Question 5: (see full question) Three nurses are transferring a patient from a bed to a chair. Which ofthe following is a recommended guideline for handling patients safely during a transfer? You selected: Use assistive devices if lifting over 50 pounds. Incorrect Correct response: If patient is in pain, administer analgesics in advance. Explanation: Ifthe patient is in pain, administerthe prescribed analgesic sufficiently in advance ofthe transfer to allowthe patient to participate inthe move comfortably. Patients should be encouraged to assist in their own transfers. During any patient transferring task, if any caregiver is required to lift more than 35 pounds of a patient's weight, thenthe patient should be considered to be fully dependent and assistive devices should be used forthe transfer. Handling aids should be used whenever possible to help reducethe risk of injury tothe nurse and patient. (less) Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1062. Chapter 32: Activity - Page 1062 Question 7: (see full question) The nurse is turning a patient in bed. Where wouldthe nurse stand when usingthe friction-reducing sheet to turnthe patient tothe opposite side ofthe bed? You selected: Atthe patient's center. Incorrect Correct response: Oppositethe patient's center. Explanation: When pullingthe friction-reducing sheet to turn a patient in bed,the nurse onthe side ofthe bed toward whichthe patient is turning should stand oppositethe center ofthe patient's body with feet shoulder width apart and one leg in front ofthe other. This position ensures thatthe nurse is stable with good body alignment and is prepared to use large muscle masses to turnthe patient.the maneuvers supportthe patient's body and make use ofthe nurse's weight to assist with turning. (less) ________________________________________ Question 8: (see full question) Three nurses are transferring a patient from a bed to a chair. Which ofthe following is a recommended guideline for handling patients safely during a transfer? You selected: Use assistive devices if lifting over 50 pounds. Incorrect Correct response: Explanation: Ifthe patient is in pain, administerthe prescribed analgesic sufficiently in advance ofthe transfer to allowthe patient to participate inthe move comfortably. Patients should be encouraged to assist in their own transfers. During any patient transferring task, if any caregiver is required to lift more than 35 pounds of a patient's weight, thenthe patient should be considered to be fully dependent and assistive devices should be used forthe transfer. Handling aids should be used whenever possible to help reducethe risk of injury tothe nurse and patient. (less) Question 10: (see full question) Usingthe Katz Index of Independence in Activities of Daily Living, what indicators would causethe nurse to categorizethe client as dependent? (Select all that apply.) You selected: • Requires someone to prepare meals • Usesthe bedpan for toileting Incorrect Correct response: • Needs partial assistance with feeding • Usesthe bedpan for toileting Explanation: The client who needs partial or total help with feeding is dependent.the client is categorized as dependent when help transferring tothe toilet or cleaning self is needed, and when use of a bedpan or commode is required.the client who is able to get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners is categorized as independent, even though help tying shoes is needed.the client who is able to bathe self completely or needs help in bathing only a single part ofthe body, such asthe back, genital area, or disabled extremity is categorized as independent.the client is categorized as independent when able to get food fromthe plate intothe mouth without help, even though preparation of meals is required by another person. (less) Question 18: (see full question) The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left sided weakness fromthe bed tothe chair.the nurse should intervene whenthe (UAP) does which ofthe following? (Select all that apply.) You selected: • Instructsthe client to hold tothe side rail when standing to move intothe chair • Stands nearthe client’s shoulders before sittingthe client up in bed Incorrect Correct response: • Instructsthe client to hold tothe side rail when standing to move intothe chair • Stands next tothe client whenthe client is sitting onthe side ofthe bed • Stands nearthe client’s shoulders before sittingthe client up in bed Explanation: The nurse keepsthe client in good body alignment and protectsthe client from injury while being moved. Safety and comfort are key concerns when assisting a client out of bed.the side rails should be down when transferring a client out of bed.the client should be instructed to use an arm to steady him- or herself onthe arm ofthe chair when getting out of bed for support and stability.the nurse should stand in front of, not next tothe client whenthe client is sitting onthe side ofthe bed to prevent falls or injuries from orthostatic hypotension. When assistingthe client to sit up onthe side ofthe bed,the nurse should stand nearthe patient’s hips.the nurse’s center of gravity is placed nearthe patient’s greatest weight to assistthe client to a sitting position safely.the head ofthe bed should be elevated to placethe client in a sitting position or as high asthe client can tolerate.the amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased. Bracingthe knees against a weak extremity prevents a weak knee from buckling andthe client from falling. (less) Question 4: (see full question) The nurse observes a nurse’s aide placing a client inthe fowler’s position. To prevent complications tothe client, in which situation shouldthe nurse intervene? (Select all that apply.) You selected: •the knee gatch onthe bed is engaged. •the client’s foot is inthe plantar flexion position. Incorrect Correct response: • There is a large pillow underthe client’s head. •the knee gatch onthe bed is engaged. •the client’s foot is inthe plantar flexion position. Explanation: Inthe fowler’s position,the client’s head should be againstthe mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture ofthe neck.the knee gatch should be avoided to prevent pressure onthe popliteal artery that may compromise lower extremity circulation. Whenthe client’s foot is inthe plantar flexion position,the client is at risk for developing footdrop. A footboard, high top sneakers or improvised firm foot support should be used. It is appropriate to placethe client’s forearms on pillows. This will prevent pull onthe shoulders and help to prevent dislocation ofthe shoulder. A rolled towel or trochanter roll will help prevent external rotation ofthe hips. (less) Question 5: (see full question) A nurse is promoting body movements for a patient during range-of-motion exercises. Which movements provide for flexion? (Select all that apply.) You selected: • Bendingthe hand or foot backward and forward • Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position. Incorrect Correct response: • Bendingthe hand or foot backward and forward • Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position. • Movingthe head from side to side, then bringingthe chin toward each shoulder Explanation: Flexion isthe state of being bent. Bendingthe hand or foot backward and forward would be an example of flexion. Bendingthe leg and bringingthe heel towardthe back ofthe leg and then returningthe leg tothe straight position would be an example of flexion. Movingthe head from side to side, then bringingthe chin toward each shoulder would includethe movement of flexion. (less) Question 10: (see full question) A patient will be ambulating forthe first time since his cardiac surgery. What shouldthe nurse consider when assisting this patient? You selected: Patients who can lift their legs only 1 to 2 inches offthe bed do not have sufficient muscle power to permit walking. Incorrect Correct response: If an ambulating patient whom a nurse is assisting begins to fall,the nurse should slidethe patient down his or her own body tothe floor, carefully protectingthe patient’s head. Explanation: The nurse would usethe gait belt to easethe client backward against one’s own body and gently easethe client tothe floor while protectingthe client’s head.the client should not look at their feet, but rather out at eye level at their surroundings.the nurse should consultthe plan of care forthe client, butthe nurse regularly ambulates a client without a physical therapist present.the evaluation of a client’s muscle power to permit walking cannot be measured by their ability to lift their legs offthe bed. (less)