MED SURG 1232: ATI Practice A: Louisiana State University, Eunice. Questions, Answers & Rationale

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1) A nurse is caring for a patient who has a terminal illness and is approaching death. The patient is short of breath and has noisy respirations from secretions in their airway. Which of the followin... g actions should the nurse take? a) Turn the patient every 2 hr i) The nurse should turn the pt at least once every 2 hr to break up the secretions in the pt’s lungs and prevent noisy respirations b) Administer an antiemetic every 6 hr i) The nurse should admin antiemetics for pts experiencing nausea or vomiting. However, this is not the correct action to take when assisting a pt who’s experiencing respiratory difficulty at the end of life c) Hold oral care i) The nurse should provide frequent oral care in order to keep the pt’s mouth moist and provide comfort d) Increase the room’s temperature i) Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a pt who is dying and will decrease air hunger 2) A nurse is caring for a group of patients. Which of the following actions should the nurse take to prevent the spread of infection? a) Carry a patient’s soiled linens out of the room in a mesh linen bag i) The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission b) Place a patient who has tuberculosis in a room with negative pressure airflow i) A pt who has tb req’s airborn precautions, which include placing the pt in a room that has negative pressure airflow to reduce the risk of infection transmission c) Provide disposable plates and utensils for a patient who is HIV positive i) Ppl transmit HIV mainly by blood and sexual activity; therefore, a pt who is HIV+ does not req disposable plates and utensils. Standard precautions are sufficient d) Dispose of a patient’s blood saturated dressing in a trash bag inside a second trashbag i) The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms 3) A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary catheter. Which of the following actions should the nurse take? a) Place the client in a side lying position i) The nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter b) Instill 15 mL of irrigation fluid into the catheter with each flush i) Open irrigation technique requires instilling 30-40 mL of irrigation fluid c) Subtract the amount of irrigant used from the client’s urine output i) The nurse should calculate the fluid used for irrigation and subtract itfrom the clients total urinary output d) Perform the irrigation using a 20 mL syringe i) The nurse should use a 30- 50 mL syringe to perform open irrigation 4) A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a) The client is receiving formula at room temperature i) Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is likely not because of the clients diarrhea b) The feedings in fuse at a slow, continuous drip over 8 hr each night i) Diarrhea is more likely to develop with rapid installation of enteral formula c) The clients caregiver washes out the feeding bag with warm water once every 24 hr i) Feeding bags should be washed out after each feeding and replaced with a new feeding back every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the clients caregiver to avoid future contamination d) The clients caregiver flushes the tubing with water before and after administering medications i) It is correct to flush the tubing with water before and after administering medications to prevent clogging of the tube 5) A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? a) Make sure the client’s room has at least six air exchanges per hour i) A protective environment requires at least 12 air exchanges per hour b) Make sure the client wears a mask when outside her room if there is construction in the area i) And allogeneic stem cell transplant compromises the client’s immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. c) Place the client in a private room with negative pressure airflow i) The nurse should place the client in a private room that provides positive pressure airflow d) Wear an N95 respirator when it giving the client direct care i) The nurse should wear an N 95 respirator mask when caring for clients who require airborne precautions, not a protective environment 6) A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a) Protective environment i) Client to have a compromised immune system require a protective environment b) Airborne precautions i) Airborne precautions or a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles c) Droplets precautions i) Droplet precautions or a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and a streptococcal pharyngitis d) Contact precautions i) Major wound infections required contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client 7) A nurse is teaching a client and his family how to care for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a) Remove the outer cannula cautiously for routine cleaning i) The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning b) Use a tracheostomy covers when outdoors i) Tracheostomy covers protect the client’s airway from cold air, dust and other airborne particles c) Use sterile technique when performing tracheostomy care at home i) In the home environment, medical a sepsis with clean technique is appropriate d) Cleaned irritated skin with full strength hydrogen peroxide i) Hydrogen peroxide can irritated skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation 8) A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? a) Document the provider’s statement in the medical record i) The nurse should document the provider’s directions in the medical record for later reference; however, another action is the nurse’s priority b) Complete an incident report i) The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse’s priority c) Consult the facility’s risk manager i) The nurse should discuss the situation with the facility’s risk management dept to help determine the need for preventative actions; however, another actions is the nurse’s priority d) Notify the nursing manager i) The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care 9) A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? a) “I think I should take my pain medication more often, since it is not controlling my pain” i) As a 2 on a scale of 0 to 10, this client’s pain is mild. Additional analgesic medication is unnecessary at this time b) “Breathing faster will help me keep my mind off the pain.” i) Rapid breathing can lead to hyperventilation, while slow, focused, breathing helps induce relaxation, which can help with managing pain c) “It might help me to listen to music while I’m lying in bed.” i) Listening to music is an effective nonpharmacological intervention for the management of mild pain d) “I don’t want to walk today because I have some pain.” i) Postoperative clients need to ambulate even if they are having mild pain 10) A nurse is assessing a client’s readiness to learn about insulin self administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a) “I can concentrate best in the morning.” i) The pt’s statement indicates a readiness to learn bc he’s verbalizing the best time for him to learn b) “It is difficult to read the instructions because my glasses are at home.” i) The pt’s statement indicates the pt is not ready to learn. The pt has to have the tools he needs to learn and comprehend the info c) “I’m wondering why I need to learn this.” i) The pts statement indicates a reluctance to learn information he thinks he might not need to know d) “You will have to talk to my wife about this.” i) With this statement, the pt is redirecting the nurse’s attempt to teach toward someone else, indicating that he is not ready to learn 11) A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a) Comine client care tasks when caring for multiple clients i) The nurse should complete the tasks for one pt before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors b) Wait until the end of the shift to document client care i) Documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. Performing documentation at the end of the shift tis not effective time management c) Use the planning step of the nursing process to prioritize client care delivery i) Setting up a list of goals and tasks to perform for pts can help the nurse set care priorities and plan tasks accordingly. The priority to do list is an efficient tool for optimal time management d) Allow for interruptions in tasks to discuss client care issue with colleagues i) An important principle of time management is controlling interruptions to reduce errors and loss of care delivery time 12) A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? a) “They allow the court to overrule and adult client’s refusal of medical treatment.” i) A court can only overrule an adult pt’s refusal of medical treatment if the pt is legally incompetent b) “They indicate the form of treatment a client is willing to accept in the event of a serious illness” i) Advanced directives include a living will, which permits pts to direct the treatment they will receive in the even of a medical emergency or serious illness c) “They permit a client to withhold medical information from health care personnel” i) The Americans with Disabilities Act, not advance directives, protects the privacy of a pt who chooses not to disclose a medical disability d) “They allow health care personnel in the emergency department to stabilize a client’s condition.” i) The Emergency Medical Treatment and Active Labor Act, not advance directives, directs emergency personnel to provide screening and stabilizing care before discharging or transferring pts to another facility 13) A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? a) Ask another nurse to observe the medication wastage i) A second nurse must witness the disposal of any portion of a dose of a controlled substance b) Notify the pharmacy when wasting the medication i) Pharmacies do not req notification of the disposal of a portion of a dose of a controlled substance c) Lock the remaining medication in the controlled substances cabinet i) The nurse should not lock the remaining controlled substance in the cabinet bc this is a violation of the Controlled Substances Act d) Dispose of the vial with the remaining medication in the sharps container i) The nurse should not dispose of the remaining controlled sub in the sharps bc this is a violation of the Controlled Substances Act 14) A nurse is caring for a pt who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the pt’s partner indicates effective coping? a) “I am not worried bc I still have hope that he will be okay” i) This statement reflects false hope and possible denial of the terminal nature of the pt’s illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety b) “I am relying on support from our family during this time” i) This statement indicates effective coping bc the partner is relying on others in the family for support during a time of crisis c) “We can plan our family reunion once he recovers and comes home” i) This statement reflects false hope and possibly denial of the terminal nature of the pt’s illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety d) “We don’t see any reason to start discussing funeral arrangements right now” i) This statement reflects potential false hope about and possible denial of the terminal nature of the pt’s illness. It also indicates the partner’s potential inability or unwillingness to address unplessant or challenging issues related to the pt’s health 15) A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a) Insert the catheter at 45* angle i) Generally, the nurse should insert the catheter at a 10*-30* angle. However, for an older adult client, an angle or 10*-50* is preferable because weins are closer to the skin surface as aging diminishes subcutaneous tissue b) Place the client’s arm in a dependent position i) The nurse should the pt’s arm in a dependent position bc the veins will dilate due to gravity c) Shave excess hair from the insertion site i) The nurse should clip excess hair from the iv insertion site and avoid shaving the area bc shaving can cause breaks and cuts in the skin that could place the pt at risk for infection d) Initiate iv therapy in the veins of the hand i) The nurse should avoid using the fragile veins of an older adult’s hands bc the loss of subq tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the pt’s hand can interfere w the pt’s performance of activities of daily living and can diminish an older adult’s sense of independence and mobility. 16) A nurse is caring for a pt who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the pt. a) Use a bed exit alarm system i) The nurse should identify that a pt who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The pt’s condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the pt is trying to get out of bed and requires assistance b) Raise four side rails while the pt is in bed i) Raising four side rails when the pt is in bed is form of restrain and increases the risk for falls and injury c) Apply one soft wrist restraint i) Applying one soft restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain pt safety should be attempted for pts who have dementia d) Dim the lights in the pt’s room i) Dimming the lights in the room for a pt who has dementia can reduce visibility and increase the risk for injury 17) A nurse is caring for a pt who is postoperative following a knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take? a) Assist the pt into a prone position i) The nurse should place the pt in a dorsal recumbent or semi Fowler’s position to facilitate application of sleeves b) Place a sleeve over the top of each leg w the opening at the knee i) The nurse should place the sleeve under each leg w the opening at the knee and then wrap the sleeve around the leg so that it is secure c) Make sure two fingers can fit under the sleeves i) The nurse should ensure that there is enough space for two fingers to fit under the sleeve bc any less space bt the sleeves and the legs can inhibit cicurlation when the sleeves inflate d) Set the ankle pressure at 65 mm Hg i) The nurse should set the ankle pressure bt 35-55 Hg to achieve a therapeutic effect while also preventing damage to the pt’s skin and circulatory impairment 18) A nurse is caring for a pt who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a) Numbness of the extremities i) Numbness of the extremities is manifestation of hyperkalemia b) Bradycardia i) Tachycardia is a manifestation of hyponatremia along with hypovolemia c) Positive Chvostek’s sign i) A positive Chvostek’s sign is a manifestation of hypomanesemia and hypocalcemia d) Abdominal cramping i) The pt has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea 19) A nurse is auscultating the anterior chest of a pt who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds (click on the audio button to listen to the clip). a) Crackles i) Unlike these breath sounds, crackles (also called rales) are discontinuous soundsheard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways b) Rhonchi i) Rhonchi are dry, low pitched, snore like noises produced in the throat or bronchial tube due to partial obstruction, such as by secretions c) Friction rub i) Friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle d) Normal breath sounds i) These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration 20) A nurse is talking with an older adult pt who is contemplating retirement. The pt states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make? a) “You would have so much more time to spend w your family” i) This response is nontherapeutic bc the nurse is minimizing the pt’s feelings and making assumptions about the pt’s relationships b) “You should consider getting a part time job or doing volunteer work.” i) This response is nontherapeutic bc the nurse is minimizing the pt’s feelings and offering personal advice c) “Let’s talk about how the change in your job status will affect you” i) The response is therapeutic bc the nurse is encouraging the pt to verbalize feelings about the life transition of retirement d) “Why wouldn’t you want to retire and relax?” i) This response is nontherapeutic bc the nurse is asking a “why” question, which can provoke a defensive response from the pt 21) A nurse is administering 1 L of 0.9% sodium chloride to a pt who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a) Increase in hematocrit i) Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease b) Increase in respiratory rate i) Fluid volume causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range c) Decrease in heart rate i) Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. d) Decrease in capillary refill time i) Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range 22) A nurse is caring for a pt who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse’s priority? a) Request that a respiratory therapist discuss the technique for incentive spirometry with the pt. i) The nurse can request that another team member discuss the use of the incentive spirometer w the pt to encourage the pt to use it; however, this is not the priority action for the nurse to take. b) Determine the reasons why the pt is refusing to use the incentive spirometer i) The 1st action the nurse should take when using the nursing process is to assess the client; therefore the priority action for the nurse to take is to determine why the pt is refusing the treatment c) Document the pt’s refusal to participate in health restorative activities i) If other interventions to promote the pt’s use of the incentive spirometer are unsuccessful, the nurse must document the pt’s refusal; however, this is not the priority action for the nurse to take. d) Administer a pain medication to the client i) Pain or incisional complication might make the pt refuse spirometry; however, administering medication is not the priority action for the nurse to take. 23) A nurse is talking w the partner of a pt who has a dementia. The pt’s partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? a) Role ambiguity i) Role ambiguity occurs when people are unclear about the expectations of their role in a given situation b) Sick role i) Sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver c) Role overload i) The partner’s expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage d) Role conflict i) Role conflict develops when a person must assume multiple roles that have opposing expectations 24) A nurse is assessing four adult patients. Which of the following physical assessment techniques should the nurse use? a) Use the face, legs, activity, and consolability (FLACC) pain rating scale for a pt who is experiencing pain i) The nurse should use an age appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for pts ages from 2 mo’s to 7 yrs b) Ensure the bladder of the blood pressure cuff surrounds 80% of the pt’s arm i) The nurse should use a blood pressure cuff w a bladder that surrounds 80% of pt’s arm circumference to give an accurate reading c) Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum i) The nurse should place the stethoscope at the point of maximal impulse, which is at the 5th intercostal space at the midclavicular line left of the sternum d) Palpate the pt’s abdomen before auscultating bowel sounds i) When assessing an adult client’s abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds 25) A nurse is admitting a pt who is having an exacerbation of heart failure. In planning this pt’s care, when should the nurse initiate discharge planning? a) During the admission process i) Discharge planning should begin as soon as the pt is undergoing the admission process. The nurse should begin to assess the pt’s needs and plan for care both during and after the pt’s time in the facility b) As soon as the pt’s condition is stable i) Although it is appropriate to defer pt teaching until the pt is stable and receptive to learning, the initation of discharge planning does not depend on the pt’s physiological stability. c) During the initial team conference i) Team conferences facilitate discharge planning, but they are not essential for initiating the planning process d) After consulting with the pt’s family i) The nurse should only consult with the pt’s family if the pt gives the nurse permission to share that information. In the case of a pt who has an exacerbation of heart failure, delating discharge planning until this time could result in overlooking essential care needs. 26) A nurse is providing discharge instructions to a pt who will be using a walker. Which of the following pt statements indicates an understanding of the teaching? a) “I can place an extension cord across my living room to plug in my television” i) Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping b) “I will hire someone to trim the tree that hangs low over the stairs of my front porch” i) Clearing stairs of any object that could cause the pt to trip or require them to bend over while walking will decrease the risk for falls. c) “I will place my alarm clock on my bedroom dresser across the room” i) Frequently used items like an alarm clock, glasses, or disposable tissues should be placed within reach, such as on the pt’s night stand. This helps to prevent the pt from needing to get up and potentially falling in the night. d) “I will replace the old throw rug in my kitchen with a new one” i) Using throw rugs increases the pt’s risk for falls bc they create a tripping and slipping hazard for the pt 27) A nurse is performing a skin assessment for a pt who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a) A lesion with uniform pigmentation i) Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. b) New appearance of petechiae i) Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. c) A mole with an asymmetrical appearance i) An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. d) The presence of a papule i) Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. The are not an expected indication of a skin malignancy 28) A nurse is providing discharge teaching to a pt about self administering heparin. Which of the following instructions should the nurse include in the teaching? a) Insert the needle at a 15* angle i) The nurse should instruct the pt to insert the needle at a 45* to 90* angle to administer the medication into the subq tissue b) Aspirate for blood return prior to administration i) The nurse should instruct the pt not to aspirate for blood return bc this can cause tissue damage and bruising c) Administering the medication into the abdomen i) The nurse should instruct the pt to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The pt should pinch or spread the skin at the injection site to administer the medication into the subq tissue. d) Massage the site following the injection i) The nurse should instruct the pt not to massage the site bc this can cause tissue damage and bruising 29) A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a) Regulate the flow rate by aligning the rate with top of the ball inside the flow meter i) The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter w the middle of the silver ball inside the meter b) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min i) Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/ min have a drying effect and force pts to swallow air excessively without increasing their fraction of inspired oxygen (FiO2) c) Make sure the reservoir bag of a partial rebreathing mask remains deflated i) The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that pts are breathing in too much of the carbon dioxide they exhale d) Use petroleum jelly to lubricate the pt’s nares, face, and lips i) Evidence-based practice supports the use of water soluble lubricant to protect the pt’s skin from the drying effect of oxygen 30) A nurse is preparing a change of shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a) Critical pathway i) A critical pathway is an interprofessional approach to planning all phases of pt care b) Situation, background, assessment, and recommendation (SBAR) i) SBAR is a communication tool nurses use to relate a pt’s status during a change of shift report c) Transfer report i) The nurse should use a transfer report when the cpt is moving from one health care area or facility to another d) Medication administration record (MAR) i) The nurse should use the MAR to document medication administration 31) A nurse is preparing to administer enoxaparin subcutaneously to a pt. Which of the following actions should the nurse take? a) Administer the medication with the needle at a 45* angle i) The nurse should insert the needle at 45* to 90* angle for a subq injection b) Administer the medication into the pt’s nondominant arm i) The nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus c) Pull the pt’s skin laterally or downward prior to administration i) The z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection d) Massage the injection site after administration i) The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising 32) A nurse is evaluating a pt’s use of cane. Which of the following actions should the nurse identify as an indication of correct use? a) The top of the cane is parallel to the pt’s waist i) The top of the cane should be parallel to the client’s greater trochanter b) When walking, the pt moves the can 46 cm (18 in) forward i) To maintain balance, the pt should advance the cane about 15 to 30 cm (6 to 12 in) at a time c) The pt holds the cane on the stronger side of her body i) The pt should hold the cane on the stronger side of her body to increase support and maintain alignment d) The pt moves her stronger limb forward with one cane i) The pt should move her weaker leg forward with the cane. The divides the pt’s body weight between the cane and stronger leg 33) A nurse is assessing a pt who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the pt’s pain? a) “Is your pain constant or intermittent?” i) Asking the pt whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain. b) “What would you rate your pain on a scale of 0-10?” i) Asking the pt to rate the pain using the pain scale determines the intensity of the pain c) “Does the pain radiate?” i) Asking the pt whether the pain radiates determines the pain’s location d) “Is your pain sharp or dull?” i) Asking the pt whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain 34) A nurse is performing a home safety assessment for a pt who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a) The pt uses a wool blanket on their bed i) The pt should use a cotton blanket instead of wool blanket to avoid generagting static electricity that could ignite the oxygen b) The pt uses nonacetone nail polish remover i) The pt should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen c) The pt stores an extra oxygen tank on its side under their bed i) The pt should store extra oxygen tanks in upright position to maintain safety d) The pt has a weekly inspection checklist for oxygen equipment i) The pt or caregiver should inspect oxygen equipment daily 35) A nurse is preparing to apply a dressing for a pt who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? a) Alginate i) Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage b) Guaze i) Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed c) Transparent i) Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing d) Hydrocolloid i) Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound be 36) A nurse is caring for a pt who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the pt? a) Insert the suction catheter while the pt is swallowing i) The nurse should insert the suction catheter while the pt is inhaling to avoid inserting the catheter into the esophagus b) Apply intermittent suction when withdrawing the catheter i) The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise c) Place the catheter in a location that is clean and dry for later use i) The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory trarct d) Hold the suction catheter with her clean, nondominant hand i) The nurse should hold the suction catheter with her dominant hand after donning a sterile glove 37) A nurse is caring for a pt who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a) Contact i) Contact precautions are a requirement for pts who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections b) Droplet i) Droplet precautions are requirement for pts who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the pt who has a disorder requiring droplet droplet precautions c) Airborne i) Airborne precautions are a requirement for pts who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles d) Protective i) Pts who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others 38) A nurse is caring for a pt who is postoperative. When the nurse prepares to change her dressing, she says, “Every time you change my bandage, it hurts so much.” Which of the following interventions is the nurse’s priority actions? a) Encourage the pt to relax and take deep breaths during the dressing change i) Encourage the pt to relax and take deep breaths during the postoperative pd is important bc relaxation can help reduce the pt’s anxiety about the procedure. However, there is another intervention that is the priority b) Educate the pt about the importance of the dressing change to prevent infection i) Educate the pt about the importance of the dressing change is important bc understanding the rationale for the procedure can help the pt relax. However, there is another intervention that is the priority c) Assist the pt to a comfortable position for the dressing change i) Moving the pt to a comfortable position for the dressing change is important bc it can help the pt relax and can also reduce strain on the wound. However, there is another intervention that is the priority d) Administer pain medication 45 min before changing the pt’s dressing i) The priority actin the nurse should take when using Maslow’s hierarchy of needs is to meet the pt’s physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the pt’s dressing 39) A nurse receives report about a pt using 0.9% sodium chloride infusing IV at 125 mL/ hr. When the nurse performs the initial assessment, he notes that the pt has received only 80 mL over the last 2 hr. which of the following actions should the nurse take first? a) Reposition the pt i) The nurse should reposition the pt to help improve flow rate; however there is another action the nurse should take first b) Document the pt’s IV intake in the medical record i) The nurse should document the pt’s IV intake in the medical record accurately to help the team prevent or correct fluid imbalances; however, there is another action the nurse should take 1st c) Request a new IV fluid prescription i) The nurse should request a new IV fluid prescription to compensate for lost fluid intake; however, there is another action the nurse should take 1st d) Check the IV tubing for obstruction i) The 1st action the nurse should take using the nursing process is to assess the pt. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed 40) A nurse is caring for a pt who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this pt? a) Have the pt wear a mask when receiving visitors i) The pt does nto need to wear a mask to prevent the spread of the infection bc shigella does not require airborne or droplet precautions b) Limit the pt’s time w visitors to no more than 30 min per day i) Limiting the pt’s time w visitors will not decrease the risk of spreading shigella. Pt’s who req isolation precautions are at risk for depression and loneliness; therefore the nurse should encourage visitation c) Assign the pt to a room w negative pressure airflow exchange i) The nurse should assign a pt who has shigella to a private room; however, negative pressure airflow is not necessary bc shigella is not airborne d) Wear a gown when caring for the pt i) The nurse should implement contact precautions for a pt who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for contact precautions due to the risk of contact w bodily fluids and contaminated surfaces. 41) A nurse is caring for a pt who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform he pt that this condition is a contraindication for which of the following therapies? a) Biofeedback i) Biofeedback is a complementary and alternative therapy to assist pts w stroke recovery, smoking cessation, headaches, and many other disorder. Herpes zoster is not a contraindication for the use of this mind body technique b) Aloe i) Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy c) Feverfew i) Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy d) Acupuncture i) The nurse should inform the pt that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin’s surface could increase the risk of further infection 42) A nurse is lifting a bedside cabinet to move it closer to a pt who is sitting in a chair. To prevent self-injury, which of following actions should the nurse take when lifting this object? a) Bend at the waist i) The nurse should bend the knees when lifting the cabinet b) Keep his feet close together i) The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet c) Use his back muscles for lifting i) The nurse should use the arm and leg muscles when lifting the cabinet bc they are generally stronger than back muscles d) Stand close to the cabinet when lifting it i) This action keeps the cabinet close the nurse’s center of gravity and decreases back strain from horizontal reaching 43) A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? a) Examine personal values about the issue i) Nurses should examine their own personal values about the issue in the question in order to provide care that is without bias b) Tell the parents that this is a necessary procedure i) The nurse should provide the parents with information about the procedure. However, telling the parents that this is a necessary procedure disregards the parents’ religious beliefs and their right to refuse treatments c) Inform the parents that the staff does not require their consent i) Parents must give consent for a child to receive a blood transfusion d) Contact a spiritual support person to explain the importance of the procedure i) The nurse or the provider should provide information about the procedure. Spiritual support people attend to pts’ and families’ spiritual needs, not their physiological needs. 44) A nurse is caring for a pt who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a) Discuss the risk factors for colon cancer i) The pt might perceive this as challenging or argumentative and react defensively. Instead, the nurse should listen to the pt’s concerns and should avoid challenging him. b) Focus teaching on what the pt will need to do in the future to manage his illness i) During the anger stage of the pt’s psychosocial adaptation to illness, the nurse should focus teaching on the present. The pt is not yet ready to face the future c) Provide the pt with written information about the phases of loss and grief i) Unless the pt requests reading materials about loss, this is not an optimal time to provide them. At this stage, the pt needs to express his feelings without any expectations for learning d) Reassure the pt that this is an expected response to grief i) During the anger stage of the pt’s psychosocial adaptation to illness, the nurse should support the pt and explain that this is an expected reaction to a cancer diagnosis 45) A nurse is responding to a call light and finds a pt lying on the bathroom floor. Which of the following actions should the nurse take first? a) Check the pt for injuries i) The 1st action the nurse should take when using the nursing process is to assess the pt for injuries b) Move hazardous objects away from the pt i) Moving hazardous objects away from the pt can prevent further injury; however, there is another action the nurse should take first. c) Notify the provider i) The nurse should notify the provider of the pt’s fall; however, there is another actin the nurse should take 1st d) As the pt to describe how she felt prior to the fall i) Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take 1st 46) A nurse is educating a pt who has a terminal illness about declining resuscitation in a living will. The pt asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make? a) “We would consult the person appointed by your health care proxy to make decisions.” i) The staff must honor the pt’s wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the pt’s health care proxy to make decisions about the pt’s care b) “We would give you oxygen through a tube in your nose.” i) Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula c) “You would be unable to change your previous wishes about your care.” i) Pts determine advance directives ahead of time to guid decision-making at the time of an emergency event. If the pt initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the pt has documented in the advance directives d) “We would insert a breathing tube while we evaluate your condition.” i) Intubation is a resuscitative measure. The staff should not implement this intervention for a pt who declines resuscitation in their living will 47) A nurse is reviewing a pt’s fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a) BUN 15 mg/dL i) This value is within the expected range of 10-20 mg/ dL b) Creatinine 0.8 mg/ dL i) This value is within the expected range of 0.5 to 1.1 mg/ dL for women 41-60 yrears of age and 0.6 to 1.3 mg/ dL for men 41 to 60 years of age. Even for pt’s within and older age ranges (with the exception of newborns through 9 years of age), 0.8 mg/ dL is within the expected reference range for creatinine c) Sodium 143 mEq/ L i) This light within the expected range of 136- 145 mEq/ L d) Potassium 5.4 mEq/ L i) This value is about the expected range of 3.5 to 5 mEq/ L, so the nurse should report this finding to the provider. This pt is at risk for dysrhythmias 48) A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include into teaching? a) “Use the complete name of the medication magnesium sulfate” i) The Institute for safe medication practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any miss interpretation of MgSO4 as MSO4, which means morphine sulfate b) “Delete this space between the numerical dose and the unit of measure” i) The Institute for safe medication practices recommends including a space between the dose and the unit of measure, such as 10 mg, to a void confusion when documenting medication dosages c) “Write the letter U when noting the dosage of insulin” i) The Institute for safe medication practices designates “unit(s)” as the correct term for use in a medication documentation d) “Use the abbreviation SC when indicating an injection” i) The Institute for safe medication practices designates either “subcut” or “subcutaneously” as the correct terms for use in medication documentation 49) A nurse is caring for a pt who has an aggressive form of prostate cancer. The provider briefly discuss his treatment options and leaves the pt’s room. When the nurse asks if the pt would like to discuss any concerns, the pt declines. Which of the following statements should the nurse make? a) “I will return shortly after I document this in your record” i) Although it is helpful to a sure the client that the nurse will return, reminding him about the nurses need to perform certain tasks is likely to sound dismissive of his profound needs at this time b) “Most men live a long time with prostate cancer” i) This statement provides false reassurance. Dinners cannot predict what his pt’s outcome might be c) “I am available to talk if you should change your mind” i) When a pt does not wish to share his feelings with a nurse, it is important for the nurse to convey a willingness to be available for the pt d) “I will make a referral to a cancer support group for you” i) Dismissing the pt’s concerns by referring him elsewhere without specific intervention by the nurse is a nontherapeutic response 50) A nurse is preparing an education program for staff about advocacy. Which of the following information to the nurse include? a) Advocacy ensures pt’s safety, health, and rights. i) Advocacy is a key component a professional nurses’ code of ethics. As a pt advocate, the nurse ensures pts’ safety, health, rights, including the right to privacy, confidentiality, and refusal of care b) Advocacy ensures that the nurses are able to explain their own actions i) Accountability, not advocacy, is the responsibility of the nurses to explain their own actions to their pts and empoyer c) Advocacy ensures that nurses follow through on their promises to pts i) Fidelity, not advocacy, is an agreement for nurses to follow through with promises made to pts d) Advocacy insurance fairness in pt care delivery and use of resources i) Justice, not advocacy, is fairness in client care delivery, including the distribution of resources in care 51) A nurse is assessing an older pt's risk for falls. Which of the following assessments should the nurse used to identify the pt’s safety needs? (Select all that apply( a) Lacimal apparatus i) If pts have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge b) Pupil clarity i) Cloudy pupils mean that the pt has cataracts. This makes vision cloudy and create halos around lights, which can increase the risk for falls because pts cannot see items in their path clearly c) Appearance of bulbar conjunctivae i) The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However the condition of the conjunctivae will not impede the pt’s safety d) Visual fields i) The nurse should use a finger to test the pt’s peripheral vision by moving the finger out of range and then back into the visual field to determine when the pt sees the finger. Pts who have visual field impairment or at an increased risk for falls because they might not see objects outside of their central vision and trip over them are bumped into them and fall e) Visual acuity i) The nurse should use a Snellen chart to assist distant vision and a handheld card to assess near vision. Pts who wear eyeglasses should wear them during the assessments. Pts who has impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall 52) A nurse is caring for a pt who requires an NG tube for stomach and decompression. Which of the following actions should the nurse take when inserting the NG tube? a) Position the pt with the head of the bed elevated to 30° prior to insertion of the NG tube i) The pt should be sitting in high Fowler’s position with the head of the bed elevated to 90° to reduce risk for aspiration b) Remove the NG tube if the pt begins together choke i) The nurse should withdraw the NG tube slightly, not to remove it, if the pt gags or chokes to reduce the risk of injury to the pt c) Apply suction to the NG tube prior to insertion i) The nurse should not apply suction until The NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the pt d) Have the pt take sips of water to promote insertion of the NG tube into the esophagus i) Taking sips of water as the NG tube passes through the oropharynx we’ll close the epiglottis over the trachea and prevent the tube from passing into the trachea 53) A nurse in a long-term care facility is caring for a pt who dies during the nurse’s shift. Identify the sequence in which the nurse should perform the following steps: a) Remove tubes and indwelling lines b) Ask the pt’s Family members if they would like to view the body c) Obtain the pronouncement of death from the provider d) Place a name tag on the body e) Wash the clients body i) C, A, E, B, D- The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the pt’s body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer 54) A nurse is performing a home safety assessment for a pt who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a) The pt uses a wool blanket on their bed b) The pt uses non-acetone nail polish remover c) The pt stores and extra oxygen tank on its side under their bed d) The pt has a weekly inspection checklist for oxygen equipment [Show More]

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