NURS1871 exam 1| Nurs 1871 CSCC Exam 1 (answered) 2023.

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gas exchange
the process by which oxygen is transported to cells and carbon dioxide is transported from cells

hypoxemia
reduced oxygenation of arterial blood

Chain of oxygenation
atmosphere (21%)
medulla
diaphragm contracts
nose
trachea
bronchi
alveoli
pulmonary capillaries w/hemoglobin to carry oxygen
perfusion to transport hemoglobin to cells
cell metabolism

chain of carbon dioxide
cell metabolism
perfusion to transport hemoglobin from cells
pulmonary capillaries w/hemoglobin carrying carbon dioxide
alveoli
bronchi
trachea
nose
diaphragm relaxes
medulla
atmosphere

ventilation
the process of inhaling oxygen into the lungs and exhaling carbon dioxide from the lungs

impaired ventilation caused by
rib fracture
muscle weakness
c-spine injury
asthma
chronic bronchitis
cystic fibrosis
pulmonary edema
acute respiratory distress syndrome
pneumonia

transport
the availability of hemoglobin and its ability to carry oxygen from alveoli to cells for metabolism and to carry carbon dioxide produced by cellular metabolism from cells to alveoli to be eliminated.

Altered transport of oxygen
occurs when insufficient number or quality of erythrocytes is available to carry oxygen or when the amount of hemoglobin in the blood is low.

perfusion
the ability of blood to transport oxygen containing hemoglobin to cells and return carbon dioxide containing hemoglobin to the alveoli

consequences of poor gas exchange
fatigue
increased heart rate and respiratory rate

populations at risk for poor gas exchange
infants
young children
older adults

Assessment for gas exchange
breathing quiet and effortless
O2 sat between 95-100
skin, nail beds, lips appropriate color
symmetric thorax
trachea is midline
clear breath sounds bilaterally

inadequate gas exchange vital signs
increased respiratory rate
decrease O2 saturation
increased heart rate
increased temperature

findings upon inspection for poor gas exchange
anxiety
pale lips
clubbing of nails
asymmetric thorax
barrel chest
trachea will shift away from lung with pneumothorax

auscultation for poor gas exchange
wheezing/stridor
mucus/secretions create rhonchi
fluid in alveoli generate crackles

clinical management of poor gas exchange
health promotion
management of emerging or present conditions
goal to optimize gas exchange

chest tubes
to remove air (pneumothorax)
to remove blood (hemothorax)

thoracentesis
relieves pleural effusion
needle into pleural space to remove fluid

positioning for poor gas exchange
fowlers
high fowlers
semi fowlers
lying horizontally

asthma
A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.

COPD
chronic airflow limitation that is not fully reversible
*chronic bronchitis and emphysema

pneumonia
inflammation of terminal bronchioles and alveoli

viral pneumonia
non-productive cough with clear secretions

bacterial pneumonia
productive cough with white, yellow, or green sputum

anemia
A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume.

pulmonary emboli
blockage of pulmonary arteries by a thrombus, fat or air embolism, or tumor tissue

problem-focused nursing diagnosis
a clinical judgment concerning an undesirable human response to a health condition/ life process that exists in an individual, family or community

defining characteristics and related factors

risk nursing diagnosis
a clinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes

health promotion nursing diagnosis
a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential

data clustering
organizing all of a patients data into meaningful and usable data clusters

data clusters
set of cues, signs/symptoms gathered during assessment

independent nursing interventions
actions that a nurse initiates without supervision or direction from others

dependent nursing interventions
actions that require an order from a health care provider

collaborative interventions
Therapies that require the knowledge, skill, and expertise of multiple health care professionals.

nursing care plan
includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation.

RACE
R rescue and remove all patients in immediate danger
A activate the alarm
C confine fire by closing doors and windows
E extinguish fire

sitting
provides full expansion of lungs and better visualization of symmetry of upper body parts

supine
most relaxed position and provides easy access to pulse sites

dorsal recumbent
position for abdominal assessment bc it promotes relaxation of ab. muscles

lithotomy
provides maximum exposure of female genitalia and facilitates insertion of vaginal speculum

sims
flexion of hip and knee improves exposure of rectal area

prone
only for assessing extension of hip joint, skin and buttocks

lateral recumbent
position aids in detecting heart murmurs

knee-chest
position provides maximum exposure of rectal area

inspection
occurs when interacting with a patient, watching for nonverbal expressions of emotional and mental status

palpation
to examine by touch

percussion
tapping the skin with the fingertips to vibrate underlying tissues and organs

auscultation
listening to sounds the body makes to detect variations from normal

substance abuse CAGE acronym
C- ever felt the need to CUT DOWN
A- ANNOYED by peoples criticism
G- ever felt GUILTY?
E- EYE OPENER: morning drink to steady nerves or feel normal

PERRLA
pupils equal, round, reactive to light and accommodation

olfactory
sense of smell

optic
visual acuity

oculomotor
eye movement
pupil constriction/dilation

trochlear
down and inward movement of the eye

trigeminal
sensory nerve to skin and face
motor nerve to muscles of jaw

abducens
lateral eye movement

facial
facial expression and taste

auditory
sense of hearing

Glossopharyngeal
taste and swallowing

vagus
sensation of pharynx
movement of vocal cords

spinal accessory
movement of head and shoulders

hypoglossal
position of tongue

respiratory physiology
respiration is the exchange of oxygen and carbon dioxide during cellular metabolism.

the airways of the lungs transfer oxygen from the atmosphere to the alveoli where the oxygen is exchanged for carbon dioxide.

oxygen transfers to the blood through the alveolar capillary membrane and carbon dioxide transfers from the blood

3 steps of oxygenation
ventilation, perfusion, diffusion

ventilation
movement of air in and out of the lungs

perfusion
The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

WOB
work of breathing

the effort required to expand and contract the lungs

inspiration
active process stimulated by chemical receptors in the aorta

expiration
passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work

surfactant
chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing

atelectasis
collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide

pulmonary circulation
primary function to move blood to and from the alveolar capillary membrane for gas exchange

cardiopulmonary physiology
involves delivery of deoxygenated blood to the right side of the heart and then to the lungs, where it is oxygenated

stroke volume
the volume of blood ejected from the ventricles during systole

cardiac output
the amount of blood ejected from the left ventricle each minute

*normal= 4-6 L/min

preload
the amount of blood in the left ventricle at the end of diastole

after load
resistance to ejection of blood from ventricle

factors affecting oxygenation
physiological, developmental, lifestyle, environmental

physiological factors affecting oxygenation
anemia
inhalation of toxic substances
hypovolemia
upper/lower airway obstruction
increased metabolic rate
conditions that affect chest wall movement

hypoventilation
Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide

hypoventilation signs and symptoms
Changes in mental status, dysrhythmias, and possible cardiac arrest.

hyperventilation
a state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism

signs and symptoms of hyperventilation
rapid respirations, sighing breaths, numbness and tingling of hands/feet, light-headedness, and loss of consciousness

hypoxia
inadequate tissue oxygenation at the cellular level

signs and symptoms of hypoxia
apprehension, restless, decreased LOC, dizzy, behavioral changes, cant lie flat, increased pulse, increased rate and depth of respirations, blood pressure elevated early on, cyanosis and respiratory decline are late stages

left sided heart failure
Abnormal condition characterized by decreased functioning of the left ventricle.

Assessment: Fatigue, breathlessness, dizziness, and confusion as result of tissue hypoxia from decrease CO.

Clinical: Crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea.

right sided heart failure
Impaired functioning of the right ventricle characterized by elevated pulmonary vascular resistance.

Causes: Pulmonary disease or long-term left-sided heart failure.

Clinical: Weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema.

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code?

  1. Improves self-health care
  2. Protects the patient’s confidentiality
  3. Ensures identical care to all patients
  4. Defines the principles of right and wrong to provide patient care
    4

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient’s wishes with them. The nurse is acting as the patient’s:

  1. Educator.
  2. Advocate.
  3. Caregiver.
  4. Communicator.
    2

The nurse spends time with a patient and family reviewing a dressing change procedure for the patient’s wound. The patient’s spouse demonstrates how to change the dressing. The nurse is acting in which professional role?

  1. Educator
  2. Advocate
  3. Caregiver
  4. Communicator
    1

The examination for registered nurse (RN) licensure is the same in every state in the United States. This examination:

  1. Guarantees safe nursing care for all patients.
  2. Ensures standard nursing care for all patients.
  3. Provides a minimal standard of knowledge for an RN in practice.
  4. Guarantees standardized education across all prelicensure programs.
    3

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.)

  1. Caregiver
  2. Autonomy
  3. Patient advocate
  4. Health promotion
  5. Genetic counselor
    1, 2, 3, 4

Match the advanced practice nurse specialty with the statement about the role.

  1. Clinical nurse specialist
  2. Nurse anesthetist
  3. Nurse practitioner
  4. Nurse-midwife

a. Provides independent care, including pregnancy and gynecological services
b. Expert clinician in a specialized area of practice such as adult diabetes care
c. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions
d. Provides care and services under the supervision of an anesthesiologist
1b, 2d, 3c, 4a

Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform?

  1. Moving from an acute illness to a health promotion, illness prevention model
  2. Moving from an illness prevention to a health promotion model
  3. Moving from hospital-based to community-based care
  4. Moving from an acute illness to a disease management model
    1

A nurse meets with the registered dietitian and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?

  1. Patient-centered care
  2. Safety
  3. Teamwork and collaboration
  4. Quality improvement
    3

A critical care nurse is using a new research-based intervention to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency?

  1. Patient-centered care
  2. Evidence-based practice
  3. Teamwork and collaboration
  4. Quality improvement
    2

The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career?

  1. Clinical nurse specialist
  2. Nurse administrator
  3. Nurse educator
  4. Nurse researcher
    4

A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating?

  1. Primary prevention
  2. Secondary prevention
  3. Tertiary prevention
  4. Transtheoretical prevention
    3

Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: “Me, stop smoking? I’ve been smoking since I was 16!”

  1. “That’s fine. Some people who smoke live a long life.”
  2. “OK. I want you to decrease the number of cigarettes you smoke by one each day, and I’ll see you in 1 month.”
  3. “What do you think is the greatest reason why stopping smoking would be challenging for you?”
  4. “I’d like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed.”
    3

A nurse working on a medical patient care unit states, “I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can’t wait for my shift to be over. I wish I felt happy again.” What are the best responses from the nurse manager? (Select all that apply.)

  1. “I’m sure this is just a phase you are going through. Hang in there. You’ll feel better soon.”
  2. “I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?”
  3. “You can take diphenhydramine over the counter to help you sleep at night.”
  4. “Describe for me what you do with your time when you are not working.”
  5. “The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?”
    2, 4, 5

A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient’s health practices? (Select all that apply.)

  1. Difficulty paying his bills
  2. Praying daily
  3. Age of patient (46 years)
  4. Stress from the divorce and the loss of a job
  5. Family practice of not routinely seeing a health care provider
    1, 5

A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each family member and reviews their 3-day food diary. She checks the mom’s blood pressure and encourages the mom to take the children for a 15- to 30-minute walk every day. The nurse is addressing which level of need, according to Maslow?

  1. Physiological
  2. Safety and security
  3. Love and belonging
  4. Self-actualization
    1

When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model?

  1. Holistic
  2. Health belief
  3. Transtheoretical
  4. Health promotion
    1

Using the Transtheoretical Model of Change, order the steps that a patient goes through to make a lifestyle change related to physical activity.
80

  1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school.
  2. Eight months after beginning walking, the individual participates with his wife in a local 5K race.
  3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lb.
  4. The individual walks 2 to 3 miles, 5 nights a week, with his wife.
  5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan.
    3, 1, 5, 4, 2

Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.)

  1. Regular participation in a book club
  2. Lack of interest in exercise
  3. Difficulty falling asleep
  4. Lack of desire to go to work
  5. Anxiety while working
    2, 3, 4, 5

We have an expert-written solution to this problem!
As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast self-examination for the women’s group. Which statement made by one of the participants is related to the individual’s accurate perception of susceptibility to an illness?

  1. “I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly.”
  2. “Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer.”
  3. “Since I am only 25 years of age, the risk of breast cancer for me is very low.”
  4. “I participate every year in our local walk/run to raise money for breast cancer research.”
    2

The nurse assesses the risk factors for coronary artery disease (CAD) in a female patient. Which of these factors are classified as genetic and physiological? (Select all that apply.)

  1. Sedentary lifestyle
  2. Mother died from CAD at age 48
  3. History of hypertension
  4. Eats diet high in sodium
  5. Elevated cholesterol level
    2, 3, 5

When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.)

  1. Check for needed adaptive equipment.
  2. Exaggerate lip movements to help the patient lip-read.
  3. Give the patient time to respond to questions.
  4. Keep communication short and to the point.
  5. Communicate only through written information.
    1, 3, 4

Nurses must communicate effectively with the health care team for which of the following reasons? (Select all that apply.)

  1. To improve the nurse’s status with the health team members
  2. To reduce the risk of errors to the patient
  3. To provide an optimum level of patient care
  4. To improve patient outcomes
  5. To prevent issues that need to be reported to outside agencies
    2, 3, 4

Motivational interviewing (MI) is a technique that applies understanding a patient’s values and goals in helping the patient make behavioral changes. When using motivational interviewing, what outcomes does the nurse expect? (Select all that apply.)

  1. Gaining an understanding of the patient’s motivations
  2. Directing the patient to avoid poor health choices
  3. Recognizing the patient’s strengths and supporting his or her efforts
  4. Providing assessment data that can be shared with families to promote change
  5. Identifying differences in patient’s health goals and current behaviors
    1, 3, 5

The nurse therapeutically responds to an adult patient who is anxious by: (Select all that apply.)

  1. Matching the rate of speech to be the same as that of the patient
  2. Providing good eye contact
  3. Demonstrating a calm presence
  4. Spending time attentively with the patient
  5. Assuring the patient that all will be well
    2, 3, 4

A nurse prepares to contact a patient’s physician about a change in the patient’s condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment, and Recommendation) communication.

  1. “She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on levofloxacin at 5 PM yesterday. She states she has a poor appetite; her weight has remained stable over the past 2 days.”
  2. “The patient reported feeling very nauseated after her dose of levofloxacin an hour ago.”
  3. “Is it possible to make a change in antibiotics, or could we give her a nutritional supplement before her medication?”
  4. “The patient started to complain of nausea yesterday evening and has vomited several times during the night.”
    4S, 1B, 2A, 3R

The patient states, “I don’t have confidence in my doctor. She looks so young.” The nurse therapeutically responds: (Select all that apply.)

  1. Tell me more about your concern.
  2. You have nothing to worry about. Your doctor is perfectly competent.
  3. You are worried about your care?
  4. You can go online and see how others have rated your doctor. I do that.
  5. You should ask your doctor to tell you her background.
    1, 3

The nurse applying effective communication skills throughout the nursing process should: (Place the following interventions in the correct order.)

  1. Validate health care needs through verbal discussion with the patient.
  2. Compare actual and expected patient care outcomes with the patient.
  3. Provide support through therapeutic communication techniques.
  4. Complete a nursing history using verbal communication techniques.
    4, 1, 3, 2

A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse’s statements in order according to these phases.

  1. The nurse states, “Let’s work on learning injection techniques.”
  2. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency.
  3. The nurse summarizes progress made during the nursing relationship.
  4. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship.
    2, 4, 1, 3

Which strategies should a nurse use to facilitate a safe transition of care during a patient’s transfer from the hospital to a skilled nursing facility? (Select all that apply.)

  1. Collaboration between staff members from sending and receiving departments
  2. Requiring that the patient visit the facility before a transfer is arranged
  3. Using a standardized transfer policy and transfer tool
  4. Arranging all patient transfers during the same time each day
  5. Relying on family members to share information with the new facility
    1, 3

The nurse uses silence as a therapeutic communication technique. What are the purposes of the nurse’s silence? (Select all that apply.)

  1. Allows the nurse time to focus and avoid saying the wrong thing
  2. Prompts the patient to talk when he or she is ready
  3. Allows the patient time to think and gain insight
  4. Allows time for the patient to drift off to sleep
  5. Determines whether the patient would prefer to talk with another staff member
    2, 3

A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.)

  1. The review of patient data in the medical record
  2. Confirming a patient’s self-report of abdominal pain by inspecting the abdomen
  3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift
  4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration
  5. Conducting an interview of a family caregiver
    1, 2, 4, 5

Match the assessment activity on the left with the type of assessment on the right.

  1. Assessment conducted at beginning of a nurse’s shift
  2. Review of a patient’s chief complaint
  3. Completion of admitting history at time of patient admission to a hospital
  4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home

A. Problem focused
B. Comprehensive
1A, 2A, 3B, 4B

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient’s lungs and hears crackles in the left lower lobe. The patient’s respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, “It is hard for me to get a breath.” Which of the following data sets are examples of subjective data? (Select all that apply.)

  1. Heart rate of 20 per minute and chest congestion
  2. Lung sounds revealing crackles and use of intercostal muscles to breathe
  3. Patient statement, “It’s hard for me to get a breath”
  4. Slumped posture and previous respiratory rate of 16 per minute
  5. Patient report of sore throat and hoarseness
    3, 5

The nurse asks a patient the following series of questions: “Describe for me how much you exercise each day.” “How do you tolerate the exercise?” “Is the amount of exercise you get each day the same, less, or more than what you did a year ago?” This series of questions would likely occur during which phase of a patient-centered interview?

  1. Orientation
  2. Working phase
  3. Data interpretation
  4. Termination
    2

A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient’s cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, “Let me get through these questions first.” Which action interferes with the nurse’s ability to use connection as a communication skill.

  1. Introducing self to patient
  2. Using the computer as a prompt for questions
  3. Making the nurse’s questions a priority
  4. Assuring the patient all information is confidential
    3

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:

  1. Reflection.
  2. Clinical inference.
  3. Cue.
  4. Validation.
    2

Place the following steps of the assessment process in the correct order.

  1. Compare data with another source to determine data accuracy.
  2. As a pattern forms, probe and frame further questions.
  3. Interview a patient, observe behavior, and gather physical assessment findings.
  4. Cluster cues that relate together, make inferences, and identify emerging patterns.
  5. Differentiate important data from the total data you collect.
    3, 5, 4, 2, 1

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history?

  1. Current medications
  2. Patient expectations of planned surgery
  3. Review of patient’s family support system
  4. History of allergies
  5. Patient’s explanation for what might be the cause of symptoms that require surgery
    5

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask.

  1. “You say you’ve lost weight. Tell me how much weight you’ve lost in the past month.”
  2. “My name is Terry. I’ll be the nurse taking care of you today.”
  3. “I have no further questions. Is there anything else you wish to ask me?”
  4. “Tell me what brought you to the hospital.”
  5. “So, to summarize, you’ve lost about 6 pounds in the past month, and your appetite has been poor—correct?”
    2, 4, 1, 5, 3

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.)

  1. Recognize normal changes associated with aging.
  2. Avoid direct eye contact.
  3. Lean forward and smile as you pose questions.
  4. Allow for pauses as patient tells his story.
  5. Use the list of questions from the clinic assessment form to complete all data.
    1, 3, 4

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

  1. A local skin infection requiring antibiotics
  2. Sensitive skin that requires special bed linen
  3. A stage 3 pressure injury needing the appropriate dressing
  4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode
    4

Match the pressure injury stages with the correct definition.

  1. Stage 1
  2. Stage 2
  3. Stage 3
  4. Stage 4

a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
d. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.
Stage 1 is b, stage 2 is a, stage 3 is d, and stage 4 is c

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)

  1. Notify the health care provider.
  2. Allow the area to be exposed to air until all drainage has stopped.
  3. Place several cold packs over the area, protecting the skin around the wound.
  4. Cover the area with sterile, saline-soaked towels immediately.
  5. Cover the area with sterile gauze and apply an abdominal binder.
    1, 4

What is the correct sequence of steps when performing wound irrigation to a large open wound?

  1. Use slow, continuous pressure to irrigate wound.
  2. Attach 19-gauge angiocatheter to syringe.
  3. Fill syringe with irrigation fluid.
  4. Place biohazard bag near bed.
  5. Position angiocatheter over wound.
    4, 3, 2, 5, 1

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)

  1. Frequent position changes
  2. Keeping the buttocks exposed to air at all times
  3. Using a large absorbent diaper, changing when saturated
  4. Using an incontinence cleaner
  5. Applying a moisture barrier ointment
    1, 4, 5

Which of the following describes a hydrocolloid dressing?

  1. A seaweed derivative that is highly absorptive
  2. Premoistened gauze placed over a granulating wound
  3. A debriding enzyme that is used to remove necrotic tissue
  4. A dressing that forms a gel that interacts with the wound surface
    4

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)

  1. Collection of wound drainage
  2. Providing support to abdominal tissues when coughing or walking
  3. Reduction of abdominal swelling
  4. Reduction of stress on the abdominal incision
  5. Stimulation of peristalsis (return of bowel function) from direct pressure
    2, 4

When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)

  1. To relieve edema
  2. To reduce shivering
  3. To improve blood flow to an injured part
  4. To protect bony prominences from pressure injuries
  5. To immobilize area
    1, 3

What is the removal of devitalized tissue from a wound called?

  1. Debridement
  2. Pressure distribution
  3. Negative-pressure wound therapy
  4. Sanitization
    1

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)

  1. Use a transfer device (e.g., transfer board)
  2. Have head of bed elevated when transferring patient
  3. Have head of bed flat when repositioning patient
  4. Raise head of bed 60 degrees when patient positioned supine
  5. Raise head of bed 30 degrees when patient positioned supine
    1, 3, 5

A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.)

  1. Teaching how activities such as reading and using crossword puzzles provide stimulation
  2. Moving him to a room away from the nurses’ station
  3. Turning on the lights and opening the room blinds
  4. Sitting down, speaking, touching, and listening to his feelings and perceptions
  5. Providing auditory stimulation for the patient by keeping the television on continuously
    1, 3, 4

The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient’s impaired vision? (Select all that apply.)

  1. Use of fluorescent lighting
  2. Use of warm incandescent lighting
  3. Use of yellow or amber lenses to decrease glare
  4. Use of adjustable blinds, sheer curtains, or draperies
  5. Indirect lighting to reduce glare
    2, 3, 4

An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply.)

  1. Talk to the patient at a distance so he or she may read your lips.
  2. Keep your arms at your side; speak directly into the patient’s left ear.
  3. Face the patient when speaking; demonstrate ideas you wish to convey.
  4. Position the patient so that the light is on his or her face when speaking.
  5. Verify that the information that has been given has been clearly understood.
    3, 5

A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.)

  1. Walk one-half step behind and slightly to her side.
  2. Have her grasp your arm just above the elbow and walk at a comfortable pace.
  3. Stand next to your mom at the top and bottom of stairs.
  4. Stand one step ahead of mom at the top of the stairs.
  5. Place yourself alongside your mom and hold onto her waist.
    2, 3

A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair?

  1. Tell patient when you are approaching the chair.
  2. Walk at a relaxed pace.
  3. Guide patient’s hand to nurse’s arm, resting just above the elbow.
  4. Position yourself one-half step in front of patient.
  5. Position patient’s hand on back of chair.
    3, 4, 2, 1, 5

A patient with progressive vision impairments had to surrender his driver’s license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.)

  1. Sharing information about senior transportation services
  2. Reassuring the patient that loneliness is a normal part of aging
  3. Maintaining distance while talking to avoid overstimulating the patient
  4. Providing information about local social groups in the patient’s neighborhood
  5. Recommending that the patient consider making living arrangements that will put him closer to family or friends
    1, 4, 5

A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse’s priority interventions include which of the following? (Select all that apply.)

  1. Conducting a home-safety assessment and identifying hazards in the patient’s living environment
  2. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury
  3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching
  4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye
  5. Alerting other nurses and health care providers about patient’s visual status during hand-off reports
    3, 4, 5

An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.)

  1. Slow, cautious behavioral style
  2. Inattention and neglect, especially to the left side
  3. Cloudy or opaque areas in part of the lens or the entire lens
  4. Visual spatial alterations such as loss of half of a visual field
  5. Loss of sensation and motor function on the right side of the body
    2, 4

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can’t hear anything.” After determining that the patient’s hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply.)

  1. Demonstrate hearing aid battery replacement.
  2. Review method to check volume on hearing aid.
  3. Demonstrate how to wash the earmold and microphone with hot water.
  4. Discuss the importance of having wax buildup in the ear canal removed.
  5. Recommend a chemical cleaner to remove difficult buildup.
    1, 2, 4

Identify the measures to ensure safety for a patient who has no sensation on one side of the body.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?

  1. Incorrect clustering of data
  2. Wrong diagnosis
  3. Condition is a collaborative problem
  4. Premature ending assessment
    2

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, “Yes, usually twice or more.” The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.)

  1. Age 42
  2. Dysuria
  3. Difficulty performing perineal hygiene
  4. Nocturia
  5. Episode of diarrhea
    2, 4

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)

  1. Offer frequent skin care because of Impaired Skin Integrity
  2. Risk of Infection
  3. Chronic Pain related to osteoarthritis
  4. Activity Intolerance related to physical deconditioning
  5. Lack of Knowledge related to laser surgery
    2, 4

Which of the following best describe a collaborative health problem? (Select all that apply.)

  1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status
  2. The language medical practitioners use to communicate a patient’s health problem and associated treatments and response
  3. A diagnostic label that classifies a patient’s response to illness so that all nurses can be familiar with a specific patient’s health care needs
  4. A language used by health care providers to communicate and consider each other’s unique perspective, so they can better manage the multiple factors that influence the health of individuals
  5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently
    1, 4

Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need?

  1. Patient obtains social support care related to caregiver stress
  2. Fear related to open-heart surgery
  3. Acute Pain related to splinting of incision
  4. Impaired Family Coping related to insufficient caregiver support
    1

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.

  1. Consider the context of patient’s health problem and select a related factor.
  2. Review assessment data, noting objective and subjective clinical information.
  3. Cluster clinical data elements that form a pattern.
  4. Identify appropriate assessment findings for diagnosis.
  5. Identify a nursing diagnosis.
    2, 3, 5, 1, 4

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of:

  1. Collaborative data set.
  2. Diagnostic label.
  3. Related factors.
  4. Data cluster.
    4

A nurse reviews data gathered regarding a patient’s response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.)

  1. Data collection
  2. Data clustering
  3. Data interpretation
  4. Making a diagnostic statement
  5. Goal setting
    2, 3, 4

A nursing assessment reveals a patient in the home setting who has reduced mobility following recovery from a stroke. The patient has weakness in the left leg and arm. The patient has a walker, which he has never used before, and his wife tells the nurse that he is unsteady in using the walker. The patient fell while in the hospital. The physical therapist came to the home, but the wife tells the nurse, “We are not sure how to get my husband upstairs. The therapist explained how to use the walker, but we have questions.” The nurse developed the following concept map. Place the links between the nursing diagnoses in the correct direction.

Fill in the Blank:
A(n)______________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.
Risk diagnosis

Setting priorities for a patient’s nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.)

  1. Priority setting establishes a preferential order for nursing interventions.
  2. In most cases wellness problems take priority over problem-focused problems.
  3. Recognition of symptom patterns helps in understanding when to plan interventions.
  4. Longer-term chronic needs require priority over short-term problems.
  5. Priority setting involves creating a list of care tasks.
    1, 3

Match the elements for correct identification of outcome statements with the SMART acronym terms below.

  1. Specific
  2. Measurable
  3. Attainable
  4. Realistic
  5. Timed

a. Mutually set an outcome that a patient agrees to meet.
b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources.
c. Be sure an outcome addresses only one patient behavior or response.
d. Include when an outcome is to be met.
e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient’s status.
1c, 2e, 3a, 4b, 5d

A nursing student is providing a hand-off report to the RN assuming her patient’s care. She explains, “I ambulated him twice during the shift; he tolerated walking to end of hall each time and back with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS. Which intervention is a dependent intervention?

  1. Providing hand-off report at change of shift
  2. Enhancing the patient’s sleep hygiene
  3. Administering IV fluids
  4. Taking vital signs
    3

A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse’s unit environment will affect the ability to set priorities? (Select all that apply.)

  1. Policy for conducting hourly rounds
  2. Staffing level
  3. Interruption by staff nurse colleague
  4. Type of hospital unit
  5. Competency of patient care technician
    2, 3, 5

A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming her patient’s care at the end of the clinical day. The student states, “The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated walking to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints. For the goal of improving the patient’s activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.)

  1. IV site not tender
  2. Uses walker to walk
  3. Walked to visitors lounge
  4. No shortness of breath
  5. Tolerated dinner meal
    3, 4

Which of the following factors should be considered when choosing an intervention for a patient’s plan of care? (Select all that apply.)

  1. The specific patient outcome against which to judge effectiveness of interventions
  2. The timing of care activities routinely conducted on the care unit
  3. The scientific evidence available in support of an intervention
  4. The amount of time required for implementation in consideration of patient’s condition
  5. The patient’s values and beliefs regarding the intervention
    1, 3, 4, 5

A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities on the left with the hand-off report categories on the right.
Activities

  1. Use a standard checklist for the report.
  2. Encourage questions and clarification.
  3. Offer specific information on how to reduce patient’s risks.
  4. Give report at time when shift has ended and other nurses are requesting information.
  5. Explain how patient’s discharge was delayed by insufficient numbers of staff.
  6. Organize time by preparing in advance what to report.

Categories
A. Strategy for Effective Hand-off
B. Strategy for Ineffective Hand-off
1A, 2A, 3A, 4B, 5B, 6A

A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient’s intravenous (IV) port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.)

  1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient.
  2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem.
  3. Explain to the IV nurse the frequency in which this port has obstructed in the past.
  4. Tell the IV nurse the problem is probably related to the physician who inserted the port.
  5. Describe to the IV nurse the type and condition of the port currently in use.
    2, 3, 5

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?

  1. Patient will be turned every 2 hours within 24 hours.
  2. Patient will have normal formed stool within 48 hours.
  3. Patient’s ability to turn self in bed improves.
  4. Erythema of skin will be mild to none within 48 hours.
    4

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right.
Goals

  1. _ Patient will ambulate independently in 3 days.
  2. _ Patient will be injury free for 1 month.
  3. _ Patient will achieve 5-pound weight gain in 1 month.
  4. _ Patient will achieve pain relief by discharge.

Outcomes
a. Patient expresses fewer nonverbal signs of discomfort within 24 hours.
b. Patient increases caloric intake to 2500 calories daily.
c. Patient walks 20 feet using a walker in 24 hours.
d. Patient identifies barriers to remove in the home within 1 week.
1c, 2d, 3b, 4a

We have an expert-written solution to this problem!
The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

  1. Appearance and behavior
  2. Measurement of vital signs
  3. Observing specific body systems
  4. Conducting a detailed health history
    1

Which number corresponds to the area of the chest where you would auscultate for the tricuspid valve?
4

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up?

  1. Auscultation of an apical heart rate of 76
  2. Absence of bowel sounds on abdominal assessment
  3. Respiratory rate of 8 breaths/min
  4. Palpation of dorsalis pedis pulses with strength of +2
    3

Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer?

  1. “I’ll make sure to schedule my colonoscopy annually after the age of 60.”
  2. “I’ll make sure to have a colonoscopy every 2 years.”
  3. “I’ll make sure to have a flexible sigmoidoscopy every year once I turn 55.”
  4. “I’ll make sure to have a fecal occult blood test annually once I turn 45.
    4

The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.)

  1. Add salt to every meal.
  2. Talk with your health care provider about taking a daily low dose of aspirin.
  3. Work with your health care provider to develop a regular exercise program.
  4. Limit daily intake of fats to less than 25% to 35% of total calories.
  5. Review strategies to encourage the patient to quit smoking.
    2, 3, 4, 5

The nurse is assessing the cranial nerves. Match the cranial nerve with its related function.
Cranial Nerves

  1. XII Hypoglossal
  2. V Trigeminal
  3. VI Adducens
  4. IV Trochlear
  5. X Vagus

Cranial Nerve Function
a. Motor innervation to the muscles of the jaw
b. Lateral movement of the eyeballs
c. Sensation of the pharynx
d. Downward, inward eye movements
e. Position of the tongue
1e, 2a, 3b, 4d, 5c

The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching?

  1. “I’ll recognize abnormal lumps because they are very painful.”
  2. “I’ll start performing testicular self-examination monthly after I turn 15.”
  3. “I’ll perform the self-examination in front of a mirror.”
  4. “I’ll gently roll the testicle between my fingers.”
    1

The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene?

  1. The student stands at a midline position behind the patient, observing for position of the spine and scapula.
  2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements.
  3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds.
  4. The student places the palm of the hand over the intercostal spaces and asks the patient to say “ninety-nine.”
    3

A patient has undergone surgery for a femoral artery bypass. The surgeon’s orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.)

  1. Place the fingers behind and below the medial malleolus.
  2. Have the patient slightly flex the knee with the foot resting on the bed.
  3. Have the patient relax the foot while lying supine.
  4. Palpate the groove lateral to the flexor tendon of the wrist.
  5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.
    3, 5

The faith community nurse is teaching the community center women’s group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.)

  1. First child at the age of 26 years
  2. Menopause onset at the age of 49 years
  3. Family history with BRCA1 inherited gene mutation
  4. Age over 40 years
  5. Onset of menses before the age of 12
  6. Recent use of oral contraceptives
    3, 4, 5, 6

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.)

  1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure.
  2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient.
  3. The nurse directs the patient care technician to set up meal trays for patients.
  4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications.
  5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.
    2, 3, 5

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.)

  1. The nurse reviews the options for pain relief for the patient.
  2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed.
  3. The nurse reviews the policy and procedure for the cold application.
  4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy.
  5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.
    1, 2, 4

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse’s current greatest priority?

  1. Patient in pain
  2. Patient newly admitted
  3. Patient who returned from surgery
  4. Patient requesting assistance with meal tray
    3

The nurse administers a tube feeding via a patient’s nasogastric tube. This is an example of which of the following?

  1. Physical care technique
  2. Activity of daily living
  3. Indirect care measure
  4. Lifesaving measure
    1

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

  1. Knowing the source of the guideline
  2. Reviewing the evidence used to develop the guideline
  3. Individualizing how to apply the clinical guideline for a patient
  4. Explaining to a patient the purpose of the guideline
    3

A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient’s adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient’s adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.)

  1. Reviewing the family caregiver’s availability during medication administration times
  2. Determining the value the patient places on taking medications
  3. Reviewing the number of medications and time each is to be taken
  4. Determining all consequences associated with the patient missing specific medicines
  5. Reviewing the therapeutic actions of the medications
    2, 4

The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions? (Select all that apply.)

  1. The application of the skin barrier is a dependent care measure.
  2. The call to the ostomy and wound care specialist is an indirect care measure.
  3. The cleansing of the skin is a direct care measure.
  4. The application of the skin barrier is an instrumental activity of daily living.
  5. Inspecting the skin is a direct care activity.
    2, 3

Match the category of direct care on the left with the specific direct care activity on the right.

  1. Counseling _
  2. Lifesaving measure __
  3. Physical care technique _
  4. Activity of daily living __

a. Assisting patient with oral care
b. Discussing a patient’s options in choosing palliative care
c. Protecting a violent patient from injury
d. Using safe patient handling during positioning of a patient
1 b, 2 c, 3 d, 4 a

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.)

  1. Checks scientific literature or policy and procedure
  2. Determines whether additional assistance is needed
  3. Collects all necessary equipment
  4. Delegates the procedure to a more experienced nurse
  5. Considers all possible consequences of the procedure
    1, 2, 3, 5

A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.)

  1. Allows nurses to act more quickly and appropriately
  2. Sets a level of clinical excellence for practice
  3. Eliminates need to create an individualized care plan for the patient
  4. Incorporates evidence-based interventions for stage II pressure injury
  5. Provides for access to patient care information within the electronic health record
    1, 2, 4

A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. The patient tells the nurse after the first medication infusion, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.)

  1. Asking patient to breathe deeply during auscultation
  2. Counting respirations per minute
  3. Asking the patient to describe how his breathing feels
  4. Starting the intravenous infusion
  5. Auscultating lung sounds
    2, 3, 5

A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient’s airways. When the nurse asks how the patient feels, he responds by saying, “I feel as if I can breathe better.” The nurse auscultates the patient’s lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient’s condition?

  1. Counting respirations per minute
  2. Asking the patient to describe how his breathing feels
  3. Observing breathing pattern
  4. Auscultating lung sounds
    2

Which of the following statements correctly describes the evaluation process? (Select all that apply.)

  1. Evaluation involves reflection on the approach to care.
  2. Evaluation involves determination of the completion of a nursing intervention.
  3. Evaluation involves making clinical decisions.
  4. Evaluation requires the use of assessment skills.
  5. Evaluation is performed only when a patient’s condition changes.
    1, 3, 4

A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse’s goal of care for this patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.)

  1. Quality of life
  2. Patient satisfaction
  3. Clinic follow-up visits
  4. Adherence to self-administration of insulin
  5. Description of side effects of medications
    1, 3, 4

From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O).

  1. _ Will achieve pain relief
  2. _ Ambulates 10 feet down hallway
  3. _ Will remain free of infection
  4. _ Will be afebrile
  5. _ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10
  6. _ Will gain improved mobility
    1G, 2O, 3G, 4G, 5O, 6G

A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse’s ability to perform patient evaluation? (Select all that apply.)

  1. Comparing patient response with previous response
  2. Examining results of clinical data
  3. Recognizing error
  4. Self-reflection
  5. Checking medical record for when IV was inserted.
    1, 2

A nurse asks how a patient’s condition from a serious infection changed since yesterday while receiving a hand-off report. The 280nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient’s body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient’s progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse’s ability to perform evaluation? (Select all that apply.)

  1. Checking the summary notes
  2. Asking the leaving RN about the patient’s condition.
  3. Assigning the technician to measure intake and output
  4. Comparing current outcomes with those set for the patient’s goals
  5. Reflecting on patient’s progress
    1, 2, 4, 5

A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient’s heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient’s situation?

  1. The patient is recovering normally.
  2. The symptoms reflecting restlessness
  3. The patient’s blood pressure trend
  4. The delay in administration of the analgesic
    4

A nurse enters a patient’s room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient’s expectations of care. Which of the following is appropriate for evaluating a patient’s expectations of care?

  1. On a scale of 0 to 10 rate your level of nausea.
  2. The nurse weighs the patient.
  3. The nurse asks, “Did you believe that you received the information you needed to follow your diet?”
  4. The nurse states, “Tell me four different foods included in your diet.”
    3

Which of the following statements correctly describe the evaluation process? (Select all that apply.)

  1. Evaluation is an ongoing process.
  2. Evaluation involves the gathering of data for recognizing errors or omissions in care.
  3. Evaluation involves making clinical decisions.
  4. Evaluation requires the use of assessment skills.
  5. Evaluation is done only when a patient’s condition changes.
    1, 2, 3, 4

Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.)

  1. Always use a single cutting board to prepare foods for cooking.
  2. Refrigerate leftovers as soon as possible.
  3. Always buy vegetables in packages marked “prewashed.”
  4. Cook meats to the proper temperature.
  5. Wash hands thoroughly before food preparation.
    2, 4, 5

A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.)

  1. A current safety inspection sticker is on the IV fluids pump.
  2. A walker is positioned near the patient’s bedside.
  3. The hospital bed is in the high position.
  4. There is no gait belt at the bedside.
  5. The overbed table with the patient’s glasses is positioned against the wall opposite the end of the bed.
    3, 4, 5

A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.)

  1. Immediately phone in to the hospital alert system the exact location of the fire.
  2. Direct the nurse technician to place empty stretchers behind the fire doors.
  3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area.
  4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms.
  5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms.
    1, 3, 4

Match the threats to safety on the right to the category of risk factors on the left.
A. Individual Risks
B. Developmental Risks

  1. An older adult has limited finances.
  2. A young toddler likes to explore objects by placing them in his mouth.
  3. A 55-year-old patient has a residual gait change due to a stroke.
  4. A school-age child chooses to play ice hockey.
  5. A patient newly diagnosed with diabetes has low health literacy.
    1A, 2B, 3A, 4B, 5A

A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse?

  1. The first patient maintains eye contact with the nurse, is calm during the nurse’s assessment, and asks questions frequently.
  2. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking.
  3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume.
  4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.
    4

A nurse working the night shift is assigned a patient who has a history of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assessment are most likely to provide information about the patient’s current fall risks? (Select all that apply.)

  1. Allergy history
  2. Medication history
  3. Patient age
  4. Patient’s occupation
  5. Physical exam of neuromuscular function
    2, 3, 5

Match the intervention for promoting child safety on the left with the correct developmental stage on the right.

  1. Teach children proper bicycle and skate board safety.
  2. Teach children how to cross streets and walk in parking lot.
  3. Teach children proper techniques for specific sports.
  4. Teach children not to operate electric toothbrushes while unsupervised.
  5. Teach children not to talk to or go with a stranger.
  6. Teach children not to eat items found in the grass.

A. School-age child
B. Preschooler
A: 1, 2, 3 B: 4, 5, 6

The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.)

  1. Ask the health care provider to order a restraint.
  2. Recommend insertion of a urinary catheter.
  3. Provide scheduled toileting rounds every 2 to 3 hours.
  4. Institute a routine exercise program for the patient.
  5. Keep the bed in high position with side rails down.
  6. Keep the pathway from the bed to the bathroom clear.
    3, 4, 6

Place the following steps for applying a wrist restraint in the correct order:

  1. Pad the skin overlying the wrist.
  2. Insert two fingers under the secured restraint to be sure that it is not too tight.
  3. Be sure that the patient is comfortable and in correct anatomical alignment.
  4. Secure restraint straps to bedframe with quick-release buckle.
  5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly.
    3, 1, 5, 2, 4

Match the fall prevention intervention on the left with the scientific rationale on the right.

  1. Prioritize nurse call system responses to patients at high risk.
  2. Place patient in a wheelchair with wedge cushion.
  3. Establish elimination schedule with bedside commode.
  4. Use a low bed for patient.
  5. Provide a hip protector.
  6. Place nonskid floor mat on floor next to bed.

A. Maintains comfort and makes exit difficult
B. Makes it difficult for patients with lower extremity weakness to stand
C. Reduces slipping when walking
D. Reduces fall impact
E. Ensures rapid response for help
F. Reduces chance of patient trying to get out of bed on own
1E, 2A, 3F, 4B, 5D, 6C

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.

  1. Apply suction.
  2. Assist patient to semi-Fowler’s or high Fowler’s position, if able.
  3. Advance catheter through nares and into trachea.
  4. Have patient take deep breaths.
  5. Lubricate catheter with water-soluble lubricant.
  6. Apply sterile gloves.
  7. Perform hand hygiene.
  8. Withdraw catheter.
    7, 2, 6, 4, 5, 3, 1, 8

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)

  1. Initiate oxygen therapy via nasal cannula.
  2. Perform nasotracheal suctioning of a patient.
  3. Educate the patient about the use of an incentive spirometer.
  4. Assist with care of an established tracheostomy tube.
  5. Reposition a patient with a chest tube.
    4, 5

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?

  1. Start oxygen at 2 L/min via nasal cannula.
  2. Elevate the head of the bed to 45 degrees.
  3. Encourage the patient to use the incentive spirometer.
  4. Notify the health care provider.
    2

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?

  1. “Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles.”
  2. “When I am sick, I should limit the amount of fluids I drink so that I don’t produce excess mucus.”
  3. “I will ensure that I receive an influenza vaccine every year, preferably in the fall.”
  4. “I will look for a smoking-cessation support group in my neighborhood.”
    2

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.)

  1. SpO2 value of 95%
  2. Retractions
  3. Respiratory rate of 28 breaths per minute
  4. Nasal flaring
  5. Clubbing of fingers
    2, 3, 4

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.)

  1. The patient has visible secretions in the airway.
  2. There is a sawtooth pattern on the patient’s EtCO2 monitor.
  3. The patient has clear breath sounds.
  4. It has been 3 hours since the patient was last suctioned.
  5. The patient has excessive coughing.
    1, 2, 5

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?

  1. New, vigorous bubbling in the water seal chamber.
  2. Scant amount of sanguineous drainage noted on the dressing.
  3. Clear but slightly diminished breath sounds on the right side of the chest.
  4. Pain score of 2 one hour after the administration of the prescribed analgesic.
    1

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.)

  1. Perform chest compressions.
  2. Ask someone to bring the defibrillator to the room for immediate defibrillation.
  3. Apply oxygen via nasal cannula.
  4. Place the patient in the high Fowler’s position.
  5. Educate the family about the need for CPR.
    1, 2

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?

  1. Clear breath sounds
  2. Patient speaking to nurse
  3. SpO2 reading of 96%
  4. Respiratory rate of 18 breaths/minute
    2

Which number corresponds to the spot where you would assess for an air leak in the patient with a chest tube?
1

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