NUR 112 Nursing Process I: Fundamentals of Patient Care CUNY Borough of Manhattan Community College A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b.Eliminate health behaviors in America. c.Eliminate quality of life in America. d.Eliminate healthy life in America. A. eliminate health disparities in America -There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages. A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d.Focus on illness treatment to provide fast recuperation. C. create social & physical environments that promote good health A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a.Making sure the patients are disease free b.Making sure to involve the whole person c.Making sure care is strictly personal in nature d.Making sure to focus only on the pathological state B. making sure to involve the whole person -The World Health Organization (WHO) defines health as a “state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” Therefore, nurses’ attitudes toward health and illness should consider the total person, as well as the environment in which the person lives The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a.Health belief model b.Holistic health model c.Health promotion model d.Maslow’s hierarchy of needs A. Health belief model -The health belief model addresses the relationship between a person’s beliefs and behaviors. The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behavior-specific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Maslow’s’ hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person’s level of health. A nurse is using Maslow’s hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? A. anxiety B. not eating C. mental health D. not seeing family members B. not eating According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? A. Health belief model B. Holistic health model C. Health promotion model D. Maslows hierarchy of needs B. Holistic health model The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person’s beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person’s level of health. Maslow’s hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs. A nurse is assessing internal variables that are affecting the patient’s health status. Which area should the nurse assess? A. perception of functioning B. socioeconomic factors C. cultural background D. family practices A. perception of functioning Internal variables include a person’s developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person’s health beliefs and practices include family practices, socioeconomic factors, and cultural background. The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse’s actions? a.External variables have little effect on compliance. b.A person’s compliance is affected by economic status. c.Employment status is an internal variable that impacts compliance. d.Noncompliant patients thrive on the disapproval of authority figures. B. A persons compliance is affected by economic status A person’s compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. External variables can have a major impact on compliance. Employment status is an external variable, not an internal variable. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices; noncompliance does not occur from thriving on disapproval of authority figures. The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion D. passive health promotion Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way. The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a.Primary prevention b.Secondary prevention c.Tertiary prevention d.Risk factor prevention A. Primary prevention Primary prevention precedes disease or dysfunction and is applied to people considered physically/emotionally healthy. Primary prevention: health education programs, immunizations, & physical/nutritional activities. Secondary prevention focuses on individuals who are experiencing health problems/illnesses & at risk for developing complications or worsening conditions. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. While risk factor modification is an integral component of health promotion, it is not a type of preventive care The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a.Primary prevention b.Secondary prevention c.Tertiary prevention d.Health promotion B. Secondary prevention Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities for healthy people. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a.Primary prevention b.Secondary prevention c.Tertiary prevention d.Health promotion C. Tertiary prevention Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration Upon completing a history, the nurse finds that a patient has risk factors for lung disease. How should the nurse interpret
this finding? a.A person with the risk factor will get the disease. b.The chances of getting the disease are increased. c.Risk modification will have no effect on disease prevention. d.The disease is guaranteed not to develop if the risk factor is controlled. B. the changes of getting the disease are increased The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness. The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a.The patient does not want to and will never quit smoking. b.The patient must pick up the attempt right where the patient left off. c.The patient will return to the contemplation or precontemplation phase. d.The patient will need to adopt a new lifestyle for change to be effective. C. the patient will return to the contemplation or precontemplation phase When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up the attempt where left off. It is believed that change involves movement through a series of stages (precontemplation, contemplation, preparation, action, and maintenance). Anticipating that the patient does not want to and will never quit is premature. While the patient will need to adopt a new lifestyle for change to be effective, it does not correlate to this scenario since the patient relapsed. The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for “detox.” What should the nurse do next? a.Identify the patient’s stage of change. b.Realize that the patient is ready to change. c.Teach the patient that choices will have to change. d.Instruct the patient that relapses will not be tolerated. A. Identify the patients stage of change The nurse should identify the stage of change and assess where the patient is currently in this situation. To be most effective, nursing interventions should match the stage of change. The nurse cannot realize the patient is ready for change because only a minority of people are actually in the action stage of changing. While teaching that choices will have to change, it will follow later after the nurse has determined which stage the person is in. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a.Precontemplation b.Contemplation c.Preparation d.Action B. contemplation This patient is planning to make the change within the next 6 months and is in the contemplation stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). A patient has had emphysema (lung disease) for many years. When approached by the nurse, the patient states “I would be better off dead.” The patient supports the family, and now because of oxygen dependency the patient must quit work. The patient’s spouse will have to go to work. Which action should the nurse take? a.Develop a plan of care for the family. b.Contact psychiatric services for a referral. c.Assure the patient that things will work out. d.Focus the plan of care solely on maximizing patient function. A. develop a plan of care for the family Because of the effects of chronic illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable. Focusing only on the patient will not help the family adjust. Which areas should the nurse assess to determine the effects of external variables on a patient’s illness? (Select all that apply.) a.Patient’s perception of the illness b.Patient’s coping skills c.Socioeconomic status d.Cultural background e.Social support C, D, E External variables influencing a patient’s illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient’s perceptions of symptoms and the nature of the illness, as well as the patient’s coping skills and locus of control. A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a.Understands the challenges of today’s health care system b.Identifies actual and potential risk factors c.Has coined the term “illness behavior” d.Minimizes the effects of illnesses e.Experiences compassion fatigue A, B, D Nurses understand the challenges of today’s health care system. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Nurses did not coin the phrase “illness behavior.” While nurses can experience compassion fatigue, it does not help in meeting patient goals. The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? a.Capitation provides the hospital with a means of recovering variable charges. b.The hospital will be paid for the full cost of the patient’s hospitalization. c.Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. d.Medicare will pay the national average for the patient’s condition. C. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost A nurse is teaching the staff about managed care. Which information should the nurse include in the teaching session? a.Managed care insures full coverage of health care costs. b.Managed care only assumes the financial risk involved. c.Managed care allows providers to focus on illness care. d.Managed care causes providers to focus on prevention. D. managed care causes providers to focus on prevention Managed care describes health care systems in which the provider or the health care system receives a predetermined capitated (fixed amount) payment for each patient enrolled in the program. Therefore, the focus of care shifts from individual illness care to prevention, early intervention, and outpatient care. The actual cost of care is the responsibility of the provider. The managed care organization (provider) assumes financial risk, in addition to providing patient care. A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act? a.A family can choose whether to have health insurance with no consequences. b.Primary care physician payments from Medicaid services can equal Medicare. c.Adult children up to age 26 are allowed coverage on the parent’s plan. d.Private insurance companies can deny coverage for any reason. C. adult children up to age 26 are allowed coverage on the parent's plan A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a.When the patient is ready b.Close to the time of discharge c.Upon admission to the hospital d.After an order is written/prescribed C. upon admission to the hospital Discharge planning begins the moment a patient is admitted to a health care facility. When the patient is ready may be too late. Close to the time of discharge and after an order is written/prescribed are too late. The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? a.Secondary acute b.Continuing c.Restorative d.Tertiary C. Restorative Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Restorative care includes cardiovascular and pulmonary rehabilitation, sports medicine, spinal cord injury programs, and home care. A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? a.Primary care b.Preventive care c.Restorative care d.Continuing care B. preventative care Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation. Primary care is health promotion that includes prenatal and well-baby care, nutrition counseling, family planning, and exercise classes. A nurse is following the PDSA cycle for quality improvement. Which action will the nurse take for the letter “A”? a.Act b.Alter c.Assess d.Approach A. Act There are many models for quality improvement and performance improvement. One model is the PDSA cycle: plan, do, study, and act An older adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? a.Hospice b.Respite care c.Assisted living d.Skilled nursing D. Skilled nursing An intermediate care or skilled nursing facility offers skilled care from a licensed nursing staff. This often includes administration of IV fluids, wound care, long-term ventilator management, and physical rehabilitation. A hospice is a system of family-centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness. Respite care is a service that provides short-term relief or “time off” for people providing home care to an individual who is ill, disabled, or frail. Assisted living offers an attractive long-term care setting with an environment more like home and greater resident autonomy. A nurse working in a community hospital’s emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? a.Continuing care b.Restorative care c.Preventive care d.Tertiary care D. Tertiary care Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care. Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Continuing care is available within institutional settings (e.g., nursing centers or nursing homes, group homes, and retirement communities), communities (e.g., adult day care and senior centers), or the home (e.g., home care, home-delivered meals, and hospice). Preventive care is more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a.Completes a comprehensive database b.Identifies pertinent nursing diagnoses c.Intervenes based on priorities of patient care d.Determines whether outcomes have been achieved A. Completes a comprehensive database The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a.Complete the questions in chronological order. b.Focus on the patient’s presenting situation. c.Make accurate interpretations of the data. d.Conduct an observational overview. B. focus on the patients presenting situation A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection The nurse is gathering data on a patient. Which data will the nurse report as objective data? a.States “doesn’t feel good” b.Reports a headache c.Respirations 16 d.Nauseated C. Respirations 16 Objective data are observations or measurements of a patient’s health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States “doesn’t feel good,” reports a headache, and nausea are all subjective data. Subjective data include the patient’s feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Which method of data collection will the nurse use to establish a patient’s database? a.Reviewing the current literature to determine evidence-based nursing actions b.Checking orders for diagnostic and laboratory tests c.Performing a physical examination d.Ordering medications C. performing a physical examination A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a.Carefully review lab results. b.Conduct the physical assessment. c.Perform a thorough nursing health history. d.Prolong the termination phase of the interview. C. Perform a thorough nursing health history A nurse is conducting a nursing health history. Which component will the nurse address? a.Nurse’s concerns b.Patient expectations c.Current treatment orders d.Nurse’s goals for the patient B. Patient expectations Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment orders are located under the Orders section in the patient’s chart and are not a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database. Goals that are mutually established, not nurse’s goals, are part of the nursing care plan. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a.Tell the patient to just focus on the leg and cast right now. b.Document the sleep patterns and information in the patient’s chart. c.Explain that a more thorough assessment will be needed next shift. d.Ask the patient about usual sleep patterns and the onset of having difficulty resting. D. ask the patient about usual sleep patterns & the onset of having difficulty resting The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient’s report of a problem or postpone it till the next shift. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a.Gordon’s Functional Health Patterns b.Activity-exercise pattern assessment c.General to specific assessment d.Problem-oriented assessment D. problem-oriented assessment The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problem-oriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a.“Data interpretation occurs before data validation.” b.“Validation involves looking for patterns in professional standards.” c.“Validation involves comparing data with other sources for accuracy.” d.“Data interpretation involves discovering patterns in professional standards.” C. "validation involves comparing data with other sources for accuracy" Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a.The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b.The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c.The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d.The nurse elevates a leg cast when the patient reports decreased mobility. A. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change & notices old & new drainage The only scenario that validates a patient’s report with a nurse’s observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse’s assessment. While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first? a.Immediately place the patient in isolation. b.Ask the patient to describe the type of reaction. c.Proceed to the termination phase of the interview. d.Document the latex allergy on the medication administration record. B. Ask the patient to describe type of reaction The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a.Pulse b.Respirations c.Temperature d.Blood pressure A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a.Radiation b.Conduction c.Convection d.Evaporation C. convection Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature? a.Radiation b.Conduction c.Convection d.Evaporation B. Conduction Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement. A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a.Apply just a diaper. b.Double the clothing. c.Place a cap on their heads. d.Increase room temperature to 90 degrees. C. Place a cap on their heads A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a.Wait 30 minutes and recheck the patient’s temperature. b.Assume that the patient has an infection and order blood cultures. c.Encourage the patient to move around to increase muscular activity. d.Be aware that temperatures this high are harmful and affect patient safety. A. wait 30 mins & recheck the patients temp Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a.Stethoscope b.Thermometer c.Blood pressure cuff d.Sphygmomanometer B. thermometer Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a.Hyperthermia and fever are the same thing. b.Hyperthermia is an upward shift in the set point. c.Hyperthermia occurs when the body cannot reduce heat production. d.Hyperthermia results from a reduction in thermoregulatory mechanisms C. Hyperthermia occurs when the body cannot reduce heat production The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a.Place the patient on oxygen. b.Encourage the patient to cough. c.Restrict the patient’s fluid intake. d.Increase the patient’s metabolic rate. A. place patient on oxygen Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a.Using appropriate route and device b.Assessing changes in body temperature c.Being aware of the usual values for the patient d.Obtaining temperature measurement at ordered frequency B. Assessing changes in body temp The nurse is responsible for assessing changes in body temperature The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature? a.Oral b.Rectal c.Axillary d.Tympanic D. Tympanic The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to best obtain the infant’s pulse? a.Radial b.Brachial c.Femoral d.Popliteal The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a.Radial b.Apical c.Carotid d.Brachial C. carotid he heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a.Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist. b.Place the tips of the first two fingers over the groove along the little finger side of the patient’s wrist. c.Place the thumb over the groove along the little finger side of the patient’s wrist. d.Place the thumb over the groove along the thumb side of the patient’s wrist. A. place the tips of the first two fingers over the groove along the thumb side of patients wrist Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse. The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a.60 b.80 c.140 d.200 B. 80 The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 − 60 = 80). The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a.Allow the patient to breathe into a paper bag. b.Use oxygen cautiously in this patient. c.Administer high levels of oxygen. d.Give CO2 via mask. B. use oxygen cautiously in this patient Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or “rebreathed” with a paper bag. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate? a.The patient has a fever. b.The patient has possible hemorrhage or bleeding. c.The patient has chronic obstructive pulmonary disease (COPD). d.The patient has calcium channel blockers or digitalis medication prescriptions. D. the patient has calcium channel blockers or digitalis medication prescriptions Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body’s need for oxygen, leading to an increased heart rate. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms? a.Red blood cell count of 5.0 million/mm3 b.Hemoglobin level of 8.0 g/100 mL c.Hematocrit level of 45% d.Pulse oximetry of 95% B. Hemoglobin level of 8.0 g/100 mL The concentration of hemoglobin reflects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)? a.Smoking increases BP for up to 3 hours. b.Caffeine increases BP for up to 15 minutes. c.Smoking result in vasoconstriction, falsely elevating BP. d.Caffeine intake should not have occurred 30 to 40 minutes before BP measurement. C. Smoking result in vasoconstriction, falsely elevating BP Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? a.Review the procedure with the patient. b.Position the patient comfortably. c.Maintain surgical aseptic technique. d.Gather available supplies. C. maintain surgical aseptic technique You maintain surgical aseptic technique at the patient’s bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure since the patient already has a compromised immune response. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The nurse teaches the patient about rest, exercise, and eating properly and how to utilize deep breathing and visualization. What is the primary rationale for the nurse’s actions related to the teaching? a.Topics taught are standard information taught during health care visits. b.The patient requested this information to teach the extended family members. c.Stress for long periods of time can lead to exhaustion and decreased resistance to infection. d.These techniques will help the patient manage the pain and loss of personal belongings. C. Stress for long periods of time can lead to exhaustion and decreased resistance to infection The body responds to emotional or physical stress by the general adaptation syndrome. If stress extends for long periods of time, this can lead to exhaustion, whereby energy stores are depleted and the body has no defenses against invading organisms. Techniques of deep breathing and visualization may be helpful with pain, but they are not the primary reason. The teachings listed are not all standard interventions taught at every health care visit. There is no data to indicate the patient requested this information for the family. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a.Teaching the patient about fall prevention b.Teaching the patient to take a temperature c.Teaching the patient to select nutritious foods d.Teaching the patient about the effects of alcohol C. teaching the patient to select nutritious foods A patient’s nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual’s risk for infection. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a.Observe the patient for decreased activity tolerance. b.Assume the patient is in pain and treat accordingly. c.Provide the patient ice chips as requested. d.Maintain the room temperature at 65° F A. Observe the patient for decreased activity tolerance Systemic infection, like pneumonia, causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise; be alert for changes in the patient’s level of activity and responsiveness. Nurses do not assume but assess and communicate with the patient about pain. While providing the patient with ice chips may be appropriate, it is not a priority and there is no reason for the patient to be limited to ice. Maintaining the room temperature at 65° F is too cold. 16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care–associated infection? a.Use local anesthetic on reddened areas. b.Use nonallergenic tape on dressings. c.Use a chlorhexidine wash. d.Use filtered water. C. Use a chlorhexidine wash The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care–associated infection by, for example, decreasing microbial counts like a CHG bath. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care–associated infection will the nurse report? a.Vector b.Exogenous c.Endogenous d.Suprainfection B. Exogenous An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient’s flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? a.Reusing the patient’s graduated receptacle to empty the drainage bag. b.Allowing the drainage bag port to touch the graduated receptacle. c.Emptying the urinary drainage bag at least once a shift. d.Irrigating the catheter infrequently. B. Allowing the drainage bag port to touch the graduated receptacle Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross-contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk. Which nursing action will most likely increase a patient’s risk for developing a health care–associated infection? a.Uses surgical aseptic technique to suction an airway b.Uses a clean technique for inserting a urinary catheter c.Uses a cleaning stroke from the urinary meatus toward the rectum d.Uses a sterile bottled solution more than once within a 24-hour period B. Uses a clean technique for inserting a urinary catheter Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care–associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient’s cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is most appropriate for the nurse to take? a.Complete the assessment, remove gloves, and silence the alarm. b.Discontinue the assessment, silence the alarm, and assess the intravenous site. c.Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d.Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. C. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion Completing the assessment while wearing gloves, removing gloves, washing hands after contact with body fluids, and then assessing the intravenous infusion will assist in the prevention and transfer of any potential organisms to this intravenous line. Completing the assessment, removing gloves, and silencing the alarm leaves out the crucial step of decontaminating and washing the hands. Discontinuing the assessment and assessing the IV leaves out removing the gloves and decontamination, as well as completing the assessment for the patient. Discontinuing the assessment, removing gloves, using hand gel, and assessing the IV is incorrect because upon exposure to body fluids, washing hands is appropriate. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? a.Donning clean goggles, gown, and gloves to dress the wound b.Donning sterile gown and gloves to remove the wound dressing c.Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing d.Utilizing clean gloves to remove the dressing and clean supplies for the new dressing C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis–sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? a.Washing hands after removing gloves b.Disinfecting endoscopes in the workroom c.Removing gloves to transfer the endoscope d.Placing the endoscope in a container for transfer C. removing gloves to transfer the endoscope Standard precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer; therefore, the nurse must intervene. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and standard precautions and can break the chain of infection. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? a.Teaches the patient about good nutrition b.Dons gloves when wearing artificial nails c.Disposes an uncapped needle in the designated container d.Wears eyewear when emptying the urinary drainage bag D. wears eyewear when emptying the urinary drainage bag Standard precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter, like when emptying the urinary drainage bag. Teaching the patient about good nutrition is positive but does not apply to standard precautions. Standard precautions apply to contact with blood, body fluid (except sweat), nonintact skin, and mucous membranes from all patients. Artificial nails are not worn when using standard precautions. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? a.Contact b.Droplet c.Standard d.Protective environment C. Standard Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact precautions apply to individuals with infections that can be transmitted by direct or indirect contact. Protective environment precautions apply to individuals who have undergone transplantations and gene therapy. Droplet precautions focus on diseases that are transmitted by large droplets. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a.The nurse is responsible for providing a safe environment for the patient. b.Different scopes of practice allow modification of procedures. c.Allowing the water to run is a waste of resources and money. d.This is a key step in the procedure for washing hands. A. the nurse is responsible for providing a safe environment for the patient After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? a.Sending to central sterile for cleaning and sterilization b.Sending to central sterile for cleaning and disinfection c.Sending to central sterile for cleaning and boiling d.Sending to central sterile for cleaning A. Sending to
central sterile for cleaning and sterilization The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? a.The family member places the used dressings in a plastic bag. b.The family member saves part of the dressing because it is clean. c.The family member removes gloves and gathers items for disposal. d.The family member wraps the used dressing in toilet tissue before placing in trash A. the family member places the used dressings in a plastic bag Contaminated dressings and other infectious, disposable items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present. The nurse is caring for a group of patients. Which patient will the nurse see first? a.A patient with Clostridium difficile in droplet precautions b.A patient with tuberculosis in airborne precautions c.A patient with MRSA infection in contact precautions d.A patient with a lung transplant in protective environment precautions A. A patient with Clostridium difficile in droplet precautions A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? a.Shaking hands b.Performing treatments c.Opening the refrigerator d.Working on a computer B. Performing treatments Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? a.Apply a new mask. b.Reapply the mask after it air-dries. c.Change the mask when relieved by next shift. d.Do not change the mask if the nurse is comfortable. A. Apply a new mask After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture does not provide a barrier to microorganisms and is ineffective. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? a.Place the patient in a room with negative airflow. b.Wear a gown, gloves, face mask, and goggles for interactions with the patient. c.Transport the patient safely and quickly when going to the radiology department. d.Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. D. use a dedicated blood pressure cuff that stays in the room and is used for that patient only Contact precautions are a type of isolation precaution used for patients with illness that can be transmitted through direct or indirect contact. Patients who are on contact precautions should have dedicated equipment wherever possible.A gown and gloves may be required for interactions with a patient who is on contact precautions. A face mask and goggles are not part of contact precautions. A room with negative airflow is needed for patients placed on airborne precautions; it is not necessary for a patient on contact precautions. When a patient on contact precautions needs to be transported, the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a.Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b.Immediately wash the site with soap and running water, and seek guidance from the manager. c.Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. d.Delay washing of the site until the nurse is finished providing care to the patient B. Immediately wash the site with soap and running water and seek guidance from the manager After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? a.Placing the scalpel in a needle safe container b.Testing the patient and offering treatment to the nurse c.Removing sterile gloves and disposing of in kick bucket d.Providing a medical evaluation of the nurse to the manager B. testing the patient and offering treatment to the nurse Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles. 3. remove gloves 1. remove eyewear/ face shield and goggles 4. untie gown, allow gown to fall from shoulders and do not touch outside of gown, dispose 5. remove mask by strings, do not touch outside of mask 2. perform hand hygiene, leave room and close door 6. dispose of all contaminated supplies and equipment in designated receptacles The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first
step? 1. A mode of transmission 2. An infectious agent or pathogen 4. A reservoir or source for pathogen growth 6. A portal of exit from reservoir 1. A mode of transmission 5. A portal of entry to a host 3. A susceptible host The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all that apply.) a.Wear an N95 respirator when entering the patient’s room. b.Maintain airflow rate greater than 12 air exchanges/hr. c.Place in special room with negative-pressure airflow. d.Open drapes during the daytime. e.Listen to the patient’s interests. f.Place dried flowers in a plastic vase. B. maintain airflow rate greater than 12 air echanges/hr D. open drapes during daytime E. Listen to patients interest The nurse is assessing a new patient admitted to home health. Which questions will be most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.) a.“Can you explain the risk for infection in your home?” b.“Have you traveled outside of the United States?” c.“Will you demonstrate how to wash your hands?” d.“What are the signs and symptoms of infection?” e.“Are you able to walk to the mailbox?” f.“Who runs errands for you?” A. "can you explain the risk for infection in your home?" B. "Have you traveled outside of the US" C. "Will you demonstrate how to wash your hands" D. "what are the
signs/symptoms of infection?" The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct? (Select all that apply.) a.Ties the back of own gown b.Touches only the inside of gown c.Slips arms into arm holes simultaneously d.Extended fingers fully into both of the gloves e.Uses hands covered by sleeves to open gloves f.Applies surgical cap and face mask in the operating suite B. touches only inside of gown C. Slips arms into arm holes simultaneously D. Extended fingers fully into both of the gloves E. Uses hands covered by sleeves to open gloves The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.) a.While putting on the first glove, touch only the outside surface of the glove. b.With gloved dominant hand, slip fingers underneath second glove cuff. c.Remove outer glove package by tearing the package open. d.Lay glove package on clean flat surface above waistline. e.Glove the dominant hand of the nurse first. f.After second glove is on, interlock hands. B. With gloved dominate hand, slip fingers underneath second glove cuff D. Lay glove package on clean flat surface above waistline E. Glove the dominate hand first F. After second glove is on, interlock hands The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) a.Private room b.Negative-pressure airflow in room c.Surgical mask, gown, gloves, eyewear d.N95 respirator, gown, gloves, eyewear e.Communication signs for droplet precautions f.Communication signs for airborne precautions A. Private room B. Negative-pressure airflow in room D. N95 respirator, gown, gloves, eyewear F. Communication signs for airborne precautions The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) a.Dispose of supplies to prevent the spread of microorganisms. b.Wash hands before entering and leaving both of the patients’ rooms. c.Be consistent in nursing interventions since there is only one difference in the precautions. d.Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e.Have patients in airborne precautions wear a mask during transportation to other departments. f.Check the working order of the negative-pressure room for the airborne precaution patient on admission and at discharge. A. dispose of supplies to prevent the spread of microorganisms B. wash hands before entering & leaving both of the patients rooms D. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms E. Have patients in airborne precautions wear a mask during the transportation to other departments A nurse is completing an assessment of the patient. Which principle is a priority? a.Foot care will always be important. b.Daily bathing will always be important. c.Hygiene needs will always be important. d.Critical thinking will always be important. D. Critical thinking will always be important A patient’s condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Apply the elements of critical thinking as you use the nursing process to meet patients’ hygiene needs. Critical thinking will help you determine when foot care, daily bathing, and hygiene needs are important and when they are not. When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse’s action? a.Outer skin layer becomes more resilient. b.Less frequent bathing may be required. c.Skin becomes less subject to bruising. d.Sweat glands become more active. B. Less frequent bathing may be required In older adults, daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry. As the patient ages, the skin thins and loses its resiliency and moisture, and lubricating skin glands become less active, making the skin fragile and prone to bruising and breaking. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver’s license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? a.Stand to the side of the patient’s eye and observe the cornea. b.Conclude that the glasses were lost during the accident. c.Notify the ambulance personnel for missing glasses. d.Ask the patient where the glasses are. A. Stand to the side of the patients eye and observe the cornea An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patient’s eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time and cannot assume the glasses are missing. Asking the patient where the glasses are is inappropriate since the patient is unresponsive. A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity? a.A patient who is afebrile b.A patient who is diaphoretic c.A patient with strong pedal pulses d.A patient with adequate skin turgor B. A patient who is diaphoretic Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is. The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action? a.Inadequate blood flow leads to decreased tissue ischemia. b.Patients with limited caloric intake develop thicker skin. c.Pressure reduces circulation to affected tissue. d.Verbalization of skin care needs is decreased. C. Pressure reduces circulation to affected tissue Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Verbalization is affected when altered cognition occurs from dementia, psychological disorders, or temporary delirium, not from immobility. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? a.Decreased pain sensation and increased risk of skin impairment b.Decreased caloric intake and accelerated wound healing c.High risk for skin infection and low saliva pH level d.High risk for impaired venous return and dementia A. Decreased pain sensation and increased risk of skin impairment Patients with paralysis, circulatory insufficiency, or peripheral neuropathy (nerve damage) are unable to sense an injury to the skin (decreased pain sensation). The presence of urinary incontinence, circulatory insufficiency, and neuropathy can combine to result in breakdown, so the patient has an increased risk of skin impairment. While the patient may have decreased caloric intake, the patient will not have accelerated wound healing with circulatory insufficiency, neuropathy, and incontinence. While the patient is at high risk for skin infection, the low salivary pH level is not an issue. While the patient may have a high risk for impaired venous return from the circulatory insufficiency, there is no indication the patient has dementia The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? a.Assess surfaces exposed to the edges of the cast for pressure areas. b.Keep the patient’s blood pressure low to prevent overperfusion of tissue. c.Do not allow turning in bed because that may lead to redislocation of the leg. d.Restrict the patient’s dietary intake to reduce the number of times on the bedpan A. Assess surfaces exposed to the edges of the cast for pressure areas Assess surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic devices. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues, promoting pressure ulcers. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? a.Insert an indwelling urinary catheter. b.Limit caloric and protein intake. c.Turn the patient every 2 hours. d.Assess for pain during a bath. D. Assess pain during a bathDuring a bath, assess the status of sensory nerve function by checking for touch, pain, heat, cold, and pressure. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. A mobile patient can use bathroom facilities or a urinal and does not need a urinary catheter A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1. Face 2. eyes 1. face 4.Arm and chest 5. Hands and nails 7. Abdomen and legs 3. Perineum 6. Back and buttocks The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the
nurse clean the body, starting with the first area? 1. Neck, shoulders, and chest 1. neck, shoulders, and chest 5. both arms, both hands, web spaces and axilla 2. abdomen and groin/perineum 3. legs, feet and web spaces 4. back of neck, back and buttocks A nurse is providing AM care to patients. Which action will the nurse take? a.Soaks feet of patient with peripheral vascular disease b.Applies CHG solution to wash perineum of patient with a stroke c.Cleanses eye from outer canthus to inner canthus of patient with diabetes d.Uses long, firm stroke to wash legs of patient with blood-clotting disorder B. applying CHG solution to wash perineum of patient with a stroke CHG is safe to use on the perineum and external mucosa. If patient has diabetes or peripheral vascular disease with impaired circulation and/or sensation, do not soak feet. Maceration of skin may predispose to infection. Do not use long, firm strokes to wash the lower extremities of patients with history of deep vein thrombosis or blood-clotting disorders. Use short, light strokes instead. Eye should be cleansed from the inner to outer canthus on all patients. The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do? a.Rinse thoroughly. b.Allow the skin to air-dry. c.Do not use a bath towel. d.Dry the skin with a towel. B. Allow the skin to air-dry The nurse should allow the skin to air-dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. Do not rinse when using a bag bath A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use? a.Avoid commercial mouthwashes. b.Avoid normal saline rinses. c.Brush with a hard toothbrush. d.Brush with an alcohol-based toothpaste A. avoid commercial mouthwashes Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise patients to avoid alcohol and commercial mouthwash and stop smoking. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. In some cases, flossing needs to be temporarily omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime help clean the oral cavity. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next? a.Insert an oral airway. b.Place the patient in a flat, supine position. c.Use undiluted hydrogen peroxide as a cleaner. d.Quickly proceed while not talking to the patient. A. insert an oral airway If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed. The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) a.Administer ordered analgesic 1 hour before bath time. b.Increase the frequency of skin assessment. c.Reduce triggers in the environment. d.Keep the room temperature cool. e.Be as quick as possible. B. increase the frequency of skin assessment C. reduce triggers in the environment If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment. Adapt your bathing procedures and the environment to reduce the triggers. For example, administer any ordered analgesic 30 minutes before a bath and be gentle in your approach. Keep the patient’s body as warm as possible with warm towels and be sure the room temperature is comfortable. The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.) a.Abnormal gait b.Foot deformities c.Absent or decreased pedal pulses d.Muscle wasting of lower extremities e.Decreased hair growth on legs and feet A. abnormal gait B. foot deformities D. Muscle wasting of lower extremities A patient with peripheral neuropathy has muscle wasting of lower extremities, foot deformities, and abnormal gait. A patient with vascular insufficiency will have decreased hair growth on legs and feet, absent or decreased pulses, and thickened nails. 3. A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a.Do not rinse. b.Clean under breasts. c.Inform that the skin will feel sticky. d.Dry thoroughly between skin folds. e.Use two wipes for each area of the body. A. do not rinse B. clean under breasts C. inform that skin will feel sticky CHG wipes are easy to use and accessible for older patients and bariatric patients, offering a no-rinse or -drying procedure. For a bariatric patient or a patient who is diaphoretic, provide special attention to body areas such as beneath the woman’s breasts, in the groin, skin folds, and perineal area, where moisture collects and irritates skin surfaces. Use wipes as directed on package—one wipe per each area of the body. CHG can leave the skin feeling sticky. If patients complain about its use, you need to explain their vulnerability to infection and how CHG helps reduce occurrence of health care–associated infection. Which patients will the nurse determine are in need of perineal care? (Select all that apply.) a.A patient with rectal and genital surgical dressings b.A patient with urinary and fecal incontinence c.A circumcised male who is ambulatory d.A patient who has an indwelling catheter e.A bariatric patient A. a patient with rectal and genital surgical dressings B. a patient with urinary and fecal incontinence D. a patient who has an indwelling catheter E. a bariatric patient Patients most in need of perineal care include those at greatest risk for acquiring an infection (e.g., uncircumcised males, patients who have indwelling urinary catheters, or those who are recovering from rectal or genital surgery or childbirth). A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling. Bariatric patients need special attention to body areas such as skin folds and the perineal area. In addition, women who are having a menstrual period require perineal care. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide perineal self-care. The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) a.Apply sterile gloves. b.Keep soiled linen close to uniform. c.Advise patient will feel a lump when rolling over. d.Turn clean pillowcase inside out over the hand holding it. e.Make a modified mitered corner with sheet, blanket, and spread. C. Advise patient will feel a lump when rolling over D. turn clean pillowcase inside out over the hand holding it E. make a modified mitered corner with sheet, blanket, and spread When making an occupied bed, advise patients they will feel a lump when turning, turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves are used. Keep soiled linen away from uniform. A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a.Moves patient’s arm in a full circle b.Moves patient’s arm cross the body as far as possible c.Moves patient’s arm behind body, keeping elbow straight d.Moves patient’s arm until thumb is upward and lateral to head with elbow flexed D. moves patients arms until thumb is upward and lateral to head with elbow flexed External rotation: With elbow flexed, move arm until thumb is upward and lateral to head. Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball-and-socket joint.) Adduction: Lower arm sideways and across body as far as possible. Hyperextension: Move arm behind body, keeping elbow straight. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? a.Each movement is repeated 5 times by the patient. b.Each movement is performed until the patient experiences pain. c.Each movement is completed quickly and smoothly by the nurse. d.Each movement is moved just to the point of resistance by the nurse. D. each movement is moved just to the point of resistance by the nurse Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated 5 times during the session. The patient moves all joints through ROM unassisted in active ROM. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a.Maintain a narrow base of support. b.Dangle the patient at the bedside. c.Encourage isometric exercises. d.Suggest a high-calcium diet. B. dangle the patient at the bedside To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan? a.Encourage the patient to perform as many self-care activities as possible. b.Provide a complete bed bath to promote patient comfort. c.Coordinate with occupational therapy for gait training. d.Place the patient on bed rest to prevent fatigue. A. encourage the patient to perform as many self-care activities as possible Nurses should encourage the older-adult patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient’s immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use? a.Supine position b.Lateral position c.Lateral position with positioning supports d.Supine position with no pillow under the patient’s head B. lateral position Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning supports from the bed except for the pillow under the head, and support the body with an adequate mattress. The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system? a.Inspect chest wall movements primarily during the expiratory cycle. b.Auscultate the entire lung region to assess lung sounds. c.Focus auscultation on the upper lung fields. d.Assess the patient at least every 4 hours. B. Auscultate the entire ling region to assess lung sounds Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take? a.Remove elastic stockings every 4 hours. b.Measure the calf circumference of both legs. c.Lightly rub the lower leg for redness and tenderness. d.Dorsiflex the foot while assessing for patient discomfort.
B. measure the calf circumference of both legs Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral increases in calf circumference are an early indication of thrombosis. Homan’s sign, or calf pain on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present in other conditions. Remove the patient’s elastic stockings and/or sequential compression devices (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a.Assess the skin every 4 hours. b.Limit the amount of fluid intake. c.Use a standardized tool such as the Braden Scale. d.Have special times for inspection so as to not interrupt routine care. C. use a standardized tool such as the Branden scale Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a.Imbalance b.Hemiplegia c.Muscle sprain d.Lower extremity paralysis A. imbalance Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A complete transection of the spinal cord can lead to lower extremity paralysis. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? a.Encourage the patient to do self-care. b.Keep the patient as mobile as possible. c.Encourage the patient to perform ROM. d.Assist the patient with comfort measures. D. assist the patient with comfort measures The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more able to move. Pain must be controlled so the patient will not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient? a.Thick, tenacious pulmonary secretions b.Low-molecular-weight heparin doses c.SCDs wrapped around the legs d.Elastic stockings (TED hose) B. low-molecular weight heparin doses Heparin and low-molecular-weight heparin are the most widely used drugs in the prophylaxis of deep vein thrombosis. Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding. Pulmonary secretions that become thick and tenacious are difficult to remove and are a sign of inadequate hydration or developing pneumonia but not of bleeding. SCDs consist of sleeves or stockings made of fabric or plastic that are wrapped around the leg and are secured with Velcro. They decrease venous stasis by increasing venous return through the deep veins of the legs. They do not usually cause bleeding. Elastic stockings also aid in maintaining external pressure on the muscles of the lower extremities and in promoting venous return. They do not usually cause bleeding. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 3. position one nurse at each side of bed 4. place drawsheet under patient from shoulder to thigh 1. grasp the drawsheet firmly near the patients 5. place your feet apart with a forward-backward stance 6. flex knees and hips and on count of three shift weight from the front to back leg 2. move the patient and drawsheet to the desired position The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend? a.High protein, high calorie b.High carbohydrate, low fat c.High vitamin A, high vitamin E d.Fluid restricted, bland A. high protein, high calorie Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-carbohydrate, low-fat diet is not beneficial for an immobilized patient. Vitamins B and C are needed rather than A and E. Fluid restriction can be detrimental to the immobilized patient; this can lead to dehydration. A bland diet is not necessary for immobilized patients The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy? a.After the acute phase of the disease has passed b.As soon as the ability to move is lost c.Once the patient enters the rehab unit d.When the patient requests it B. as soon as the ability to move is lost Passive ROM exercises should begin as soon as the patient’s ability to move the extremity or joint is lost. The nurse should not wait for the acute phase to end. It may be some time before the patient enters the rehab unit or the patient requests it, and contractures could form by then. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which areas will the nurse observe? a.Chin, elbow, hips b.Ileum, clavicle, knees c.Shoulder, anterior iliac spine, ankles d.Occipital region of the head, coccyx, heels B. Ileum, clavicle, knees In the Sims’ position pressure points include the ileum, humerus, clavicle, knees, and ankles. The lateral position pressure points include the ear, shoulder, anterior iliac spine, and ankles. The prone position pressure points include the chin, elbows, female breasts, hips, knees, and toes. Supine position pressure points include the occipital region of the head, vertebrae, coccyx, elbows, and heels. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.) a.Consult a dietitian. b.Increase fiber in the diet. c.Place on chest physiotherapy. d.Increase frequency of turning. e.Place on pressure-relieving mattress. A. consult a dietitian D. Increase frequency of turning E. place on pressure-relieving mattress The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.) a.Footdrop b.Somnolence c.Hypostatic pneumonia d.Impaired skin integrity e.Increased socialization A. footdrop C. hypostatic pneumonia D. impaired skin integrity A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? a.Eccentric tension and isotonic contraction b.Eccentric tension and isometric contraction c.Concentric tension and isotonic contraction d.Concentric tension and isometric contraction A. Eccentric tension and isotonic contraction This movement causes eccentric tension and isotonic contraction. Eccentric tension helps control the speed and direction of movement. For example, when using an overhead trapeze, the patient slowly lowers himself to the bed. The lowering is controlled when the antagonistic muscles lengthen. By pushing on the chair arms and rising eccentric tension and isotonic contraction occurred. In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement such as when a patient uses an overhead trapeze to pull up in bed. Concentric and eccentric muscle actions are necessary for active movement and therefore are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle (e.g., instructing the patient to tighten and relax a muscle group, as in quadriceps set exercises or pelvic floor exercises). A nurse is caring for a patient who has some immobility from noninflammatory joint degeneration. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? a.This will affect synovial fluid. b.This will affect the body systemically. c.This involves mostly non–weight-bearing joints. d.This involves overgrowth of bone at the articular ends. D. this involves overgrowth of bone at the articular ends Joint degeneration, which can occur with inflammatory and noninflammatory disease, is marked by changes in articular cartilage combined with overgrowth of bone at the articular ends. Degenerative changes commonly affect weight-bearing joints. Synovial fluid is normal in noninflammatory diseases. Inflammatory joint disease (e.g., arthritis) is characterized by inflammation or destruction of the synovial membrane and articular cartilage and by systemic signs of inflammation. The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. What is the rationale for the nurse’s action? a.Narrows the nurse’s base of support. b.Allows the nurse to bring feet closer together. c.Prevents a shift in the nurse’s base of support. d.Shifts the nurse’s center of gravity farther away from the base of support. C. Prevents a shift in the nurse's base of support Raising the height of the bed when performing a procedure prevents bending too far at the waist and shifting the base of support. Balance is maintained by proper body alignment and posture through two simple techniques. First, widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support. A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? a.Swimming, jogging, and bicycling b.Tightening or tensing of muscles without moving body parts c.Quadriceps set exercises and contraction of the gluteal muscles d.Push-ups, hip lifting, pushing feet against a footboard on the bed A. swimming, jogging and bicycling Examples of isotonic exercises are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isometric exercises involve tightening or tensing of muscles without moving body parts. Examples include quadriceps set exercises and contraction of the gluteal muscles. Examples of resistive isometric exercises are push-ups and hip lifting, as well as placing a footboard on the foot of the bed for patients to push against with their feet. An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? a.Tendon b.Ligament c.Synergistic muscle d.Antagonistic muscle B. ligament Ligaments are white, shiny, and flexible bands of fibrous tissue that bind joints and connect bones and cartilage. Tendons are strong, flexible, and inelastic as they serve to connect muscle to bone. Muscles attach bone to bone. Synergistic muscles contract to accomplish the same movement. Antagonistic muscles cause movement at the joint. The nurse gives instructions to a nursing assistive personnel (NAP) regarding exercise for a patient. Which action by the NAP indicates a correct understanding of the directions? a.Determines the patient’s ability to exercise b.Teaches the patient how to do the exercises c.Reports the patient got dizzy after exercising d.Advises the patient to work through the pain C. reports the patient got dizzy after exercising The NAP notifies the nurse if a patient reports increased fatigue, dizziness, or light-headedness when obtaining preexercise and/or postexercise vital signs. The nurse first must assess the patient’s ability and tolerance to exercise. The nurse also teaches patients and their families how to implement exercise programs. The NAP can prepare patients for exercise (e.g., putting on shoes and clothing, providing hygiene needs, and obtaining preexercise and postexercise vital signs). The NAP can help the patient exercise. The nurse is evaluating care of a patient for crutches. Which finding indicates a successful outcome? a.The top of the crutch is three to four finger widths from the armpit. b.The elbows are slightly flexed at 30 to 35 degrees when the patient is standing. c.The tip of the crutch is 4 to 6 inches anterior to the front of the patient’s shoes. d.The position of the handgrips allows the axilla to support the patient’s body weight. C. the tip of the crutch is 4 to 6 inches anterior to the front of the patients shoes When crutches are fitted, the tip of the crutch is 4 to 6 inches anterior to the front of the patient’s shoes, and the length of the crutch is two to three finger widths from the axilla. Position the handgrips so the axillae are not supporting the patient’s body weight. Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. Determine correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20 to 25 degrees. The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan? a.Fatigue b.Ineffective coping c.Activity intolerance d.Decreased cardiac output C. activity intolerance You consider nursing diagnoses of Activity intolerance or Fatigue in a patient who reports being tired and weak. Further review of assessed defining characteristics (e.g., abnormal heart rate and verbal report of weakness and the assessment findings occurring during the activity of climbing the stairs) leads to the definitive diagnosis (Activity intolerance). There is no data to support ineffective coping or decreased cardiac output. A patient with diabetes mellitus is starting an exercise program. Which types of exercises will the nurse suggest? a.Low intensity b.Low to moderate intensity c.Moderate to high intensity d.High intensity B. low to moderate intensity Instruct patients diagnosed with diabetes mellitus to perform low- to moderate-intensity exercises, carry a concentrated form of carbohydrates (sugar packets or hard candy), and wear a medical alert bracelet. Low intensity is not beneficial. Moderate to high and high intensity are not recommended for a beginner exercise program. A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? a.Heart rate decreased. b.Contractures developed. c.Muscle strength improved. d.Joint mobility maintained. D. joint mobility maintained A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? a.Blood pressure sitting 120/64; blood pressure 140/70 standing b.Blood pressure sitting 126/64; blood pressure 120/58 standing c.Blood pressure sitting 130/60; blood pressure 110/60 standing d.Blood pressure sitting 140/60; blood pressure 130/54 standing C. blood pressure sitting 130/60; blood pressure 110/60 standing Orthostatic hypotension results in a drop of 20 mm Hg systolic or more in blood pressure when rising from sitting position (110/60). 120 to 140 means the blood pressure increased rather than dropped. 126 to 120 is only a six points’ difference. 140 to 130 is only a 10 points’ difference. The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session? a.Place the cane at the top of the hip bone. b.Place the cane on the stronger side of the body. c.Place the cane in front of the body and then move the good leg. d.Place the cane 10 to 15 inches in front of the body when walking B. place the cane on the stronger side of the body Have the patient keep the cane on the stronger side of the body. A person’s cane length is equal to the distance between the greater trochanter and the floor. The cane should be moved first and then the weaker leg. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is then moved forward to the cane, so body weight is divided between the cane and the stronger leg. A nurse is assisting the patient to perform isometric exercises. Which action will the nurse take? a.Encourage wearing tight shoes. b.Set the pace for the exercise session. c.Stop the exercise if pain is experienced. d.Force muscles or joints to go just beyond resistance C. stop the exercise if pain is experienced Instruct the patient to stop the activity if pain, fatigue, or discomfort is experienced. Assess for pain, shortness of breath, or a change in vital signs; if present, stop the exercise. Let each patient move at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise. Teach patient to wear comfortable shoes and clothing for exercise. The nurse is preparing to transfer an uncooperative patient who does not have upper body strength. Which piece of equipment will be best for the nurses to obtain? a.Drawsheet b.Full body sling c.Overhead trapeze d.Friction-reducing slide sheet B. Full body sling Using a mechanical lift and full body sling to transfer an uncooperative patient who can bear partial weight or a patient who cannot bear weight and is either uncooperative or does not have upper body strength to move from bed to chair prevents musculoskeletal injuries to health care workers. The nurse should not attempt to move the patient with a drawsheet. The patient does not have upper body strength so an overhead trapeze is not appropriate. A friction-reducing slide sheet that minimizes shearing forces is not as effective as a full body sling. The nurse is caring for a group of patients. Which patient will the nurse see first? a.A patient with chronic obstructive pulmonary disease doing stretching exercises b.A patient with diabetes mellitus carrying hard candy while doing exercises c.A patient with a heart attack doing isometric exercises d.A patient with hypertension doing Tai Chi exercises C. a patient with a heart attack doing isometric exercises The nurse must see the myocardial infarction patient first to stop this type of exercise. It is important to understand the energy expenditure (increased respiratory rate and increased work on the heart) associated with isometric exercises because the exercises are sometimes contraindicated in certain patients’ illnesses (e.g., myocardial infarction or chronic obstructive pulmonary disease). All the rest are appropriate. Stretching exercises are beneficial for patients with chronic obstructive pulmonary disease. Also instruct patients to perform low- to moderate-intensity exercises, carry a concentrated form of carbohydrates (sugar packets or hard candy), and wear a medical alert bracelet. The effect of a Tai Chi exercise program has demonstrated a significant reduction in systolic and diastolic blood pressures A nurse is preparing to move a patient who is able to assist. Which principles will the nurse consider when planning for safe patient handling? (Select all that apply.) a.Keep the body’s center of gravity high. b.Face the direction of the movement. c.Keep the base of support narrow. d.Use the under-axilla technique. e.Use proper body mechanics. f.Use arms and legs. B. face direction of movement E. use proper body mechanics F. use arms and legs A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.) a.Skeletal abnormalities b.Emotional factors c.Pregnancy status d.Race e.Age A. skeletal abnormalities B. emotional factors C.pregnancy status E.age A nurse is teaching a patient about medications. Which statement from the patient indicates teaching is effective? a.“My parenteral medication must be taken with food.” b.“I will rotate the sites in my left leg when I give my insulin.” c.“Once I start feeling better, I will stop taking my antibiotic.” d.“If I am 30 minutes late taking my medication, I should skip that dose.” B. I will rate the sites in my left leg when I give my insulin For daily insulin, rotate site within anatomical area. Rotating injections within the same body part (instrasite rotation) provides greater consistency in absorption of medication. Parenteral medication absorption is not affected by the timing of meals. Taking a medication 30 minutes late is within the 60-minute window of the time medications should be taken. Medications are usually stopped based on the provider’s orders except in extenuating circumstances. With some medications, such as antibiotics, it is crucial that the full course of medication is taken to avoid relapse of infection. A nurse is preparing to administer an injection to a patient. Which statement made by the patient is an indication for the nurse to use the Z-track method? a.“I am allergic to many medications.” b.“I’m really afraid that a big needle will hurt.” c.“The last shot like that turned my skin colors.” d.“My legs are too obese for the needle to go through.” C. the last shot like that turned my skin colors The Z-track is indicated when the medication being administered has the potential to irritate sensitive tissues. It is recommended that, when administering IM injections, the Z-track method be used to minimize local skin irritation by sealing the medication in muscle tissue. The Z-track method is not meant to reduce discomfort from the procedure. If a patient is allergic to a medication, it should not be administered. If a patient has additional subcutaneous tissue to go through, a needle of a different size may be selected. A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take? a.Pull the auricle down and back to straighten the ear canal. b.Pull the auricle upward and outward to straighten the ear canal. c.Sit the child up for 2 to 3 minutes after instilling drops in ear canal. d.Sit the child up to insert the cotton ball into the innermost ear canal. A. pull the auricle down and back to straighten the ear canal Children up to 3 years of age should have the auricle pulled down and back, children 3 years of age to adults should have the auricle pulled upward and outward. Solution should be instilled 1 cm (1/2 in) above the opening of the ear canal. The patient should remain in the side-lying position 2 to 3 minutes. If a cotton ball is needed, place it into the outermost part of the ear canal. A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe will the nurse obtain to administer the medication? a.3-mL syringe b.U-100 syringe c.Needleless syringe d.Tuberculin syringe D. tuberculin syringe Because there is no syringe currently designed to prepare U-500 insulin, many medication errors result with this kind of insulin. To prevent errors, ensure that the order for U-500 specifies units and volume (e.g., 150 units, 0.3 mL of U-500 insulin), and use tuberculin syringes to draw up the doses. A 3 mL and U-100 can result in inaccurate dosing. A needleless syringe will not be acceptable in this situation. A patient has an order to receive 12.5 mg of hydrochlorothiazide. The nurse has on hand a 25 mg tablet of hydrochlorothiazide. How many tablet(s) will the nurse administer? a.1/2 tablet b.1 tablet c.1 1/2 tablets d.2 tablets The patient is to receive phenytoin (Dilantin) at 0900. When will be the ideal time for the nurse to schedule a trough level? a.0800 b.0830 c.0900 d.0930 B. 0830 Trough levels are generally drawn 30 minutes before the drug is administered. If the medication is administered at 0900, the trough should be drawn at 0830. A patient is receiving vancomycin. Which function is the priority for the nurses to assess? a.Vision b.Hearing c.Heart tones d.Bowel sounds B. hearing A side effect of vancomycin is ototoxicity—hearing. It does not affect vision, heart tones, or bowel sounds. A health care provider orders lorazepam (Ativan) 1 mg orally 2 times a day. The dose available is 0.5 mg per tablet. How many tablet(s) will the nurse administer for each dose? a.1 b.2 c.3 d.4 B. 2 The nurse will give 2 tablets. It will take 2 tablets (0.5) to equal 1 mg OR ordered dose (1) over dose on hand (0.5). 1/0.5 = 2 tablets. The nurse is preparing to administer an injection into the deltoid muscle of an adult patient. Which needle size and length will the nurse choose? a.18 gauge × 1 1/2 inch b.23 gauge × 1/2 inch c.25 gauge × 1 inch d.27 gauge × 5/8 inch C. 25 gauge x 1 in For an intramuscular injection into an adult deltoid muscle, a 25-gauge, 1-inch needle is recommended. An 18-gauge needle is too big. While a 23-gauge needle can be used, a 1/2-inch needle is too small. A 27-gauge, 5/8 -inch needle is used for intradermal. When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the rationale for the nurse aspirating? a.Prevent the patient from choking. b.Increase the force of the injection. c.Ensure proper placement of the needle. d.Reduce the discomfort of the injection. C. ensure proper placement of the needle The purpose of aspiration is to ensure that the needle is in the muscle and not in the vascular system. Blood return upon aspiration indicates improper placement, and the injection should not be given. While a patient can aspirate fluid and food into the lungs, this is not related to the reason for why a nurse pulls back the syringe plunger after inserting the needle (aspirates) before injecting the medication. Reducing discomfort and prolonging absorption time are not reasons for aspirating medications. |
Which information would the nurse include in an educational session for a group of nurses regarding
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