Term
3 When you conduct a scientific literature review, your aim is to gather articles about studies that involved scientific rigor. Order the sources of scientific evidence, beginning with the most rigorous. Use all options.
a Single descriptive study
b Controlled trial without randomization
c Systematic review
d Case control study
e One randomized controlled trial
f Systematic review of qualitative study |
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Definition
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Term
4 A committee of nurses have collected a set of six articles about approaches for preventing falls. They have read each article, reviewed the relevance of the articles to their practice, and discussed the strength of evidence available. This is an example of which step of evidence-based practice?
1 Ask a clinical question.
2 Collect the most relevant and best evidence.
3 Critically appraise the evidence you gather.
4 Apply the evidence along with your clinical expertise, patient preferences, and values. |
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Definition
| 3; Rationale: Evidence review and critique determine if the evidence is strong enough to eventually apply in practice. |
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Term
5 A group of staff nurses are meeting to discuss evidence-based practice issues. Which of the following clinical questions is an example of a knowledge-focused trigger?
1 The unit has seen an increased rate of falls, and staff wonder if it is related to patients receiving opioid analgesics.
2 The nurses on the unit have seen an increase in wound infections.
3 The nurses anticipate that physicians will be using more local anesthesia for surgical procedures.
4 During the last 3 months the unit has had more medication errors. |
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Definition
| 3; Rationale: The nurses seek scientific information about local anesthesia as an opportunity to build knowledge about a new procedure. |
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Term
6 When attempting to identify a PICO question, what are the limitations of asking a background question? Select all that apply.
1 The background question will lead you to too many articles to read.
2 The background question will limit your search to only systematic review articles.
3 The background question will lead you to a set of articles on diverse topics.
4 The background question limits the focus of your search. |
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Definition
| 1 and 3; Rationale: Background questions are broad and less focused than a foreground or PICO question; thus they often lead to too many articles to read on diverse topics not relevant to your question. |
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Term
7 Nurses on an evidence-based practice committee find an article that describes a research study that examined nurses’ perceptions of communication with physicians. This is an example of which of the following type of studies?
1 Descriptive study
2 Case control study
3 Randomized controlled trial
4 Systematic review |
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Definition
| 1; Rationale: A descriptive study describes phenomena, in this case perceptions of nurses. It usually involves analysis of surveys, interviews, or questionnaires. |
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Term
8 Which of the following are characteristics of a randomized controlled trial research study? Select all that apply.
1 The study examines the subjective context in which persons’ experiences occur.
2 The study includes two groups, both measured on the same outcomes, to see if there are differences.
3 The study tests a new intervention against the usual standard of care.
4 The study examines subjects with a certain condition at the same time as another group of subjects who do not have the condition. |
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Definition
| 2, 3; Rationale: Randomized trials are experimental studies involving a control and experimental (intervention) group. Both the control and intervention groups are measured by the same outcomes to determine if the intervention was more effective than the control. |
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Term
9 When reading a scientific article, what information will the nurse learn after reading the literature review or background section?
1 A discussion about what led the author to conduct a study or report on a clinical topic
2 Information about the purpose of the article and the importance of the topic for the audience who reads it
3 Identification of the concepts that will be researched
4 Explanation of whether a hypothesis is correct or how a research question is answered |
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Definition
| 1; Rationale: The literature review summarizes available literature on the researcher's topic of interest. A good review explains why the author decided to study or report on a topic, usually because of a gap in the literature. |
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Term
1 A nurse manager reviews the nurses’ notes in a patient's medical record and finds the following entry, “Patient is difficult to care for, refuses suggestions for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note?
1 Avoid rushing when charting an entry.
2 Use correction fluid to correct a mistake.
3 Enter only objective and factual information about the patient.
4 Use a black marker to cover over the mistaken entry. |
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Definition
| 3; Rationale: Nurses should document only factual and objective information and not express opinions or assumptions in the medical record. |
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Term
2 The nurse observes the patient quickly pacing back and forth in the room and asks the patient what is wrong. The patient states, “I don't know what is going to happen to me. I am afraid I will be put in a nursing home.” How does the nurse document this interaction with the patient?
1 “Patient observed to be agitated and confused.”
2 “The patient appears to be anxious.”
3 “The patient is disoriented and paranoid.”
4 “The patient stated, ‘I don't know what is going to happen to me.’” |
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Definition
| 4; Rationale: The nurse should quote what the patient states if it is relevant and appropriate to nursing care. |
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Term
3 The nurse is caring for a patient over a 12-hour shift. She conducts her routine assessment at the beginning of the shift and assists the patient to the bathroom to void. During that time the nurse administers medications at 0900 and at 1500. At 1400 the patient receives 1 unit of packed red blood cells (PRBCs) intravenously. At 1530 the physical therapist visits with the patient to discuss discharge. Which of the activities performed by the nurse should be recorded immediately? Select all that apply.
1 Visit by the physical therapist
2 Medication administration
3 Urine output
4 Patient's ability to ambulate to bathroom
5 Administration of blood product |
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Definition
| 2, 5; Rationale: Administration of any treatments should be documented as soon as possible after administration. The other activities should be included in routine charting either periodically during the shift or at end of shift. |
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Term
4 Match the correct entry with the appropriate SOAP category
1 Repositioned patient on right side
2 “The pain increases every time I turn on my left side.”
3 Acute pain related to surgical incision
4 Left lower surgical incision sutures intact; no drainage noted |
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Definition
| 2 matches S: ‘The pain increases every time I turn on my left side.” Rationale: This is subjective data. 4 matches O: Left lower surgical incision sutures intact, no drainage noted. Rationale: This is objective data. 3 matches A: Acute pain related to surgical incision. Rationale: This is the assessment of the situation. 1 matches P: Repositioned patient on right side. This is the plan of care. |
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Term
| 5 List two ways that the nurse as caregiver can maintain confidentiality of patient data when using electronic medical record keeping. |
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Definition
Examples:
• Never share passwords and keep own password private.
• Delete documentation mistakes from the record using agency protocol.
• Do not leave patient information on the monitor where others can view. |
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Term
6 Which of the following information is included in an occurrence report? Select all that apply.
1 Information about the person involved in the incident
2 Data from individuals who witnessed the event
3 Information received from nurses from another unit
4 Your opinion of what happened and how the incident could have been prevented |
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Definition
| 1, 2; Rationale: When completing an incident report, information specific to the individual involved in the incident and information from witnesses, if any, should be included. Data that are hearsay or the nurse's opinions about the incident should not be included. |
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Term
7 According to HIPAA regulations, patients do not have the right to access their medical records.
True/False |
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Definition
| False; Rationale: HIPAA provides patients with the right to review their medical records. Patients have to follow protocols established by the institution. |
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Term
8 Military time is frequently used to document care. A patient was ambulated in the hall at 5:30 PM. What time would it be if documented according to military time?
1 0530
2 1530
3 1730
4 1630 |
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Definition
| 3; Rationale: 0530 is equivalent to 5:30 AM; 1530 is equivalent to 3:30 PM; and 1630 is equivalent to 4:30 PM. |
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Term
9 Which of the following is/are an example(s) of objective data? Select all that apply.
1 “The skin is warm to the touch.”
2 “Patient is demanding.”
3 “The patient reports having abdominal cramping.”
4 “The patient is wringing her hands while pacing in the room.” |
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Definition
| 1, 4; Rationale: Objective data are those that are observed. To say that the patient is demanding is neither objective nor subjective data, but the writer's opinion. When the patient reports feelings, it is subjective data. |
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Term
10 Which of the following information would not be included in a patient's record?
1 Patient's report of pain not relieved by analgesic medication
2 Assessment of patient's surgical wound
3 Incident report filed after patient fell out of bed
4 Patient's response to a PRN medication |
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Definition
| 3; Rationale: When an incident report is completed, the nurse does not document in the chart that the incident report was completed. |
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Term
1 Which of the following is the best approach to prevent removal of Mrs. Smith's IV line?
1 Obtain a health care provider's order for a restraint.
2 Place a tethered mitten on the hand opposite the extremity with the IV line.
3 Camouflage the IV site with a stockinette.
4 Place a soft wrist restraint on the extremity opposite the extremity with the IV line. |
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Definition
| 3; Rationale: Because the goal is to maintain the least restrictive environment, restraint alternatives must be tried before deciding to restrain the patient. A restraint alternative does not require a physician's order. It must be something that the patient is cognitively and physically able to remove on her own. |
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Term
2 Mrs. Smith becomes agitated and keeps trying to get out of bed. The nurse assesses her risk for fall. Which of the following factors increase her risk for fall? Select all that apply.
1 Her age
2 Multiple medications
3 Patient care equipment
4 History of pneumonia
5 Altered cognition |
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Definition
| 1, 2, 3, 5; Rationale: Evidence has shown that being on four or more medications, advancing age, patient care equipment, and altered cognition are independent factors that increase the risk for fall. |
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Term
3 The nurse's co-worker is standing in some spilled water holding the refrigerator door. He is being electrocuted. What is the first thing that the nurse is going to do?
1 Take his vital signs.
2 Call the rapid response team.
3 Unplug the refrigerator.
4 Wipe up the water from the floor. |
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Definition
| 3; Rationale: It is important to eliminate the electric current. Unplug the refrigerator without stepping in the water or touching your co-worker. Call the rapid response team after you have unplugged it or if you are unable to unplug it. Do not wipe up the water or take his vital signs until after the refrigerator is unplugged. |
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Term
4 The nurse enters a patient's room to find him actively seizing. What is the nurse's primary responsibility?
1 Insert an airway.
2 Call the physician.
3 Protect the patient from harm.
4 Put up the side rails. |
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Definition
| 3; Rationale: The nurse's first responsibility is to protect the patient from harm. Different interventions may be needed, depending on what is occurring, and may include putting up the side rails. |
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Term
5 The nurse is asked to participate in a root cause analysis related to a serious medical error that occurred on her nursing unit. Why should the nurse be pleased to participate in this project?
1 The nurse gets off of the division for several hours.
2 This is a problem-solving approach to preventing future similar errors.
3 The nurse wants to be sure that the person who committed the error is punished.
4 It will provide the nurse with a chance to network. |
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Definition
| 2; Rationale: The purpose of a root cause analysis is to investigate the cause of an error without placing blame or relieving accountability. It is a systematic process with the goal of preventing future similar errors. |
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Term
6 The nurse is giving Mr. Jones his morning medications. When she says, “Here is your warfarin,” he responds, “I don't take warfarin.” Which response is best in this situation?
1 Tell him the doctor ordered it for him and he should take it.
2 Tell him that he probably calls it by a different name at home.
3 Ignore him because he doesn't understand his medications.
4 Hold the medication until the nurse is able to verify that the patient should take it. |
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Definition
| 4; Rationale: The registered nurse has a responsibility to listen to patient concerns. Many patients are very aware of their medications. Do not give the medication without verifying that he is indeed supposed to receive it. |
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Term
7 Mr. Macalister threw his cigarette in the trash as the nurse walked into his room. Now the trash is smoldering. What is the first thing that the nurse should do?
1 Activate the fire alarm.
2 Contain the fire with a blanket.
3 Move Mr. Macalister into the hall.
4 Tell Mr. Macalister that he cannot smoke in the hospital. |
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Definition
| 3; Rationale: Using the acronym RACE, the nurse would remove Mr. Macalister from the room. Although the steps are not necessarily always sequential, it is important to remove the patient from harm first. |
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Term
8 The nurse is rounding on a patient with wrist restraints. It has been 2 hours since the last rounds for this patient. Which of the following will she do? Select all that apply.
1 Release the restraints for range of motion (ROM).
2 Assess the extremity for perfusion and skin integrity.
3 Offer toileting.
4 Offer a drink of water. |
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Definition
| 1, 2, 3, 4; Rationale: All of these interventions are important for the patient in restraints. Without ROM, the patient may rapidly decondition. Restraints can restrict circulation and lead to skin breakdown. Therefore these assessments must be made at least every 2 hours. Toileting and hydration are basic human needs that a restrained person cannot provide for himself. All of these interventions also show respect for the patient. |
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Term
9 Mrs. Jones tends to wander. Sometimes she forgets where she is. She likes to go down the stairs and outside. What can the nurse do to avoid restraining her? Select all that apply.
1 Schedule walks into her day.
2 Offer a diversional activity.
3 Move her to a room close to the nurses’ station.
4 Notify the police that she may be found wandering outside. |
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Definition
| 1, 2, 3; Rationale: Planned activities such as walks or other activities can decrease wandering. Keeping a patient near the nurses’ station where her activities can be watched more closely is also helpful. |
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Term
1 A nurse enters the room of a patient who has been diagnosed with pneumonia. The nurse instructs the patient to cover the mouth when coughing. This will reduce transmission of infection by:
1 Contact
2 Small droplet nuclei
3 Vector
4 Splashing |
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Definition
| 2; Rationale: Small droplets cannot be transmitted when there is a barrier such as a hand or tissue in place. This reduces the risk of transmission of infection. |
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Term
2 Put the following steps in order for removal of protective barriers, after leaving an isolation room:
1 Untie bottom mask strings.
2 Untie waist and neck strings of gown. Allow gown to fall from shoulders.
3 Remove gloves.
4 Remove eyewear or goggles.
5 Untie top mask strings.
6 Remove hands from gown sleeves without touching outside of gown; hold gown inside at shoulder seams, fold inside out, and then discard.
7 Pull mask away from face and drop into container. |
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Definition
| 3, 4, 2, 6, 5, 1, 7; Rationale: This sequence ensures that the risk of contaminating any other surfaces or health care personnel is reduced. |
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Term
3 Identify all of the following that classify as a case of a health care–associated infection:
1 An infected bedsore on a patient admitted from a nursing home
2 A urinary tract infection that develops after a Foley catheter placement
3 A patient tested as human immunodeficiency virus positive
4 The development of purulent drainage exiting from a central venous catheter insertion site
5 A Staphylococcus infection that develops in an incisional wound |
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Definition
| 2, 4, 5; Rationale: No. 1 has happened outside of the hospital, and No. 3 is not acquiring a problem but just testing for that problem. All other answers are acquired in a hospital setting. |
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Term
4 When a nurse applies clean gloves when collecting a urine specimen, how does this technique break the chain of infection?
1 Blocks the portal of entry of a microorganism
2 Reduces susceptibility of the host
3 Controls a reservoir source of organism growth
4 Blocks the portal of exit |
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Definition
| 4; Rationale: Gloves protect health care personnel from contamination with body fluids, which is a method of blocking the portal of exit from the patient. |
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Term
5 Which of the following breaks the chain of infection by controlling the reservoir source of microorganism growth?
1 Changing a soiled dressing
2 Cleaning a wound site
3 Avoiding sneezing
4 Disposing of used needles in a puncture-proof container |
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Definition
| 1; Rationale: A dressing serves as a source of a reservoir for microorganisms. Changing dressings reduces the risk of bacterial growth. |
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Term
6 Place an “S” next to the procedures requiring sterile (aseptic) technique and place an “M” next to those requiring only medical aseptic technique.
1 Urinary catheterization
2 Tracheal suctioning
3 Insertion of rectal suppository
4 Insertion of a feeding tube
5 Lumbar puncture
6 Sitz bath |
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Definition
| 1: S, 2: S, 3: M, 4: M, 5: S, 6: M; Rationale: Nos. 1, 2 and 5 all require sterile technique because of the high risk of bacterial entrance into sterile body cavities through the urethra, trachea, or central nervous system. |
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Term
7 The nurse has applied the first sterile glove on her right hand (dominant) without touching the sterile outer surface. She takes her gloved right hand and picks up the remaining glove at the top of the cuff and slips it over her left hand. Which of the following statements is correct?
1 The first glove is applied correctly but is contaminated while applying the second glove.
2 The first glove is applied incorrectly, but the second glove is applied correctly.
3 The first glove is applied correctly, and the second glove becomes contaminated.
4 Both gloves have been applied correctly. |
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Definition
| 1; Rationale: The second glove was picked up incorrectly. The nurse should have picked up the second one under the cuff, not at the top of the cuff. |
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Term
8 When opening a sterile pack, which of the following compromises the sterility of the contents?
1 Keeping the contents of the pack away from the table edge
2 Holding or moving the object below the waist
3 Opening the pack just before the procedure
4 Allowing movement around the sterile field that does not touch near the sterile field |
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Definition
| 2; Rationale: To maintain a sterile field, objects must be maintained and handled above the waist. |
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Term
9 Select all of the following persons who are at risk for a latex allergy:
1 A patient who has had a surgical procedure
2 A health care worker who works in the operating room
3 A patient who reports frequent nausea and diarrhea after eating peaches
4 A patient who develops hives after the taping of his surgical dressing
5 A health care worker who comes to work with coughing and respiratory congestion |
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Definition
| 2, 3, 4; Rationale: Reactions to latex-containing products such as gloves and food reactions such as peaches and kiwis place patients at high risk for developing latex reactions. |
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Term
10 In setting up a sterile field, which of the listed actions would require intervention?
1 The first flap of the sterile package is opened toward the nurse.
2 The glove for the dominant hand is pulled on first.
3 The sterile drape is allowed to unfold, keeping it above the waist.
4 The bottle of solution is poured with the label facing up. |
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Definition
| 1; Rationale: The first flap in a sterile field is opened away from, not toward, the nurse. |
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Term
5 Mrs. Malone is admitted with pneumonia. Her vital signs are: BP 112/64 mm Hg, HR 102, RR 26, tympanic temperature 37.9° C (100.2° F). What vital sign requires immediate attention?
1 Heart rate
2 Pulse pressure
3 Respiratory rate
4 Temperature |
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Definition
| 3; Rationale: The blood pressure and heart rate are acceptable for a patient with a fever. The respiratory rate reflects complications of pneumonia, and interventions are needed. |
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Term
6 Mr. Amenta is a 62-year-old retired accountant who arrives at the outpatient clinic complaining of a headache. His BP is 170/88 mm Hg in the right arm and 188/92 mm Hg in the left arm. He reports that he ran out of blood pressure medication last week and has not been able to afford to refill the prescription. What is the nurse's priority nursing action?
1 Allow the patient to relax for 15 minutes and reevaluate the blood pressure measurements.
2 Contact the social worker for financial assistance.
3 Notify the physician.
4 Retake the blood pressure in the left arm with a different-size cuff. |
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Definition
| 3; Rationale: The associated symptoms of hypertension (e.g., headache) support the blood pressure measurements, making repeating the blood pressure values unnecessary. Although the social worker should be contacted, the physician needs to be notified to treat the hypertension. |
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Term
7 Mr. Meyer is a 69-year-old retired pilot who arrives at the pacemaker clinic for his routine visit. He has had a pacemaker for the past 10 years for a slow heart rate. The NAP reports that, when she obtained his vital signs, his right radial pulse was irregular and his rate was 52. His other vital signs are within normal limits. What action should the nurse take?
1 Direct the NAP to obtain the left radial pulse rate.
2 Assess for a pulse deficit with the NAP.
3 Obtain an apical pulse.
4 Notify the nurse in charge. |
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Definition
| 3; Rationale: An irregular pulse rate should be verified by assessing the apical pulse. If there are still irregularities, a pulse deficit assessment is indicated. |
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Term
8 During report the nurse obtains information on Mrs. Gardner, a 98-year-old patient who has terminal lung cancer and is admitted for palliative care. The nurse describes her breathing as labored, with periods of apnea alternating with deep breathes. The NAP reports her RR as 12. After the nurse's assessment confirms these findings, she describes this pattern as:
1 Kussmaul's respirations
2 Cheyne-Stokes respirations
3 Agonal respirations
4 Hypoventilation |
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Definition
| 2; Rationale: Cheyne-Stokes is a pattern of apnea and hyperventilation. The respiratory rate of 12 was counted with the apneic phase. |
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Term
9 The NAP obtains a blood pressure of 188/70 when taking frequent vital signs on a postoperative patient. She appropriately notifies the nurse of the value, and the nurse checks the patient. The electronic blood pressure machine reads 112/80, and the patient is awake and alert and offers no complaints. How does the nurse explain the difference in values?
1 The patient flexed her arm when the machine was inflating during the initial assessment.
2 The blood pressure cuff is too loose.
3 The blood pressure cuff is too large.
4 The patient's blood pressure is very sensitive. |
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Definition
| 1; Rationale: Nos. 2 and 3 create a false low blood pressure. A blood pressure does not fluctuate with an asymptomatic patient. Flexing increases resistance to flow. |
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Term
10 Mr. Ryan is admitted to the nurse's unit for observation following a motorcycle accident. He broke his left arm and right leg, both of which are in casts. An IV line is infusing in his right hand. Mr. Ryan complains that his left hand is cool. Which finding would indicate the need for further assessment?
1 Tympanic temperature of 36.2° C (97.2° F)
2 Apical pulse rate of 92
3 Blood pressure R arm 118/84
4 L radial pulse 1+ strength |
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Definition
| 4; Rationale: Decreased pulse strength on affected side may indicate vascular compromise. |
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Term
| 1 The nurse's postoperative patient has an intravenous infusion, an abdominal dressing, a Foley catheter to gravity, and a Jackson-Pratt drain in place. What body systems would she assess for this patient? Describe key elements for this patient. |
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Definition
Focused assessments would include cardiovascular and peripheral neurovascular, respiratory, abdominal and perineal, I&O. Key elements of each system:
a Cardiovascular: Blood pressure; heart rate; inspection, palpation, and auscultation of the heart
b Peripheral neurovascular: Inspection and palpation of the extremities; checking peripheral pulses, edema, skin color and temperature, capillary refill; sensation and movement
c Respiratory: Checking rate and depth of respirations, chest excursion, and lung sounds
d Abdominal: Checking size and shape of abdomen, palpation of bladder, assessing bowel sounds, assessing dressing
e I&O: Intake, output (Foley, Jackson-Pratt drain) |
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Term
| 2 The nurse auscultates her postoperative patient's abdomen. After listening for 60 seconds at a site below and to the left of the umbilicus, the nurse is unable to hear bowel sounds. What is the best assessment of this situation? |
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Definition
| You must listen for 5 minutes over each quadrant before deciding that bowel sounds are absent. It is common for bowel sounds to be hypoactive for 24 hours or more following abdominal surgery. |
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Term
3 In conducting a general survey of a patient, the nurse knows that the survey should include which of the following? Select all that apply.
1 Appearance
2 Obtaining peripheral pulses
3 Measuring chest excursion
4 Conducting a detailed history
5 Behavior
6 Pupillary response
7 Posture |
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Definition
| 1 and 5; Rationale: The general survey includes assessment of vital signs, height and weight, general behavior, and appearance. |
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Term
4 In teaching a patient about skin lesions, the nurse knows that teaching has been successful when the patient identifies which lesion as abnormal?
1 A symmetrical lesion
2 A lesion with regular edges and borders
3 One that is blue/black or varied in color
4 One that is less than 7 mm in diameter |
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Definition
| 3; Rationale: A lesion colored blue/black or variegated, nonuniform pigmentation or variations/multiple colors (tan, black) with areas of pink, white, gray, blue, or red may indicate a melanoma. |
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Term
5 On respiratory assessment the nurse notes high-pitched, musical sounds on auscultation. The nurse interprets these sounds as:
1 Normal; vesicular
2 Rhonchi
3 Crackles
4 Wheezes |
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Definition
| 4; Rationale: Crackles sound like crushing cellophane; rhonchi sound like blowing air through fluid with a straw. |
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Term
6 The nurse determines that the patient has an audible S2 on auscultation during cardiovascular assessment. After documenting this finding, the nurse should:
1 Reposition the patient for comfort.
2 Report the finding to the health care provider.
3 Initiate fluid restriction.
4 Do nothing as this is a normal finding. |
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Definition
| 4; Rationale: S1 and S2 are normal components of the cardiac cycle and an expected physical assessment finding. |
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Term
7 Place the following components of the abdominal assessment in the correct order:
1 Palpation
2 Inspection
3 Auscultation
4 Percussion |
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Definition
| Correct order is 2, 3, 4, 1; Rationale: Percussion and palpation are completed after inspection and auscultation because of the risk for causing increased bowel sounds that could be interpreted as an abnormal finding. |
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Term
8 The patient has an IV infusing in the left arm. The skin looks reddened at the site. Which of the following techniques is most appropriate for the nurse to use to check if there is warmth at the site?
1 Places palm of hand over site
2 Grasps skin at site with fingers
3 Applies dorsum of hand over site
4 Places pads of fingertips above site |
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Definition
| 3; Rationale: The dorsum of the hand is most sensitive to temperature variations. |
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Term
9 Which of the following does the nurse document as an abnormal finding during a muscular-neurological assessment?
1 Pupils equal, round, and reactive to light and accommodation
2 Uses hands to sit down in chair during Get Up and Go Test
3 Negative Romberg's test
4 Uvula rises symmetrically |
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Definition
| 2; Rationale: In a normal Get Up and Go Test, a patient does not use the arms to sit up from a chair or to sit back down. |
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Term
| 10 Calculate the patient's intake in milliliters based on the following fluids: 3 ounces of apple juice, carton of milk (250 mL per carton), 6 ounces of soda, and an 8-ounce cup of ice. |
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Definition
| Total 352 mL intake (3 ounces apples juice = 90 mL; carton milk = 63 mL; 6 ounces soda = 180 mL; and 8 ounces of ice ( volume) = 120 mL). |
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Term
1 The nurse calls the physician and receives an order for a urine culture and sensitivity (C&S). The nurse takes the urine sample from the needleless port of the catheter. Place the following steps in correct order for obtaining a sterile urine specimen: (a) Withdraw 3 to 5 mL of urine and, using sterile technique, instill into a sterile urine container. (b) Perform hand hygiene and apply gloves. (c) Attach completed requisition and immediately send to the laboratory. (d) Wipe needleless port with antiseptic wipe and attach 3-mL Luer-Lok syringe. (e) Attach label to sterile urine container and double bag.
1 d, b, a, c, e
2 b, d, c, a, e
3 d, b, c, e, a
4 b, d, a, e, c |
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Definition
| 1 4; Rationale: Performing procedure using appropriate steps minimizes contamination of the specimen, increases efficiency, and allows timely delivery to the laboratory. |
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Term
2 Which of the following indicates that Mrs. Sanchez understands the importance of having a C&S test done on her mother's urine?
1 “The C&S test is not necessary if her diabetes is under control.”
2 “She always gets the same medication for her urine infections; so she doesn't need a test.”
3 “The C&S test is important so the doctor can order the correct medication for the kind of bacteria in the urine.”
4 “The C&S test is only necessary when she has a catheter.” |
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Definition
| 2 3; Rationale: Indicates understanding that a culture is for identification of the pathogenic microorganism and sensitivity identifies medications that are active against the microorganism. |
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Term
3 Mrs. Murphy, newly diagnosed with diabetes, performs her blood glucose test before meals and at bedtime. She tells the nurse that her fingers are getting sore and she has trouble getting a droplet of blood large enough for testing. Which of the following interventions would be most appropriate for the nurse?
1 Instruct her to use the forearm for a blood droplet.
2 Apply pressure to the puncture site for at least 1 minute before a puncture.
3 Cleanse site with warm water and allow to dry.
4 Place the lancet firmly against the site to ensure an appropriate depth of puncture. |
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Definition
| 1; Rationale: The forearm is an appropriate alternate site, especially if blood sugars are not changing. The patient is having a routine check. Applying pressure to the puncture site might cause an abnormal reading because of the changes of cellular metabolism. Warm water increases blood flow to the area but does not address patient's discomfort. Placing the lancet firmly against the skin is not likely to reduce pain in fingers. |
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4 Which is the preferred vein for venipuncture for phlebotomy?
1 The antecubital vein, which is less painful
2 The basilic vein, which is straight
3 The cephalic vein, which is in the hand and well anchored
4 The median cubital vein, which is larger and closer to the surface |
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Definition
| 4; Rationale: The median cubital vein is easier to puncture and less likely to rupture. The basilic and cephalic veins of the lower arm and hand are preferred for administering IV fluids. The antecubital vein is often less visible. |
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5 One of the unexpected outcomes of collection of a nasal culture is nasal bleeding. Which of the following interventions would be most appropriate if it occurs?
1 Provide analgesia as ordered.
2 Administer antibiotics as ordered.
3 Perform nasal suctioning of involved naris.
4 Apply pressure and ice over bridge of nose. |
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Definition
| 4; Rationale: Pressure controls bleeding and allows for clot formation. Ice decreases circulation to area. Analgesia medication is for pain relief, not nasal bleeding. Antibiotic is used for an infection, not nasal bleeding. Hemoccult testing is used for assessment of stool for blood. |
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6 The laboratory results for a wound specimen indicated contamination with superficial skin cells. Which of the following actions would the nurse take?
1 Begin antibiotic therapy.
2 Monitor patient.
3 Perform repeat wound specimen collection.
4 Clean wound with sterile water. |
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Definition
| 3; Rationale: A repeat wound specimen is necessary to correctly identify pathogenic organism. Antibiotic therapy begins after results from the specimen. Monitoring a patient is not indicated as a result of specimen contamination. Water would cause drying of the wound. |
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7 Mrs. Henderson started on a 24-hour urine collection at 0800. At 1200 the nurse notes that the hat for collection of urine is on the floor in the bathroom and empty. Questioning indicates that the patient has been voiding in the toilet and flushing. Which is the nurse's most appropriate initial intervention?
1 Assess Mrs. Henderson's understanding of a 24-hour urine collection.
2 Continue to collect urine for the remainder of the 24 hours.
3 Stop the procedure and restart urine collections.
4 Have patient drink at least one glass of water every hour. |
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Definition
| 1; Rationale: Assessing Mrs. Henderson's understanding would allow reinforcement of the information and determine what action the nurse may need to take to ensure that all urine is collected for 24 hours. All urine needs to be collected for a full 24-hour period; not including urine results in an inaccurate report. Restarting the procedure is necessary, but the nurse must first determine the patient's ability to collect the specimen. Drinking water would be helpful for voiding but would not influence the patient's ability to collect the specimen. |
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8 This is the third admission for Mr. Burger in 4 months for hyperglycemia. He has insulin-dependent diabetes and has been instructed to perform fingersticks before each meal and at bedtime. Which statement indicates that Mr. Burger understands and does not need further teaching? Select all that apply.
1 “My sight is poor; so I need to have my son Jeff to help me read the meter.”
2 “My friend Stan said I should do like he does and only poke my finger in the morning to save money.”
3 “I need to be sure that I take my blood sugar before I eat and before bed.”
4 “I take the same amount of insulin every morning but still need to do the fingerstick.” |
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Definition
| 1, 3, 4; Rationale: The patient's blood sugar remains uncontrolled. To control his diabetes it is important for him to understand the need to be consistent and follow his personal regimen for blood sugars. |
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9 The nurse plans to collect a blood specimen. After placing the tourniquet above the elbow, she palpates absence of the radial pulse. Which nursing intervention should be first?
1 Remove the tourniquet impeding venous blood flow, wait 60 minutes, and then reapply.
2 Continue performing the phlebotomy; the blood specimen is from the venous system.
3 Remove the tourniquet to allow arterial blood flow to return, wait 60 seconds, and then reapply the tourniquet.
4 Palpate for the brachial pulse above the tourniquet. |
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Definition
| 3; Rationale: The absence of the radial pulse indicates absence of arterial blood flow, which can cause injury to the patient. Blood returns to the arterial system immediately, and in 60 seconds flow is normal. |
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Term
Mr. Kline is an 80-year-old patient with a history of heart failure and diabetes. He was admitted to the hospital because of increasing shortness of breath, especially on exertion. He has had diabetes for 30 years, and recently his blood glucose levels have been out of control. He had all of his teeth pulled recently and now wears dentures.
1 Place the following steps for assisting a patient with denture care in the order in which they should be performed.
a Rinse dentures thoroughly in tepid water
b Perform hand hygiene and don clean gloves; remove upper denture plate by applying gentle downward pressure with 4 × 4–inch gauze.
c Hold dentures over emesis basin or sink lined with washcloth and containing 1 inch of water.
d Gently lift lower denture from jaw and rotate one side downward to remove from patient's mouth.
e Ask patient about preferences for denture care and products used.
f Apply cleaning agent to brush and brush surfaces of dentures.
g Store dentures in a denture cup with patient's identification label.
1 b, d, e, a, c, f, g
2 e, b, d, c, f, a, g
3 d, b, a, e, f, c, g
4 g, e, b, d, c, a, f |
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Definition
| 2; Rationale: It is important to ask patient preferences before beginning procedure so the nurse knows what supplies to gather. Perform hand hygiene and don gloves before removing dentures. After upper and lower dentures are removed, hold dentures over emesis basin or lined sink to protect them in event they are dropped before brushing the dentures. Storing dentures would be the last step. |
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2 Mr. Kline states that he is feeling uncomfortable and wants a bath. Which type of bath would be most appropriate at this time?
1 Complete bath
2 Partial bath
3 Tub bath
4 Shower |
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Definition
| 2; Rationale: Mr. Kline becomes short of breath with any exertion. It would be best at this time to give a partial bath. A complete bath requires more time and movement. Tub bath and shower require more exertion and would not be appropriate at this time. |
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3 Which of the following actions are appropriate steps when making an unoccupied bed? Select all that apply.
1 Raise bed to working height.
2 Wear gloves at all times.
3 Apply all bottom linen on one side of bed before moving to opposite side.
4 Remove soiled linen and place on the floor.
5 Tuck top sheet and spread in at bottom of bed using a modified mitered corner.
6 Keep top covers at head of bed when procedure is completed.
7 Make horizontal toe pleat with all top layers of linen. |
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Definition
| 1, 3, 5, 7; Rationale: To be safe, the bed must be elevated to working height. Tuck in the top sheet and spread at the foot of the bed and then make a modified mitered corner. To save steps, apply all bottom linen on one side of bed before moving to opposite side. Horizontal toe pleats are made on all beds. Gloves do not need to be worn except if drainage is present. Soiled linen should be placed in linen bag, not on the floor. Top covers need to be fanfolded to the end of the bed when the procedure is complete. |
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4 Which of the following is an appropriate guideline when providing perineal care for a patient?
1 Leave the foreskin in an uncircumcised male retracted after cleansing.
2 Cleanse from the most contaminated to the least contaminated area for a female patient.
3 Wash the tip of the penis at the meatus outward in a circular motion.
4 A patient with a Foley catheter needs minimal perineal care. |
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Definition
| 3; Rationale: Follows the principle of cleansing from least contaminated to most contaminated. Leaving a foreskin retracted results in tightening of the foreskin around the shaft of the penis, which can lead to permanent urethral damage. Cleansing the perineum should proceed from the least to most contaminated; in this case from “front to back” or perineum to rectum. A patient with a Foley catheter needs more frequent perineal care because of the increased risk of infection. |
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5 A patient who has a lowered level of consciousness needs mouth care. When performing mouth care, in what position should the patient be placed?
1 Supine
2 Semi-Fowler's
3 High-Fowler's
4 Side-lying |
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Definition
| 4; Rationale: The side-lying position because it is less likely that the patient will aspirate in this position since fluid would most likely pool in the mouth, where it can be suctioned. Nos. 1, 2, and 3 place the patient at risk for aspiration. |
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6 The nurse begins to prepare a patient for a partial bed bath. The nurse brings a bag bath packet into the room and prepares to bathe the patient. The patient asks, “Why aren't you using soap and water?” The nurse's best response would be:
1 The bag bath is a bit quicker and causes less discomfort.
2 The bag bath is easier for me to use.
3 The bag bath is what our agency uses.
4 The bag bath poses less risk of infection than using a basin of water. |
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Definition
| 4; Rationale: Although bath bags are easy to use, quick, and promote comfort, the patient was concerned about not using a basin. No. 4 addresses that concern. Bath basins may be a reservoir and a way that harmful bacteria are spread. |
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7 What is the most important reason that the nurse washes the patient's extremities from distal to proximal?
1 Enhance patient comfort.
2 Prevent skin irritation.
3 Promote venous return.
4 Reduce any noticeable swelling. |
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Definition
| 3; Rationale: Washing from distal to proximal promotes venous return to the right side of the heart. It does not enhance comfort, prevent skin irritation, or reduce swelling. |
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8 Which steps should the nurse take to facilitate the shaving of a male patient's facial hair with a disposable razor? Select all that apply.
1 Use the disposable razor at a 45-degree angle.
2 Place a cool, moist washcloth over the patient's face.
3 Shave in the direction of hair growth.
4 Use long, downward strokes while shaving. |
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Definition
| 1, 3; Rationale: Using the razor at 45 degrees and shaving in the direction of hair growth facilitates shaving of facial hair. A warm, moist washcloth is used; and short downward strokes are recommended to facilitate shaving of facial hair. |
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9 The nurse is providing a bed bath to a patient. In which sequence should the nurse bathe the patient (first to last)?
1 Eyes, face, arms, chest, abdomen, legs, back
2 Face, eyes, arms, legs, back, chest, abdomen.
3 Eyes, arms, legs, face, chest, back, abdomen.
4 Arms, chest, abdomen, legs, back, eyes, face. |
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Definition
| 1; Rationale: Eyes are first, using plain water without soap. Bathing then proceeds from top (face) to bottom so the most contaminated areas are last. |
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10 A patient with diabetes wants to have his nails trimmed. What is the nurse's first step on hearing this request?
1 Clip the nails to fit the contour of his fingers.
2 Use manicure scissors to cut the nails straight across.
3 Use an emery board to shape the nails before being trimmed.
4 Make sure that there is a physician's order to cut the nails. |
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Definition
| 4; Rationale: Individuals with diabetes have poor circulation. Cutting nails could cause trauma, impaired skin integrity, and infection. Always use nail clippers to trim nails straight across; clipping nails to fit the contour of the fingers could result in ingrown nails. Use an emery board to shape nails after being trimmed. |
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1 When the nurse checks the position of the tube, which of the following pH values should be expected?
1 7.0
2 4.0
3 5.0
4 3.0 |
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Definition
| 3; Rationale: The nurse would expect a pH 5.0 because of the continuous tube feeding that contains a basic solution. A pH of 3.0 and 4.0 would be expected if feedings were not being administered. A pH of 7.0 suggests that the tube is in the small intestine or tracheobronchial tree. |
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2 The nurse prepares to irrigate the feeding tube to prevent clogging. The use of sterile water for irrigation is indicated in which situation? Select all that apply.
1 When the pH of gastric aspirate is <4
2 During routine irrigation every 4 hours
3 After administering a medication through the tube
4 When the patient receiving a tube feeding is immunocompromised |
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Definition
| 3, 4; Rationale: Sterile water is indicated for irrigation when a patient is immunocompromised or critically ill and before and after the patient receives a medication via the tube. Sterile water is not necessary for routine irrigation, and pH values of gastric aspiration do not influence selection of irrigation fluid. |
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3 A nurse is assigned to a patient with the diagnosis of stroke, which is affecting the left side of his body. The patient is right handed. During breakfast that morning as the patient is feeding himself, the nurse notices a number of clinical signs. Which of the following suggest that the patient is at risk for aspiration? Select all that apply.
1 Wet voice
2 Difficulty smiling
3 Coughing on food
4 Aversion to food
5 Change in taste |
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Definition
| 1, 3; Rationale: A wet voice and coughing on food are two common signs of dysphagia that are predictive for the risk of aspiration. The patient may have difficulty smiling if there is facial nerve paralysis following the stroke. The ability to smile has not been associated with dysphagia. Aversion to food and change in taste are not predictors of aspiration. |
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4 When feeding a patient who is known to have dysphagia, which of the following interventions prevents gastric reflux?
1 Monitoring pulse oximetry readings
2 Providing patient oral hygiene before feeding
3 Positioning patient upright in a chair
4 Adding thickener to thin liquids |
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Definition
| 3; Rationale: Placing a patient upright at a 90-degree angle reduces the incidence of gastric reflux. Providing oral hygiene reduces the number of bacteria in the saliva that could be aspirated. Pulse oximetry may reveal oxygen desaturation in patients who have aspirated. Adding thickener to liquids reduces risk of aspiration. |
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5 A nurse observes a student nurse performing an irrigation of a feeding tube. The patient is receiving a continuous tube feeding. Which of the following observations by the nurse suggests the student is correctly following the irrigation protocol?
1 Four hours after the last irrigation the student draws up 30 mL of air into an irrigating syringe, instills it into the feeding tube, withdraws fluid to verify placement, kinks tubing, draws up 30 mL of water into irrigating syringe, inserts syringe tip into end of feeding tube, and irrigates tube.
2 Eight hours after the last irrigation the student draws up 30 mL of air into an irrigating syringe, instills it into the feeding tube, withdraws fluid to verify placement, kinks tubing, draws up 30 mL of water into irrigating syringe, inserts syringe tip into end of feeding tube, and irrigates tube.
3 Four hours after the last irrigation the student draws up 30 mL of air into an irrigating syringe, instills it into the feeding tube, draws up 30 mL of water into irrigating syringe, inserts syringe into end of feeding tube, and irrigates tube.
4 Eight hours after the last irrigation the student draws up 30 mL of air into an irrigating syringe, instills it into the feeding tube, draws up 30 mL of water into irrigating syringe, inserts syringe into end of feeding tube, and irrigates tube. |
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Definition
| 1; Rationale: The correct technique requires the nurse to first check tube placement and then irrigate. The procedure is done every 4 hours. |
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6 A patient on a medical oncology unit has been receiving continuous tube feedings for the last 2 days. During a morning assessment the nurse gathers information about the patient's tolerance and response to NG feedings. Which of the following are unexpected outcomes of the feedings? Select all that apply.
1 The patient shows signs of aspiration.
2 The patient develops symptoms of constipation.
3 The patient's tube yields a gastric residual volume of 300 mL.
4 The patient's tube cannot be irrigated.
5 The patient has a small ulcer on the inner naris. |
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Definition
| 1, 3, 4; Rationale: Unexpected outcomes of a tube feeding include aspiration, the retention of large residual volumes 250 mL or more, and clogging of a tube indicated by the inability to irrigate. Diarrhea, not constipation, is a symptom of tube-feeding intolerance. The ulcer on the naris is an unexpected outcome resulting from improper tube care, not the feeding. |
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7 When a nurse educates patients and families about their nutritional needs, food safety is an important topic. Which of the following precautions ensure that it is safe to eat prepared foods? Select all that apply.
1 Wash hands with warm soapy water before touching food.
2 Encourage intake of unpasteurized milk.
3 Keep foods properly refrigerated at 4.4° C (40° F).
4 Do not save leftovers for more than a week in the refrigerator. |
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Definition
| 1 and 3; Rationale: Always wash hands before touching food and keep the refrigerator at 4.4° C (40° F). Discourage drinking unpasteurized milk, which might contain bacteria. Never use leftovers past 2 days. |
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8 A patient who is 2 days postoperative and has normal GI function but is unable to chew because of facial surgery would benefit most from:
1 Clear-liquid diet
2 High-fiber diet
3 Mechanical diet
4 Pureed diet |
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Definition
| 4; Rationale: A patient unable to chew is able to have a clear-liquid, full-liquid, or pureed diet. Full liquid is indicated if the patient cannot tolerate solid foods. However, the pureed diet provides the most nutrients of the three and is indicated when the patient's GI function is normal. Mechanical and high-fiber diets require chewing. |
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9 The nurse caring for a patient in the nursing home notices that the patient routinely has a bowel movement every 3 to 4 days and sometimes the stool is reportedly hard in consistency. The patient is alert and able to tolerate solid foods. The patient wears dentures. The best diet selection for this patient would be:
1 Pureed diet
2 High-fiber diet
3 Fat-modified diet
4 Low-residue diet |
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Definition
| 2; Rationale: High-fiber foods such as fresh uncooked fruits and steamed vegetables are useful in relieving constipation. Just because the patient has dentures does not mean that he is unable to chew; thus a pureed diet would be inappropriate. There is no indication for a fat-modified diet, and a low-residue diet is low in fiber content. |
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10 A patient on the neurosurgery unit is recovering from a traumatic injury resulting in an unstable vertebral fracture. He is ordered to remain supine and is on an air fluidized bed to prevent pressure ulcers. Which of the following positions does the nurse have the patient assume before a tube feeding?
1 Head of bed elevated 90 degrees
2 Reverse Trendelenburg's position
3 Side-lying position
4 Trendelenburg's position |
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Definition
| 2; Rationale: When a patient is forced to remain supine, place in reverse Trendelenburg's position when administering a tube feeding. |
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Term
Mrs. Salem has had chronic arthritis for over 5 years. When her pain reaches a level affecting her ability to perform ADLs such as cooking and grooming, she takes an NSAID for pain relief. Her joint pain usually involves a deep ache, and it limits her ROM. She does not always get complete relief from taking an analgesic, but it “lessens my pain so I can get around.” She tries to avoid taking analgesics as much as she can because she knows the side effects of NSAIDs.
1 What factors make Mrs. Salem a good candidate for nonpharmacological pain therapy?
2 What advice would the nurse give Mrs. Salem to improve the likelihood of the NSAIDs providing pain relief? |
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Definition
1 The patient will benefit from avoiding or reducing drug therapy; since she has incomplete pain relief with NSAIDs, she would be a good candidate for nonpharmacological alternatives.
2 The patient should take the NSAID before her pain increases in severity and before any activities that might aggravate her pain. If her pain increases, the nurse might recommend that she talk with her doctor about the safety of taking medication ATC. |
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3 A patient had a knee replacement performed 48 hours ago and has a local analgesia infusion pump with catheter in place. The nurse notes that the gauze dressing over the infusion catheter is damp and clear in color. What does this indicate?
1 The patient is developing an infection at the surgical site.
2 The infusion catheter has become dislodged and is leaking medication.
3 Nothing; the patient is postop at 48 hours, and clear drainage is normal.
4 The gauze dressing has become soiled from excess perspiration. |
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Definition
| 2; Rationale: If the dressing over a local analgesia infusion catheter becomes moist, it indicates that the tubing is either disconnected or displaced, resulting in leakage of medication onto the gauze. If an infection were present, drainage would likely be green or yellow in color. Normal drainage from a postoperative wound is serosanguineous at 48 hours. Excess perspiration would unlikely cause moistening of a dressing over the knee area. |
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4 A nurse caring for a patient with Alzheimer's suspects that the patient is in pain. Unfortunately the patient's advanced stage of dementia prevents him from being able to verbally describe if something hurts. Which of the following will improve the nurse's ability to assess if the patient is in pain? Select all that apply.
1 Assume that the patient is having pain and rule out any other problems such as constipation.
2 Ask a family member to explain the location of the patient's pain.
3 Observe the patient's facial expressions, body movements, and vocal noises.
4 Conduct a physical examination, using gentle palpation to find the source of pain.
5 Consult the last nurse's pain assessment and assume that the pain is unchanged. |
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Definition
| 1, 3, and 4; Rationale: The nurse can ask a family member to describe patient behaviors, but she cannot assume that the family member will know the pain location. Pain is what a patient says it is, either verbally or nonverbally. A previous assessment is not necessarily current and reflective of the patient's present condition. |
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5 A nurse is completing a massage for a patient and tells him to inhale deeply, exhale, and then move slowly as he sits up in bed. Why does the nurse end the massage in this manner?
1 To prevent muscle cramping
2 To prevent intravascular clotting
3 To prevent a Valsalva maneuver
4 To prevent postural hypotension |
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Definition
| 4; Rationale: A massage can cause deep relaxation; thus sitting up quickly may cause temporary postural hypotension. Deep breathing relaxes the patient but does not affect muscle cramping or clotting. Holding one's breath and straining are Valsalva maneuvers. |
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6 Review each of the clinical cases below and identify the patient most at risk for respiratory depression from opioid use.
1 Respirations 20, deep; sedation level 1 at baseline. Respirations 14, shallow; sedation level 2 after analgesia.
2 Respirations 18, deep; sedation level 2 at baseline. Respirations 12, deep; sedation level 4 after analgesia.
3 Respirations 18, deep; sedation level 1 at baseline. Respirations 10, shallow; sedation level 4 after analgesia.
4 Respirations 16, shallow; sedation level 2 at baseline. Respirations 12, shallow; sedation level 2 after analgesia. |
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Definition
| Clinical case 3 is most at risk. Rationale: Respiratory depression is only clinically significant if there is a decrease in the rate and depth of respirations from the patient's baseline assessment. Also, sedation always occurs before respiratory depression. In case 3 the patient's rate and depth of respiration deteriorate, and sedation increases. |
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7 A nurse would suspect bupivacaine (Marcaine) toxicity in a patient connected to a local infusion pump when observing which of the following symptoms:
1 Hypotension, dizziness, and severe itching
2 Reduced sensation in lower extremities, urinary urgency, and distended bladder
3 Reduced respiratory rate and depth with increase in sedation level
4 Orthostatic hypotension and tingling in extremities |
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Definition
| 1; Rationale: Bupivacaine (Marcaine) toxicity presents with hypotension, dizziness, tremor, severe itching, swelling of the skin or throat, irregular heartbeat, palpitations, confusion, ringing in the ears, muscle twitching, numbness around the mouth, metallic taste, and seizures. |
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8 The nurse enters the room of a patient who underwent major abdominal surgery in the morning. The patient's epidural catheter is intact, the dressing is dry, and the infusion pump is running at the ordered rate. The nurse finds the patient breathing shallowly at 8 breaths per minute and difficult to arouse. Which of the following steps should she take? Select all that apply.
1 Try to arouse patient and have him take deep breaths.
2 Check the infusion tubing to be sure that it is connected to the epidural catheter.
3 Discuss with physician need for possible basal dose of analgesic.
4 Prepare to administer naloxone per physician order.
5 Stop or reduce rate of epidural infusion and notify physician. |
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Definition
| 1, 4, and 5; Rationale: There is no indication that the catheter is disconnected since the dressing is dry and intact. Seeking a basal dose is not appropriate since the patient is oversedated and requires immediate treatment. |
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9 Following the acronym PQRSTU allows the nurse to complete a comprehensive pain assessment. Fill in the blanks to describe each of the assessment parameters:
P = _____________________
Q = _____________________
R = _____________________
S = _____________________
T = _____________________
U = _____________________ |
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Definition
| P: Precipitating/palliative factors; Q: Quality of pain; R: Region of pain or radiation; S: Severity; T: Timing; and U: How is pain affecting U (patient) regarding ADLs, work, relationships, and enjoyment of life. |
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10 The nurse is caring for a 71-year-old patient who had a recent stroke and suffers from expressive aphasia, the inability to express oneself verbally. He is found lying flat in bed with head slightly elevated. He acts irritable when the nurse awakens him. As he rolls onto his right side, he places his left hand over his abdomen. The nurse assesses the vital signs and finds HR 88 and regular, BP 134/88, and respirations 12 and deep. The patient's skin is slightly diaphoretic. The nurse suspects that he is in pain because of which factors? Select all that apply.
1 Flat position with head raised.
2 Irritability
3 Respiratory rate
4 Diaphoresis
5 Placement of hand over abdomen |
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Definition
2, 4, 5; Rationale: Nonverbal indications of pain include guarding, diaphoresis, and irritability. The patient's respiratory rate would be slow during sleeping. He is lying in an anatomically correct position. An abnormal posture might indicate pain.
Chapter 14 |
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Term
Mr. G is a 48-year-old fireman who is married with three young children and has a 25-year history of smoking. He had a recent diagnosis of lung cancer and consequently a right thoracotomy (removal of right lung). He has a right chest tube and is receiving oxygen via a nasal cannula with the oxygen regulator set at 2 L/min. The chest tube with a three-chamber system is set on suction at 20 cm. Bubbling is noted during expiration.
1 The nurse performs a respiratory assessment on this patient, who is short of breath. Which of the following are appropriate when assessing respiratory status? Select all that apply.
1 Inspect the patient for rate, rhythm, and depth of breathing.
2 Auscultate anterior lung sounds while he is flat on his side.
3 Obtain vital signs and a pulse oximeter reading to assess oxygenation.
4 Evaluate the chest tube for working order. |
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Definition
| 1, 2, 3, 4; Rationale: All of these are correct. The nurse initially observes the patient throughout the respiratory cycle. In this patient it is also important to obtain vital signs because these data will give the nurse information about the overall status of the patient. Auscultation provides information about lung expansion; the nurse also notes if the expansion is symmetrical. The chest tube is an intervention to improve lung expansion, and in this patient it is part of the respiratory assessment. |
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Term
Mr. G is a 48-year-old fireman who is married with three young children and has a 25-year history of smoking. He had a recent diagnosis of lung cancer and consequently a right thoracotomy (removal of right lung). He has a right chest tube and is receiving oxygen via a nasal cannula with the oxygen regulator set at 2 L/min. The chest tube with a three-chamber system is set on suction at 20 cm. Bubbling is noted during expiration.
2 The nurse caring for this patient recognizes the need for supplemental oxygen therapy. It is determined that Mr. G needs an FIO2 of 80%. Which oxygen delivery devices can deliver oxygen at this FIO2 level? Select all that apply.
1 Nasal cannula at 6 L/min
2 Venturi mask at 12 L/min
3 Nonrebreathing mask at 6 L/min
4 Partial rebreathing mask at 6 L/min |
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Definition
| 2; Rationale: A Venturi mask is the only method of delivering an FIO2 of 80% with the stated liters per minute. The nasal cannula delivers 44% at most, the partial rebreather must be set at a minimum of 8 L, and the nonrebreather must be set at a minimum of 6 L. |
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Term
Mr. G is a 48-year-old fireman who is married with three young children and has a 25-year history of smoking. He had a recent diagnosis of lung cancer and consequently a right thoracotomy (removal of right lung). He has a right chest tube and is receiving oxygen via a nasal cannula with the oxygen regulator set at 2 L/min. The chest tube with a three-chamber system is set on suction at 20 cm. Bubbling is noted during expiration.
3 The nurse notices that this patient's chest tube is bubbling continuously. Which of the following steps is/are appropriate for the nurse to complete? Select all that apply.
1 Check to ensure that all connections are secure.
2 Determine that no kinks are affecting the tubing from the chest tube to the drainage system.
3 Disconnect the chest tube from the drainage tube to assess for adequate suction.
4 Assess for location of leak by clamping chest tube with two rubber-shod or toothless clamps close to the chest wall. |
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Definition
| 1 and 4; Rationale: Assess for location of leak by clamping chest tube with two rubber-shod or toothless clamps close to the chest wall. If bubbling stops, an air leak is inside patient's thorax or at chest insertion site. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down drainage tubing away from patient and toward suction control chamber. When bubbling stops, leak is in section of tubing or connection between the clamps. If the tube becomes kinked, tidaling will stop; but bubbling will not be noted unless there is a breach in a connection of the system. The nurse should never disconnect the tubing unless hemostats are in place when changing the drainage system. |
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4 An RN is mentoring a new graduate RN who is suctioning a patient through an ET tube. Which of the following steps indicate acceptable technique?
1 Hyperoxygenates patient with 21% oxygen before suctioning
2 Uses a clean catheter for suctioning
3 Inserts catheter with nurse's thumb covering the suction control port
4 Dips catheter in saline before suctioning |
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Definition
| 4; Rationale: By dipping the catheter in normal saline before suctioning, the catheter is lubricated for easier insertion. A nurse should hyperoxygenate a patient with 100% oxygen, use a sterile catheter, and only activate suction when the catheter is being withdrawn from the ET tube to decrease risk of damage to tracheal mucosa. |
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Term
5 Suctioning the patient may cause which of the following complications? Select all that apply.
1 Hypoxia
2 Dysrhythmias
3 Increased intracranial pressure
4 Thick secretions |
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Definition
| 1, 2, 3; Rationale: The effects of hypoxia from suctioning can cause dysrhythmias, hemodynamic instability, and increased intracranial pressure, among other complications. A maximum of two suction passes is recommended to minimize effects of hypoxemia. |
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Term
6 Which activities could a nurse delegate to assistive personnel? Select all that apply.
1 Suctioning an ET tube
2 Tracheostomy care for a chronically ill patient on humidified oxygen
3 Application of functioning nasal cannula
4 Tracheostomy care on an acutely ill mechanically ventilated patient |
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Definition
| 2, 3; Rationale: Tracheostomy care and suctioning can be delegated to NAP if the tracheostomy is well established and not for an acutely ill patient. An NAP can attach a nasal cannula, if the RN previously adjusted oxygen flow rate and assessed the patient. Suctioning for any patient with an ET tube cannot be delegated to NAP. |
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7 The nurse is assessing a patient with an artificial airway. Which of the following would indicate that the patient might need to be suctioned? Select all that apply.
1 Wheezes auscultated on inspiration
2 Decreased breath sounds in the bases
3 Weak cough
4 Thick secretions |
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Definition
| 2, 3, 4; Rationale: Assess for clinical indicators for suctioning: coarse breath sounds, noisy breathing or adventitious breath sounds, weak cough, increased or decreased pulse, increased or decreased respirations, increased or decreased blood pressure, prolonged expiratory breath sounds, and decreased lung expansion. Secretions in the airway, decreased oxygen saturations or level of consciousness, anxiety, lethargy, unilateral breath sounds, and cyanosis may also indicate a need for suctioning. Wheezing indicates hyperactive airways and can be worsened by suctioning. |
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Term
8 Current best practice indicates that the following interventions are advantageous in preventing VAP. Select all that apply.
1 Elevating the head of the bed at 30 to 45 degrees to prevent aspiration
2 Changing patient position every 2 hours to decrease risk for atelectasis and pulmonary infections
3 Providing oral care with a toothette daily to remove dental plaque organisms
4 Limiting patient mobility to promote rest and conserve oxygen |
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Definition
| 1, 2; Rationale: Toothbrushes should be used every 8 hours to provide oral care for ventilated patients. Toothettes are not adequate to clean the dental plaque, but they may be used between brushing for moistening mucosa. Although increasing mobility in this population is challenging, such interventions as repositioning, sitting, or standing at the bedside or ambulation have decreased the risk of VAP. |
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Term
9 Patients are unable to speak when they have an ET tube. What are some of the recommended ways to communicate with these patients? Select all that apply.
1 Talk to patients as if they have a hearing loss by speaking very loudly.
2 Leave a pen and paper within reach of patient so he or she can write comments to health care providers and family members.
3 Provide an alphabet board for family and friends to communicate with patient.
4 Ask family members to explain the plan of care to patient. |
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Definition
| 2, 3; Rationale: When caring for an intubated patient, nurses are encouraged to use positive verbal and nonverbal communication with direct eye contact and questions that only require yes or no responses. Alphabet charts, pen and paper, slates or chalkboards, or magnetic pen doodle boards are some common communication tools. Intubated patients do not have a hearing loss; thus speaking loudly does not help communication and may frustrate the patient even more. Families can speak to the patient, but the patient still needs a mechanism with which to reply. |
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Term
10 Patients with chest tubes to remove blood drainage from the chest cavity have many care priorities. Which of the two pairs of priorities are the most important?
1 Monitoring chest tube drainage and maintaining chest tube patency
2 Monitoring chest tube drainage and promoting activity
3 Promoting airway clearance and maintaining chest tube patency
4 Promoting airway clearance and promoting activity |
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Definition
| 1; Rationale: Monitoring chest tube drainage and maintaining chest tube patency are the key priorities. |
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Term
Mr. Clark is a 37-year-old man who suffered a spinal cord injury in a motor vehicle accident. He is admitted on the nurse's shift. He has sustained multiple deep lacerations on his face and trunk and facial fractures of maxillary and zygomatic bones. He rates his pain at 9 on a scale of 0 to 10.
1 Mr. Clark is scheduled for a computed tomography (CT) scan of the head and spine following an auto accident. He now reports pain at a level of 7 on a 0 to 10 scale. He weighs 210 pounds and refuses to allow the nurse to move him onto the stretcher. What interventions would the nurse select to successfully get Mr. Clark to the procedure? Select all that apply:
1 Administer pain medication as ordered.
2 Use two nurses to move patient to stretcher and explain procedure to patient.
3 Prepare to have three nurses assist with transfer and explain procedure to patient.
4 Tell him that it is a physician's order and must be carried out. |
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Definition
| 1 and 3; Rationale: Mr. Clark is in pain most likely related to his lacerations and fractures. Pain management is a priority at this time. To safely transfer the patient, three nurses are necessary because of the patient's weight. In addition, explaining to Mr. Clark the purpose of the CT scan helps elicit his cooperation. Mr. Clark is most likely fearful of movement because of his pain and uncertainty of his condition. Two nurses are insufficient for the transfer. The nurse may inform Mr. Clark that it is a physician's order, but the patient has the right to refuse treatment. |
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Term
Mr. Clark is a 37-year-old man who suffered a spinal cord injury in a motor vehicle accident. He is admitted on the nurse's shift. He has sustained multiple deep lacerations on his face and trunk and facial fractures of maxillary and zygomatic bones. He rates his pain at 9 on a scale of 0 to 10.
2 Mr. Clark has returned from the CT scan. The physician or health care provider has ordered him to be turned and positioned every 1 to 2 hours until he is taken to surgery to stabilize his spinal fracture. What is the safest technique to use to move him from side to side? Fill in the blank and give rationale. |
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Definition
| Logrolling; Rationale: Mr. Clark maintains proper alignment by moving all body parts at the same time, preventing tension or twisting of the spinal column. |
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Term
3 A patient has been on bed rest for several days. When he tries to sit on the side of the bed, he becomes dizzy and nauseated. These are most likely symptoms of which of the following?
1 Rebound hypertension
2 Orthostatic hypotension
3 Dysfunctional proprioception
4 CNS rebound hypotension |
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Definition
| 2; Rationale: Hypotension would result after prolonged bed rest. There is no indication that the patient is experiencing difficulty with proprioception. There is no indication that the patient has pathology to the CNS. |
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Term
4 A patient who weighs 104.5 kg (230 pounds) is being transferred from his bed to a chair. The patient is on partial weight bearing as a result of bilateral reconstructive knee surgery. Which of the following is the best technique for transfer?
1 Friction-reducing device
2 Bariatric transfer aid
3 Three-person carry
4 Stand-and-pivot using two nurses |
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Definition
| 2; Rationale: Because of the patient's weight and limited ability to bear weight, a bariatric transfer aid provides the best and safest technique to transfer this patient. A friction-reducing device is used when transferring a patient from a bed to stretcher. A three-person carry is inappropriate and not recommended any longer. No. 4 is incorrect because of patient's weight and limited weight bearing. |
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Term
5 An adolescent has been admitted with an unstable spinal cord injury sustained from a motor vehicle accident. The patient needs to be taken to the operating room. What is the most appropriate method to move this patient to a stretcher for transport?
1 Use a step-by-step method: move the trunk, the hips, and finally the legs.
2 Logroll the patient, place a slide board, and slide the patient to the stretcher as one unit maintaining body alignment.
3 Allow the patient to stand and transfer to the stretcher.
4 Use a mechanical lift device to transfer to the stretcher. |
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Definition
| 2; Rationale: Logrolling and moving the patient as a unit prevents twisting and damage to the unstable spinal cord. The step-by-step method causes twisting and bending of the spine, resulting in further damage. The patient should remain nonweight bearing to prevent further damage to the injured spine; No. 4 is incorrect because there is risk of twisting and bending the spine during transfer. |
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Term
6 A patient is 1 day after abdominal surgery. He is refusing to move from the bed to the chair. What should the nurse assess first in determining appropriateness of transfer?
1 Level of pain
2 Any equipment connected to his body
3 Patient's weight
4 Patient's ability to follow directions |
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Definition
| 1; Rationale: The patient may be refusing to move because his pain is not under control. Nos. 2, 3, and 4 are important assessment data once the patient has agreed to transfer. |
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Term
7 The nurse is transferring a patient from bed to chair. The patient has been on prolonged bed rest. Which one of the following should the nurse do first?
1 Apply a transfer belt.
2 Use the under-axilla method to assist the patient to a sitting position.
3 Provide the patient with his or her glasses.
4 Allow the patient to dangle at the side of the bed for a few minutes. |
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Definition
| 4; Rationale: This allows the nurse to determine if the patient is experiencing symptoms of orthostatic hypotension such as dizziness. Place the transfer belt around the patient's waist after the patient is in a sitting position. The under-axilla method may cause injury to the patient and places undo stress on the patient's axilla area. Offer the patient his or her glasses after positioning in chair to prevent damage to eyeglasses. |
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Term
8 Two NAPs ask for the nurse's assistance to transfer a 56.8 kg (125-pound) patient from the bed to the stretcher. The patient is unable to assist. What is the best response?
1 “As long as we use proper body mechanics, no one will get hurt.”
2 “The patient only weighs 56.8 kg (125 pounds). You do not need my assistance.”
3 “The three-man lift technique is recommended to ensure your safety and that of the patient.”
4 “Use the slide board; it's more comfortable for the patient and will lessen the chance of injury to us.” |
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Definition
| 4; Rationale: A slide board is the most appropriate method to transfer this patient because the patient is unable to assist. If any one caregiver must lift more than 35 pounds, there is a risk of injury. Body mechanics alone are insufficient. A slide board is the most appropriate method. |
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Term
9 Place the following steps in sequence that promotes safe transfer of a patient from a wheelchair to a bed.
1 Position wheelchair at a 45-degree angle next to the bed.
2 Assist patient to move to the front of wheelchair.
3 Raise the footplates and apply transfer belt.
4 Lock the wheelchair. Push forward to lock.
5 Position yourself slightly in front of the patient to guard and protect the patient throughout the transfer.
6 Have patient stand and pivot to side of bed.
7 Adjust the height of the bed to the level of the seat of the wheelchair. |
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Definition
| The correct sequence is 7, 1, 4, 3, 2, 5, 6; Rationale: This sequence first positions the bed and wheelchair at equal height, with the wheelchair appropriately angled to the bed. The safety features of the wheelchair are used, and the patient is safely transferred to the wheelchair. |
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Term
10 Which of the following patients would benefit most from positioning in a 30-degree lateral position on the right side?
1 A patient who has shortness of breath
2 A patient who has signs of a stage I pressure ulcer on the left trochanter
3 A patient who has hemiplegia on the right side
4 A patient who is prone to orthostatic hypotension |
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Definition
| 2; Rationale: The 30-degree lateral position is designed to reduce pressure over bony prominences. The patient who has shortness of breath would benefit most from a Fowler's position. The 30-degree lateral position does not prevent orthostatic hypotension. The patient with hemiplegia needs to be turned often side to side. |
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Term
tly released from the hospital after A woman was recensuffering a heart attack. The patient lives in a single family home with her husband and two cats. She gets short of breath and feels unsteady at times when walking and will require the use of an assistive device short-term for the first time in her life. When the home health nurse visits, the patient expresses that she wants to be as mobile as possible but has her concerns about her ability to manage an assistive device.
2 The patient's husband is concerned for his wife's safety during ambulation. The nurse gives him suggestions to help his wife be as mobile as possible in a safe manner. What should the nurse instruct the husband to do?
1 Give his wife an opioid analgesic just before ambulating.
2 Encourage his wife to bend forward when walking.
3 Schedule daily activities so there is time between them.
4 Have his wife hold her breath when rising to a standing position. |
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Definition
| 3; Rationale: Space activities to avoid exhaustion. Rest is needed between activities such as bathing and ambulation. An opioid could result in dizziness. A person should blow out when rising to a standing position. |
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Term
3 The nurse is presenting a health promotion program on exercise and mobility to a group of older adults who reside in single-family homes in their communities. The older adults are on fixed incomes and are concerned that they have no options for exercise. Which activity does the nurse suggest?
1 Join a local fitness club.
2 Form a walking group.
3 Organize a book-readers club.
4 Invest in home exercise equipment. |
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Definition
| 2; Rationale: Walking does not cost the older adults anything, and it is a safe means of exercise. A local fitness club and purchase of exercise equipment would be costly. A readers’ club is an excellent social activity but does not involve exercise. |
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Term
4 The patient has returned to the nurse's unit following total knee replacement surgery. What should the nurse do as he begins to apply the CPM?
1 Inject analgesic medication directly into the patient's knee.
2 Position the machine's knee hinge 10 cm (4 inches) above the patient's knee.
3 Support the patient's leg above, below, and at the knee.
4 Instruct the patient to expect to feel severe discomfort during the therapy. |
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Definition
| 3; Rationale: It is important to support joints to prevent damage or injury. The nurse does not inject analgesic; positioning is 2 cm (0.8 inch) below knee joint; patient is continuously assessed to ensure that he or she tolerates the CPM and is not left in severe pain. |
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Term
5 The nurse is assisting a patient to the side of the bed and recognizes that the patient is experiencing orthostatic hypotension. Which of the following signs and symptoms alert the nurse to this condition? Select all that apply.
1 Pallor
2 Bradycardia
3 Nausea
4 Dizziness
5 Irritability |
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Definition
| 1, 3, 4; Rational: Pallor, nausea, and dizziness are all signs of orthostatic hypotension. Bradycardia is incorrect; tachycardia is actually a symptom. Irritability is not a classic sign of the condition. |
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Term
6 The nurse teaches a patient ROM exercises for the shoulder. For abduction, how high is the patient taught to raise the arm?
1 120 degrees
2 140 degrees
3 180 degrees
4 220 degrees |
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Definition
| 3; Rationale: Raising the arm above the head achieves 180-degree abduction. |
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Term
7 A child with cerebral palsy can experience difficulty with movement, loss of balance, and lack of muscle control. Which gait does the nurse instruct the parents of a child with cerebral palsy to use for crutch walking?
1 Four-point
2 Three-point
3 Two-point
4 Swing-to |
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Definition
| 1; Rationale: The four-point gait provides most support and improves balance. |
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Term
8 Which of the following actions prevents injury when the nurse is lifting a patient? Select all that apply.
1 Keep knees in locked position.
2 Avoid twisting.
3 Move the patient without assistance.
4 Use arms and legs, not the back.
5 Encourage patient to help if able. |
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Definition
| 2, 4, 5; Rationale: Avoid twisting to avoid injury. Using the arm and leg muscles protects the back; the arms and legs are stronger than the back. Patient assistance promotes ability and strength. |
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Term
9 Which situation is a contraindication for the use of elastic stockings?
1 Prior use of stockings within 3 months
2 Recent skin graft to the lower leg
3 Increased circulation of lower extremities
4 Immobility for more than 1 week |
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Definition
| 2; Rationale: The success of a skin graft could be compromised by the application of elastic stockings to the site. |
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Term
10 Place the following steps for climbing stairs with crutches in the correct order from first to last step.
1 Align crutches with unaffected leg on step.
2 Stand in tripod position.
3 Advance unaffected leg onto step.
4 Transfer body weight to crutches. |
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Definition
| Correct sequence: 2, 4, 3, 1; Rationale: Allows patient to balance by providing wide base of support first. |
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Term
John Jefferson is a 30-year-old with severe vomiting and abdominal pain. He has a preliminary diagnosis of pancreatitis. The health care provider ordered a series of laboratory tests and abdominal scans. However, before the scan the health care provider wants an NG tube inserted for gastric decompression.
1 During the nursing history Mr. Johnson tells the nurse that he broke his nose playing college football 9 years ago. Based on this information, what is the next step?
1 Add extra lubricant to the tube during insertion.
2 Assess patency of each naris.
3 Call the health care provider for an order for local anesthetic.
4 Tell Mr. Johnson that the prior injury will prevent the tube insertion. |
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Definition
| 2; Rationale: Nasal trauma can cause a deviated septum, which makes passing the NG tube difficult. Assess patency of each naris to determine if a deviation is present before tube insertion. If the deviation is noted, placement of the tube through that naris is contraindicated; use the other naris. |
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Term
John Jefferson is a 30-year-old with severe vomiting and abdominal pain. He has a preliminary diagnosis of pancreatitis. The health care provider ordered a series of laboratory tests and abdominal scans. However, before the scan the health care provider wants an NG tube inserted for gastric decompression.
2 Once the tube is inserted and verified with an x-ray film, which of the following aspirates indicates that the tube is properly placed in the stomach?
1 Clear aspirate with pH 6.7
2 Light brown aspirate with pH 4.8
3 Green aspirate with pH 3.2
4 Yellow aspirate with pH 5.5 |
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Definition
| 3; Rationale: The color and pH of the aspirate is consistent with acidic gastric secretions. |
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Term
3 While receiving a soaps suds enema, a patient complains of abdominal cramping. Which of the following techniques help relieve this sensation? Select all that apply.
1 Ask the patient to hold his or her breath.
2 Ask the patient to breathe slowly.
3 Lower the fluid container.
4 Raise the fluid container. |
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Definition
| 2, 3; Rationale: Breathing slowly helps the patient relax. Lowering the container slows the instillation of the enema solution, which eases cramping. If the patient continues to cramp, the enema solution will be evacuated too soon, altering the effectiveness of the enema. |
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Term
4 When a patient is suspected of having hardened feces from prolonged constipation, which of the following type of enemas would the nurse anticipate administering?
1 Kayexalate
2 Oil retention
3 Soap suds
4 Tap water |
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Definition
| 2; Rationale: The oil retention enema is absorbed into the fecal mass, softening it for easier evacuation. |
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Term
5 A patient comes to the clinic complaining of abdominal discomfort. Which of the following signs might suggest functional constipation?
1 Diarrhea and abdominal distention
2 Hard stools and reduced fluid intake
3 Lumpy, hard stools and absent bowel sounds
4 Straining with defecation and sensation of incomplete evacuation |
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Definition
| 4; Rationale: Functional constipation is characterized by straining and the sensation of incomplete evacuation. Absent bowel sounds usually are an indication of absent peristalsis, which is not associated with functional constipation. The presence of diarrhea and abdominal distention is associated with fecal impaction. |
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Term
6 One risk associated with digital removal of impacted stool is stimulation of the vagus nerve. When this nerve is stimulated, what can occur?
1 Reflex bradycardia
2 Reflex tachycardia
3 Reflex urination
4 Reflex vomiting |
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Definition
| 1; Rationale: Reflex bradycardia occurs from the manipulation of the sacral branch of the vagus nerve. The vagus nerve is a parasympathetic nerve that once stimulated decreased heart rate. |
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Term
7 When measuring length of insertion for an NG tube, which is the correct measure?
1 Corner of mouth to earlobe to xiphoid process
2 Tip of nose to earlobe to xiphoid process
3 50 cm (20 inches) from tip of tube
4 Tip of nose to umbilicus |
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Definition
| 2; Rationale: This is the approximated distance from naris to stomach so that the tip of the tube enters the patient's stomach. |
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Term
8 The patient has had an NG tube for 2 days and is complaining about abdominal pain and severe nausea. The NG output has decreased over the past 3 hours, and the nurse is concerned that the tube is not draining properly. What is the nurse's next action?
1 Irrigate the tube with saline and withdraw the instilled fluid.
2 Notify the health care provider.
3 Turn the patient to his left side to promote drainage.
4 Withdraw the tube 5 to 7.5 cm (2 to 3 inches). |
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Definition
| 1; Rationale: Over time the NG tube may rest along the stomach wall or is no longer patent because of abdominal secretions. Irrigation of the tube gently moves the tube away from the stomach lining and facilitates patency. Once the tube is patent, drainage of abdominal secretions occurs; and abdominal distention, discomfort, and nausea are relieved. If irrigation is not successful, the nurse should contact the health care provider. |
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Term
9 After removal of the NG tube, which of the following may indicate that the tube needs to be replaced? Select all that apply.
1 Abdominal distention
2 Decreased bowel sounds
3 Lack of appetite
4 Passage of flatus |
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Definition
| 1, 2; Rationale: Abdominal distention results when abdominal secretions and gas accumulate. Decreased bowel sounds indicate a decrease in peristalsis, which causes secretions and gas to accumulate, causing further distention. If these occur following NG tube removal, the tube may need to be replaced. |
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Term
10 A new nurse on the unit is caring for a patient with a Salem sump NG tube. Which of the following indicates that the nurse needs additional education to care for this patient? Select all that apply.
1 Nurse auscultates for bowel sounds.
2 Nurse measures gastric output.
3 Nurse prepares to irrigate the blue pigtail.
4 Nurse prepares to attach the blue pigtail to portable suction. |
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Definition
| 3, 4; Rationale: The blue pigtail is an air vent, which prevents suctioning of gastric mucosa at the distal end of the NG tube. This air vent is never be clamped, irrigated, or attached to suction. |
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Term
1 The nurse uses a current drug index to look up a pain medication and finds that the onset of action of the drug is 30 minutes, it peaks in 60 minutes, and the duration of action is 3 hours. The patient asks the nurse to administer this medication so it will be most effective when the patient participates in a strenuous hour-long physical therapy session later in the day. When should the nurse give this medication to the patient?
1 Stat
2 Fifteen minutes before the physical therapy session
3 An hour before the physical therapy session
4 |
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Definition
| 3; Rationale: Medication should be given 1 hour before physical therapy for peak effectiveness to minimize discomfort during the treatment. |
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Term
2 The nurse finds the following new medication order written in a patient's hospital chart: “3/17/09 0800 furosemide 40 mg twice a day.” What should the nurse do first?
1 Enter the order in the hospital computer.
2 Administer the medication.
3 Contact the prescriber.
4 Review the order with a pharmacist. |
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Definition
| 3; Rationale: The medication order lacks the route of administration and possible start time. |
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Term
| 3 List the six rights of medication administration. |
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Definition
| Medication, dose, patient, route, time, and documentation. All of the six rights must be followed to ensure safe medication administration. |
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Term
4 On admission to the medical unit, the nurse is doing a medication reconciliation of the patient's current medication. She finds that the patient is taking 8 different medications, all for management of arthritis pain. Of what is this an example?
1 Medication dependence
2 Medication tolerance
3 Polypharmacy
4 A desirable medication interaction |
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Definition
| 3; Rationale: Polypharmacy. This amount of medications for one medical problem needs further evaluation. |
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Term
5 The physician's order for a medication states: “Percocet 1 or 2 tabs BID and prn.” The physician is very busy, does not like to be bothered, and is known for being difficult to work with. What should the nurse do?
1 Consult a pharmacist to interpret the order.
2 Call the physician and have the order verified.
3 Administer the medication twice a day and as the patient needs.
4 Talk to the unit secretary on the floor who is good at reading the physician's handwriting. |
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Definition
| 2; Rationale: The nurse needs to clarify medication orders that do not follow safe medication order guidelines. |
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Term
6 The patient has an order for 1 tbsp of Robitussin for a cough. Converting this to the metric system, what dose would the nurse give to the patient?
1 5 mL
2 10 mL
3 15 mL
4 30 mL |
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Definition
| 3; Rationale: 1 tbsp = 15 mL (see Table 21-4). |
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Term
7 A patient is to receive cephalexin, 500 mg PO. The drawer of the automated medication dispensing system (AMDS) opens. There are five tablets, each labeled 250 mg cephalexin in the drawer. What should the nurse give to the patient?
1 tablet
2 1 tablet
3 tablets
4 2 tablets |
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Definition
| 4; Rationale: Tablets=1tablet2/50mg×500mg/1×500/250=2tablets |
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Term
8 The nurse has to give the following medications to her patients. To which patient should she give medications first?
1 A patient who is to receive 325 mg of aspirin who has a history of coronary artery disease
2 A patient who needs 2 tablets of acetaminophen/hydrocodone (Vicodin) who is rating his incisional pain at an 8 on a pain scale of 0 to 10
3 A patient who is to get captopril (Capoten) 25 mg for a history of hypertension whose current blood pressure is 125/72 mm Hg
4 A patient who is receiving trimethoprim/sulfamethoxazole (Bactrim DS) for a urinary tract infection |
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Definition
| 8 2; Rationale: The rest of the patients are stable; thus treating the pain in this situation is the priority. |
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Term
9 An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? Select all that apply.
1 Provide a dispensing container for each day of the week.
2 Provide larger, easier-to-read labels.
3 Tell the patient what is in each container.
4 Have the family administer the medication. |
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Definition
| 1, 2; Rationale: Larger print and a dispensing system can ensure safe medication administration to the older adult. Large-print pamphlets are also available. |
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Term
10 The nurse receives a telephone order to administer 20 mEq of potassium by mouth to her patient stat. What does she need to do first?
1 Read back the order to the prescriber to verify.
2 Prepare 20 mEq of potassium by mouth and administer it.
3 Contact the pharmacist to see if the medication can be prepared in the pharmacy.
4 Ask the prescriber to come to the unit and write the order before administering the medication. |
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Definition
| 1; Rationale: One of the 2009 patient safety goals includes a “read back” to verify any verbal or telephone orders. |
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Term
Mrs. Schneider is a 55-year-old woman who has contact dermatitis on her right forearm. She is visiting the medicine clinic for her regular checkup. Mrs. Schneider is also hypertensive and takes a diuretic and a beta-adrenergic blocker.
1 The nurse in the clinic provides instruction to Mrs. Schneider on how to apply a topical cream for her dermatitis. Which of the following statements, if made by the patient, would indicate that she needs further instruction?
1 I should wash, rinse, and dry my arm before applying the cream.
2 If the skin seems dry, it helps to apply the cream when the skin is still damp.
3 I should soften the cream in the palm of my hand before applying to the skin.
4 I will spread the cream on the skin and rub it in vigorously so it will absorb. |
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Definition
| 4; Rationale: A cream should be spread evenly over the skin surface, using long, even strokes that follow the direction of hair growth to ensure proper absorption. |
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Term
| 2 The nurse practitioner taught Mrs. Schneider how to measure her own blood pressure at home. When should Mrs. Schneider measure her blood pressure in relationship to taking her antihypertensive medications? |
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Definition
| The patient should take a preadministration measurement and retake the blood pressure 30 to 60 minutes after taking the medication to determine patient's baseline blood pressure and response to the medication. |
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Term
3 The nurse is instructing a patient on the proper method for using an MDI with spacer. The patient is to receive a bronchodilator and a corticosteroid, 2 puffs each, 3 times a day. The two medications are prescribed for the same time each day. The patient takes the bronchodilator first. Which of the following steps for self-administering an MDI are incorrect in this patient's situation? Select all that apply.
1 Shake inhaler well for 2 to 5 seconds (five or six shakes) and insert MDI into end of spacer.
2 Place spacer device mouthpiece into mouth and close lips. Pass the mouthpiece into the back of the pharynx. Avoid covering small exhalation slots with the lips.
3 Breathe normally through spacer device mouthpiece.
4 Depress medication canister, spraying one puff into spacer device.
5 Breathe in slowly and fully (for 5 seconds) and then hold breath for 10 seconds.
6 Wait 30 seconds after the second puff of bronchodilator and then take the steroid. |
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Definition
| 2, 6; Rationale: The mouthpiece should not be inserted beyond the raised lip on the mouthpiece. When taking two medications prescribed at the same time, the patient should wait 2 to 5 minutes before taking the second medication. |
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Term
4 The nurse should include which instruction when teaching the patient about using transdermal patches for chronic pain management?
1 Apply the patch to the same spot each day for consistent dosing.
2 If the patient experiences severe sedation, cut the patch in half for the next dose.
3 If pain is not relieved, apply a second patch without removing the first one.
4 Remove the old patch and cleanse the area before applying a new patch. |
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Definition
| 4; Rationale: It is important to remove any medication residue before applying a new patch. This ensures a consistent dosage delivery. When giving a transdermal patch, always rotate the application site. A patient should never cut a patch in half because there is no way to determine dosage. If the patient becomes oversedated, the health care provider should be notified. Always remove a patch before applying the next dose. |
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Term
5 The nurse is caring for a patient who has an order for an acetaminophen (Tylenol) rectal suppository. Which of the following findings in the nurse's assessment would contraindicate administration?
1 Rectal hemorrhoids
2 Presence of a fever
3 Rectal bleeding
4 Diarrhea |
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Definition
| 3; Rationale: Rectal suppositories are contraindicated in patients with rectal surgery or active rectal bleeding. A suppository can be given for hemorrhoids; however, extra lubricant is helpful for insertion. A suppository is often used for treatment of fever. The presence of diarrhea is often an indication for a suppository and does not contraindicate use in this situation. |
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6 A patient comes to the clinic and is told that he is receiving a new medication that switches him from an MDI to a DPI for delivery of an inhalant. Which of the following steps used in administering an MDI is not part of a DPI administration?
1 Do not repeat an inhalation until next scheduled dose.
2 Always count remaining doses.
3 Hold your breath for 10 seconds after an inhalation.
4 Be sure to coordinate a puff with inhalation. |
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Definition
| 4; Rationale: a DPI is breath activated; there is no need to coordinate puffs with inhalation. |
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Term
7 When administering eardrops to a 5-year-old child, how should the nurse hold the child's ear?
1 Pull the pinna down and back before administering the eardrops.
2 Pull the pinna up and outward before administering the eardrops.
3 Retract the tragus out from ear canal.
4 Have child sit up and pull pinna forward. |
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Definition
| 2; Rationale: A 5-year-old child receives an ear medication the same way as an adult receives it. The nurse straightens the ear canal by pulling the pinna upward and outward. |
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Term
| 8 Fill in the Blank. When administering a medication through a feeding tube, always flush the tubing with ___________ mL of water after each medication. After the last medication flush the tubing with _________ mL of water. |
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Definition
| When administering a medication through a feeding tube, always flush the tubing with 15-30 mL of water after each medication. After the last medication flush the tubing with 30 to 60 mL of water. |
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Term
9 When inserting a vaginal suppository, which of the following techniques is/are not correct? Select all that apply.
1 Have the patient void before insertion.
2 Have patient lie on left side.
3 With dominant gloved hand insert suppository along posterior wall of vaginal canal entire length of finger (7.5 to 10 cm [3 to 4 inches]).
4 With dominant glove hand insert the suppository 10 cm (4 inches) into the vaginal canal. |
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Definition
| 2, 4; Rationale: No. 2 is the correct position for a rectal suppository insertion, and No. 4 is the correct distance for inserting a rectal suppository. Steps 1 and 3 are correct for a vaginal suppository insertion. |
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Term
| 10 Short Answer: Describe the first two steps the nurse should follow before the administration of any nonparenteral medication. |
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Definition
| The first two steps include (1) checking accuracy and completeness of MAR with health care provider's written medication order, including patient's name, drug name, form (foam, jelly, cream, tablet, suppository, or irrigating solution), route, dosage, and time of administration; and (2) reviewing pertinent information related to medication, including action, purpose, normal dose, side effects, and nursing implications. |
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Term
| 1 The nurse is preparing to care for a patient with a newly diagnosed thrombophlebitis who is scheduled to receive heparin 5000 units subcutaneously now and every 8 hours. The heparin comes from the pharmacy as a multidose vial. What does the nurse need to know about the medication and vial before administering? |
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Definition
| 1 Answer: The nurse needs to know the following: the drug classification, effect, and nursing implications related to heparin therapy; the patient's current diet, OTC, herbal supplements, and medications to ensure that there is no increased risk of bleeding; and the safe medication dose, which must be compared to the order before administration. The nurse needs to calculate how many milliliters to draw from the vial and if he or she needs a filter needle. |
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Term
| 2 The nurse finds that, in addition to heparin, her patient is also receiving morphine sulfate 1 mg IV push every 8 hours as needed for pain. The patient has no allergies, and the nurse has reviewed medication references and the health care provider's order. What additional factors does the nurse need to assess before administering the morphine? |
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Definition
| Answer: The nurse needs to assess the rate per minute to administer and the IV compatibility of the medication. She also needs to assess the patency of the IV and the condition of the IV site. |
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Term
3 The nurse is mixing two medications in one syringe. One medication is in a vial, and the other is in an ampule. Which is the initial correct step to prepare the medication?
1 Check the volume of medication in syringe.
2 Draw up medication from the ampule first.
3 Shake the medication in the vial to ensure that there is no cloudiness.
4 Draw up the medication from the vial first. |
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Definition
| 4; Rationale: Medication is drawn from the vial first to prevent contamination of the vial with medication from the ampule. |
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Term
4 Which of the following assessment findings indicates a positive TB reaction in a patient with no known risk factors for TB?
1 A large area of redness and swelling at the injection site
2 An induration of 18 mm
3 Frequent, productive cough accompanied by a fever
4 Sudden onset of shortness of breath and wheezing |
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Definition
| 2; Rationale: An induration of greater than 10 mm in a healthy individual indicates TB exposure and requires follow-up. |
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Term
5 Which of the following symptoms may indicate that a patient has sustained an injury to a nerve after an IM injection?
1 Pain, numbness, and tingling at the injection site 2 hours after the injection
2 Pain experienced during the injection
3 Urticaria, eczema, wheezing, and dyspnea
4 Nausea, vomiting, and diarrhea |
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Definition
| 1; Rationale: Symptoms indicate paresthesia and should not be present after an IM injection. |
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Term
6 Match the best needle size to use when administering an injection in each situation listed.
1 25-gauge, to 1-inch ______
2 22-gauge, _______
3 27-gauge, ______
a Intradermal Mantoux test
b Children older than 1 year
c Average size 30-year-old female |
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Definition
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7 A patient is to receive a subcutaneous injection of heparin. The patient is 5 feet, 2 inches tall and weighs 135 pounds. The nurse plans to administer the injection in the abdomen. The most appropriate needle size to use for this injection is:
1 18 gauge, inch
2 20 gauge, 1 inch
3 22 gauge, inch
4 25 gauge, inch |
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Definition
| 4; Rationale: This is an appropriate size needle for administering a subcutaneous medication. |
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Term
8 The nurse needs to reconstitute a medication for a subcutaneous injection. Which action would indicate the procedure is completed correctly?
1 She shakes the vial after the fluid is injected into the vial to mix it completely.
2 She determines the amount of prepared medication and concentration before adding the appropriate diluent.
3 The powder is injected into the vial of diluent.
4 She evaluates the concentration after the diluent and powder are mixed. |
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Definition
| 2; Rationale: The nurse should calculate how much medication will be used for the injection while considering the route. This should be done before the diluent and powder are mixed. |
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Term
9 When you assess your patient's intravenous site, before giving an IV push medication, you note that it is cool, pale and swollen. What should you do?
1 Stop the IV infusion and change it to another site.
2 Slow the rate of the IV infusion.
3 Flush the IV line with a normal saline flush.
4 Take off the IV dressing and place a new one on that is not as tight. |
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Definition
| 1; Rationale: Stop the infusion. The IV line is infiltrated, and the site needs to be changed. |
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Term
10 What is the most important action for the nurse to implement before giving an IV push medication?
1 Assess the IV insertion site.
2 Stop the primary (maintenance) fluid infusion.
3 Dilute the medication to minimize vein irritation.
4 Ensure that the correct filter needle is used to withdraw the medication from the vial. |
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Definition
| 1; Rationale: Assessing the IV site is the nursing priority; medication cannot be given into a problem IV site. |
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Term
Mr. Garcia underwent an emergency appendectomy 3 days ago. His abdominal wound was left open because of intraabdominal contamination at the time of surgery. The dressing to his abdominal wound is changed every 8 hours using a moist saline gauze dressing. Today when the nurse removes the dressing, she notes beige drainage on the gauze. As she examines the base of the wound, she notices yellow loose tissue adhering to the base and a foul odor. The edges of the wound are red and warm.
1 The nurse is assessing the wound and wound drainage. What should be included in the assessment? Select all that apply.
1 Color, amount, and odor of drainage
2 Tissue moist and adherent to the wound base
3 Results of normal saline moist dressing application
4 Color and temperature of wound edges |
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Definition
| 1, 2, 4; Rationale: These are important descriptors that provide information about the wound. Over time the results of a wound assessment help identify how well the wound is healing (pp. 586-587). Information about the moist dressing application does not provide wound assessment information. |
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2 The nurse has consulted with the wound care nurse specialist about the best treatment for Mr. Garcia's wound. The wound care nurse has ordered a wound irrigation using 250 mL of normal saline. Which of the following steps would be included in the wound irrigation? Select all that apply.
1 Leave the gauze dressing in place and irrigate into the gauze.
2 Use a 19-gauge Angio catheter and a 35-mL syringe.
3 Saturate several gauze pads with the normal saline and drizzle the solution into the wound.
4 Direct the solution to the area of the slough tissue.
5 Pour the solution into the wound directly from the container.
6 Wear a protective gown and eye protection.
7 Position patient to allow the wound irrigant to flow out of the wound into a collection device. |
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Definition
| 2, 4, 6, 7; Rationale: The objective of using wound irrigation on this wound is to help clean out the beige drainage and soften the yellow slough tissue. Using a 19-gauge Angio catheter with a 35-mL syringe provides the necessary amount of pressure to clean the wound. Because of the amount of pressure, there may be some splashing from the wound; thus protective garments are advised. The volume of irrigant is high, and it will run out of the wound; using a collection device will collect the wound irrigation runoff. Leaving the gauze in does not give the nurse a clear view of the wound and does not allow the irrigation to reach the wound tissue. Administering the wound irrigant in either No. 3 or 5 will not allow the necessary irrigant pressure to cleanse the wound. |
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Term
3 Mr. Garcia's wound is healing by what method?
1 Primary intention
2 Secondary intention
3 Tertiary intention |
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Definition
| ; Rationale: Because Mr. Garcia's wound was contaminated by the ruptured appendix, his surgeon left the wound open to heal by secondary intention. This allows a moist wound dressing to wick any drainage from the wound and support wound healing. A wound healing by primary intention would have the wound edges approximated. |
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Term
4 Which of the following should be included in an assessment of a wound healing by secondary intention? Select all that apply.
1 Wound location
2 Estimated time to healing
3 Wound dimensions
4 Wound tissue type
5 Dimensions of healing ridge |
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Definition
| 1, 3, 4; Rationale: The location, dimensions, and tissue type are some of the wound assessment parameters that help to determine wound healing progress. The estimate of the wound healing progress is not an objective assessment parameter because the time toward healing depends on many factors that cannot be predicted. A healing ridge is only present in a wound healing by primary intention such as a surgical wound that was approximated with staples. |
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Term
5 When the nurse attempts to empty the Jackson-Pratt bulb drainage collector from her patient with an intraabdominal abscess, she notes no drainage in the collector. Based on the report she received from the outgoing nurse at the beginning of her shift, she knows that he had 100 mL in the drainage collector 8 hours ago. What should her immediate actions be? Select all that apply.
1 Call the surgeon to report her findings.
2 Gently milk the tubing to see if there is a clot in the tubing preventing drainage.
3 Assess the dressing around the tube for drainage.
4 Observe the tube and the area for 8 hours.
5 Gently irrigate the tube with 50 mL of normal saline. |
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Definition
| 2, 3; Rationale: The first intervention would be to gently milk the tubing from the insertion site to the collection device in case something is plugging the tubing. Next the nurse would check to see if the drainage is coming from around the tube rather than through it, as indicated by an increased amount of drainage on the gauze pad. She should do these before calling the surgeon because the Jackson-Pratt drain may only be plugged. It is not advisable to wait 8 hours before any intervention since you know that this patient had 100 mL of drainage only 8 hours ago. Jackson-Pratt drains are not irrigated routinely. |
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Term
6 Which of the follow care measures should be provided to a patient with a Jackson-Pratt drain?
1 Empty the bulb only when it is filled to the top of the container.
2 When the patient is ambulating, place a knot in the tubing to prevent excess drainage.
3 Pin the bulb below the insertion site to facilitate drainage.
4 Lubricate the insertion site to prevent crusting. |
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Definition
| 3; Rationale: The collection bulb should be below the insertion site to facilitate drainage. To prevent pulling of the tube at the insertion site, pin the bulb to the patient's gown. Never allow the bulb to become full because it becomes heavy as it pulls on the insertion site and the full bulb prevents further drainage collection. Never do anything to prevent drainage, and the insertion site should remain dry and clean with no lubrication to the site. |
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Term
7 What is the correct sequence for staple removal from a healing surgical incision?
a Using staple removal, gently place under staple and press the extractor down.
b Put on clean gloves.
c Place Steri-Strips horizontally over the incision.
d Palpate and verify the presence of the healing ridge.
e Explain procedure to patient.
1 c, d, e, b, a
2 e, b, d, a, c
3 e, c, b, a, d
4 e, d, b, a, c |
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Definition
| 2; Rationale: Start by explaining to patient what will happen. After applying gloves to protect patient's incision, determine if the healing ridge is present; if not, do not proceed. Remove staples and apply Steri-Strips. |
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Term
8 What is the recommended amount of pressure for a patient who has NPWT to facilitate wound healing?
1 Up to –250 mm Hg
2 –75 to –125 mm Hg
3 –50 to –100 mm Hg
4 –90 to –190 mm Hg |
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Definition
| 2; Rationale: The recommended amount of pressure to be used in NPWT is −75 to −125 mm Hg. Using more negative pressure can cause harm to the wound and pain to the patient. |
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Term
9 Which of the following interventions fix or prevent a break in the seal on an NPWT adhesive drape? Select all that apply.
1 Use pieces of the adhesive drape over the areas where air is leaking.
2 Stuff small pieces of gauze into the areas that appear to have the leak.
3 Shave the skin before application.
4 Do not use adhesive remover on the skin.
5 Soap the skin around the wound and allow to air dry. |
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Definition
| 1, 3, 4; Rationale: Use pieces of the adhesive drape over the areas where air is leaking. The leak causes a break in the seal, and the suction is no longer effective. Patching maintains the airtight seal. Shave the skin before application. Hair can interfere with the seal of the adhesive drape. Do not use adhesive remover because this can leave a residue, preventing a good seal. Many adhesive removers leave a film on the skin that is greasy and does not allow the adhesive drape to make a good seal. Patching the leaking area with gauze does not work because the gauze does not allow an airtight seal. If soap is used on the periwound area, it must be rinsed off thoroughly to obtain an adequate seal. |
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Term
10 What is the purpose of using Steri-Strips across an incision after staple or suture removal?
1 To keep the incision dry in the areas where the staples or stitches were removed
2 To support the wound by distributing tension across it
3 To keep a 2-cm (about 1 inch) separation together to facilitate healing
4 To conceal the incision from the patient, reducing anxiety |
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Definition
| 2; Rationale: The Steri-Strips provide support to the wound by distributing tension across the wound. |
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Term
1 The nurse is assessing Mr. Bass for pressure ulcer risk using the Braden Scale. Under the moisture subscale she has determined that her patient's skin moisture is related to fecal incontinence. What are two interventions that the nurse can consider as she develops her plan of care to reduce the effects of skin moisture?
1 Application of talcum powder in areas where stool is in contact with the skin
2 Use of a moisture barrier ointment after each bowel movement
3 A fecal incontinence collector
4 Placing several towels under patient's buttocks |
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Definition
| 2 and 3; Rationale: Moisture barrier ointment is applied to areas that will be in contact with the stool. A thick layer prevents the liquid stool from contacting the skin. If the amount of fecal incontinence is high and the consistency is watery to slightly pasty, the use of a fecal incontinence collector can keep the stool from contacting the skin. Talcum powder absorbs moisture and holds the moisture to the skin and should not be used in areas of fecal incontinence. The use of towels under the patient is not indicated because the towels remain moist and damage the patient's skin. |
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Term
2 During Mr. Bass's skin assessment the nurse notes an ulcer at the sacral area. The base of the wound is covered with dark necrotic tissue, and, when she presses on the tissue, it feels soft. What stage is this ulcer?
1 Stage II
2 Stage III
3 Stage IV
4 Not stageable |
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Definition
| 4; Rationale: The base of the wound must be visible to determine the true depth of the wound. Until the necrotic tissue is removed, the stage cannot be determined. |
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Term
3 Which of the following patients are likely to have factors that negatively affect wound healing? Select all that apply.
1 A patient whose surgical wound is producing yellowish drainage and whose WBC count is elevated
2 A cancer patient receiving the antiinflammatory drug cortisol
3 An older adult who has been advised to add more sources of vitamin C to her diet
4 A trauma patient who has an open wound that is being treated with a moist dressing |
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Definition
| 1, 2; Rationale: The patient with the surgical wound most likely has an infection that delays wound healing as the inflammatory phase of wound healing is prolonged. A steroid such as cortisol also delays the inflammatory phase of wound healing. Vitamin C and a moist dressing are factors that promote wound healing. |
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Term
4 Mrs. Gibbs is a 71-year-old patient who has been in the intensive care unit for 48 hours. She has an endotracheal tube inserted through the mouth to maintain ventilation. She has an intravenous (IV) line infusing at 125 mL/hr. Her abdominal wound over the right lower quadrant is dry and intact. The nurses have placed pillows under both ankles. Turning the patient is difficult because she weighs 320 pounds. She is most likely to be at risk for pressure ulcers in which of the following locations? Select all that apply.
1 Heels
2 Posterior bony prominences
3 Nose
4 Mouth
5 IV site |
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Definition
| 2, 4; Rationale: Mrs. Gibbs is at risk for pressure ulcers at the mouth or lips because of the endotracheal tube location. All patients have the risk of pressure ulcers over bony prominences, but Mrs. Gibb's risk is greater posteriorly because of her weight and difficulty turning. The pillows remove the risk of heel ulcers, and the IV site is not subject to pressure. There is no tube exiting the patient's nose. |
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Term
5 When using gauze moistened in normal saline for a wound dressing, why is the gauze pad wrung out before application?
1 To prevent excessive delivery of the solution to the wound
2 To keep the healing wound moist and wick any excessive drainage
3 To prevent moistening the secondary dressing and causing maceration
4 To allow the wound to become slightly dry to facilitate healing |
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Definition
| 2; Rationale: A moist saline gauze dressing provides a moist environment to the wound and wicks away excessive drainage, facilitating healing. |
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Term
6 What is the primary mechanism of action of a hydrocolloid dressing?
1 It covers the wound, preventing staff or patient from viewing the affected area.
2 It forms a gel over the wound to facilitate moist wound healing.
3 It forms a temporary membrane over the wound, allowing oxygen transport directly to the wound.
4 It delivers epithelial growth factors to the wound base. |
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Definition
| 2; Rationale: A hydrocolloid dressing interacts with the moist wound base and forms a gel over the wound to support moist wound healing. |
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Term
7 The dressing ordered for a patient's sacral pressure ulcer is a hydrocolloid dressing. Place the following steps in appropriate order for the dressing application:
a Cleanse wound with ordered solution.
b Remove paper backing from dressing.
c Explain to patient the purpose of the dressing change.
d Position patient to gain access to the pressure ulcer.
e Measure wound to determine correct size of dressing.
f Place dressing over wound; apply light pressure for 30 to 60 seconds.
1 a, c, e, f, b, d
2 c, d, a, e, b, f
3 c, d, a, e, b, f
4 e, a, c, d, b, f |
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Definition
| 3; Rationale: Explain the purpose of the dressing change to the patient before application. Position him in a way that provides easy access to wound for cleansing. Once cleansed, the entire wound can be visualized and measured to determine the correct size of hydrocolloid dressing (as the dressing should extend at least 2.5 cm (1 inch) beyond the wound edge. The dressing adheres best is gently pressed to the skin. |
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Term
8 Which of the following patients is most at risk for developing a pressure ulcer?
1 An 80-year-old adult with Alzheimer's who has poor oral intake
2 A 45-year-old male who is confined to a wheelchair as a result of paraplegia
3 A 50-year-old male with type I diabetes who underwent major heart surgery 24 hours ago and has diaphoresis
4 A 60-year-old female who underwent bladder surgery and now has urinary incontinence |
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Definition
| 3; Rationale: All four patients have some risk factors for developing a pressure ulcer. However, the 50-year-old patient has more factors, three, placing him at risk: poor circulation from diabetes, limited mobility from his postoperative status, and presence of diaphoresis. |
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Term
9 A patient is admitted to the intensive care unit with pneumonia and renal failure. He is receiving IV fluids of and is NPO. He has been diaphoretic and febrile and requires linen changes each shift. He is able to turn in bed but requires reminding. He is confined to bed. He is able to respond verbally and describe sources of discomfort. Which category on the Braden Scale is not included in this assessment?
1 Nutrition
2 Activity
3 Frictional shear
4 Moisture |
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Definition
| 3; Rationale: The category of frictional shear should be added. |
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Term
Mr. Alberts is a 73-year-old male who is 2 weeks postoperative for an open right colectomy. His surgical course was complicated by a wound dehiscence and subsequent infection. He has an open abdominal wound that measures 4 × 3 cm with a depth of 1.5 cm and 2 cm with undermining at 12:00. The wound has a moderate amount of serosanguineous drainage. The periwound skin is intact. His wound care regimen consists of daily packing with a hydrogel gauze.
1 Mr. Alberts has been premedicated and is ready for his dressing change. The nurse has removed the old dressing and inspected the wound bed and drainage. Place the following steps for applying Mr. Alberts’ new dressing in the correct order:
a Cleanse wound.
b Moisten 4 × 4–inch gauze in sterile saline.
c Perform hand hygiene.
d Cover gel gauze with a moisture-retentive dressing.
e Blot dry any remaining saline on skin with gauze.
f Gently cover the wound bed with hydrogel gauze.
g Apply sterile gloves or use no-touch technique with sterile forceps. |
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Definition
| c, b, g, a, e, f, d; Rationale: Using any other order would contaminate the dressing change and increase the patient risk for a wound infection. |
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Term
Mr. Alberts is a 73-year-old male who is 2 weeks postoperative for an open right colectomy. His surgical course was complicated by a wound dehiscence and subsequent infection. He has an open abdominal wound that measures 4 × 3 cm with a depth of 1.5 cm and 2 cm with undermining at 12:00. The wound has a moderate amount of serosanguineous drainage. The periwound skin is intact. His wound care regimen consists of daily packing with a hydrogel gauze.
2 Mr. Alberts’ packing strips are impregnated with hydrogel gauze. What are the benefits of using this type of dressing for his wound? Select all that apply.
1 Impregnated dressings have antimicrobial properties.
2 Dressings are less painful to remove.
3 Dressing has absorptive properties.
4 Gauze strips can be used to pack wound bed and undermined area. |
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Definition
| 2,3,4; Rationale: Hydrogel dressings are nonadherent and easy to remove. The hydrogel gauze can be easily packed into a wound and any dead space. This type of dressing is appropriate for Mr. Alberts who has 2 cm of tunneling not visible in the wound bed. The hydrogel dressings have absorptive properties and are designed to hydrate wounds. They do not have antimicrobial properties. |
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Term
3 A transparent film dressing is indicated for all but which of the following types of applications?
1 A 2-cm deep wound with copious amounts of serous drainage
2 A newborn with a skin tear
3 A laparoscopic cholecystectomy wound 1 day after surgery
4 A protective cover for an intravenous catheter |
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Definition
| 1; Rationale: A transparent dressing is a clear, adherent, nonabsorptive polyurethane moisture- and vapor-permeable dressing that can be used to manage superficial, minimally draining wounds. A transparent dressing would be inappropriate for a deep draining wound. |
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Term
4 Which of the following is not characteristic of an ideal dressing?
1 Maintains a core temperature of 37° C
2 Is impermeable to microorganisms
3 Removes exudate and allows the wound to dry
4 Is cost effective |
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Definition
| 3; Rationale: A dressing should remove exudate, but it is important not to dry out the wound. Tissue growth takes place best in a moist, warm environment. |
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Term
5 One hour ago an NAP applied an abdominal binder after the nurse observed the patient's condition. Which of the following observations pertain to the patient's tolerance to the binder?
1 The length of time the binder has been applied
2 The patient's ability to cough
3 The condition of the wound under the binder
4 The patient's heart rate |
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Definition
| 2; Rationale: It is important for the NAP to observe the patient's ventilation, determined by the ability to deep breathe and cough. This should be reported to the nurse. The length of time a binder has been applied does not indicate the patient's tolerance. The patient's heart rate does not reveal if the binder is too tight and does not measure local circulation. The condition of the wound is an important observation but does not pertain to the patient's tolerance of the binder. |
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Term
6 Which of the following statements about bacterial wound colonization is correct?
1 Signs of bacterial colonization include a sudden deterioration of the wound along with changes in the amount, color, and odor of the drainage.
2 Most chronic wounds are colonized or contaminated with low levels of bacteria.
3 Bacterial colonization is an urgent issue that requires an aggressive response to preserve wound healing.
4 Bacterial infection and colonization present with similar symptoms and require similar interventions. |
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Definition
| 2; Rationale: Unlike bacterial infections, colonization is a chronic state in which low levels of bacteria exist in the wound but do not interfere with wound healing. Colonized wounds do need to be monitored for signs of bacterial overgrowth that may lead to infection. |
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Term
7 Which of the following signs indicate that an abdominal binder has been applied too tightly? Select all that apply.
1 The patient reports a pulling sensation while ambulating.
2 A new skin abrasion is noted under the binder, just proximal to the intact dressing.
3 The patient is able to perform cough and deep-breathing exercises.
4 The patient reports new pain with deep inspiration. |
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Definition
| 2,4; Rationale: A binder applied too tightly can cause skin breakdown where the binder is rubbing against skin that is unprotected by a dressing. It can also restrict comfortable full chest expansion, thereby adversely affecting respiratory status. A pulling sensation while ambulating indicates a binder that is too loose and needs to be adjusted. |
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Term
8 Which of the following dressings are appropriate for a wound that requires debriding? Select all that apply.
1 Transparent dressing
2 Moist-to-dry dressing
3 Hydrocolloid gel
4 Dry dressing |
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Definition
| 2,3; Rationale: Moist-to-dry and hydrocolloid gels both have debriding properties. A transparent dressing is appropriate for superficial, minimally draining wounds and does not have debriding capability. A dry dressing should never be used for debriding because it is likely to cause injury to new tissue. |
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Term
9 Which of the following wound characteristics would be appropriately treated by a foam dressing?
1 A dry venous stasis ulcer
2 A heavily exudating stage III sacral ulcer
3 A small, open abdominal wound with tunneling and copious drainage
4 A skin abrasion with minimal drainage. |
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Definition
| 2; Rationale: A foam dressing is appropriate for moderate-to-heavy amounts of exudate. It generally needs to be changed daily to prevent maceration of periwound skin once the foam has reached it absorption capacity. It is not appropriate for dry wounds or any wounds with tunneling. |
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Term
10 A nurse who is changing a dry gauze dressing over a patient's postoperative incision notices that the dressing is soiled with old sanguineous drainage. The gauze is sticking to dried drainage from the incision line. What should the nurse do to remove the dressing without causing injury to the incision?
1 Pull it off and alert the patient to possible discomfort.
2 Moisten the dressing with normal saline and then remove it.
3 Remove all layers of gauze at the same time, lifting off the incision.
4 Irrigate the wound before applying the dry dressing. |
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Definition
| 2; Rationale: When removing a dry dressing, moisten it first. Once it loosens, remove it gently. Never pull a dry dressing that adheres to a wound because this can injure the wound edges. The nurse always removes a single layer of gauze at a time to be sure that she does not disrupt underlying drains. Irrigating a wound before applying a dressing will not determine if the dressing sticks or not. |
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Term
A 73-year-old patient arrives in the nursing unit following a total knee arthroplasty procedure. The nurse notes swelling and redness of the affected extremity, and the patient complains of pain of 7 on a scale of 0 to 10. The patient has an order for an ice bag to the region.
1 Which of the following is most appropriate for the nurse to do to correctly prepare ice for application to the wound?
1 Fill the bag with ice; add air to increase surface area.
2 Water test the bag to be sure that it has no leaks.
3 Expose the skin in the affected area to ready it for ice application.
4 Assess the area for numbness and tingling before application. |
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Definition
| 2; Rationale: Fill the bag and empty it to be sure that it has no leaks. This prevents maceration from unnecessary moisture. |
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Term
A 73-year-old patient arrives in the nursing unit following a total knee arthroplasty procedure. The nurse notes swelling and redness of the affected extremity, and the patient complains of pain of 7 on a scale of 0 to 10. The patient has an order for an ice bag to the region.
2 The patient is 5 minutes into having the ice pack applied. The patient reports that pain is still 7 on a scale of 0 to 10 and slight numbness to the area that is iced. The patient also reports feeling chilled and uncomfortable. Which of the following actions would be most appropriate for the nurse to take at this time?
1 Add fresh ice to the treatment to ensure that continuous cold is applied.
2 Discontinue the cold therapy and document that patient was chilled.
3 Administer prescribed pain medication to reduce pain to the affected area.
4 Inform patient that chilling is normal and continue the treatment for an additional 10 minutes. |
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Definition
| 2; Rationale: Chilling is an undesirable effect of the administration of cold therapy. It is appropriate to discontinue the treatment to allow the patient to warm and resume it at a later time when appropriate covering for the patient can be provided to maintain warmth. |
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Term
A 73-year-old patient arrives in the nursing unit following a total knee arthroplasty procedure. The nurse notes swelling and redness of the affected extremity, and the patient complains of pain of 7 on a scale of 0 to 10. The patient has an order for an ice bag to the region.
3 Which of the following would indicate a successful treatment plan using cold therapy? Select all that apply.
1 Patient reports a reduction of pain from 5 to 2 on a scale of 0 to 10.
2 Edema has been reduced over a 12-hour shift.
3 The skin has become mottled.
4 The patient has decreased his need for oral analgesics. |
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Definition
| 1,2,4; Rationale: Reduction of pain, edema, and need for analgesics are all potential desired outcomes of cold therapy. |
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Term
A 73-year-old patient arrives in the nursing unit following a total knee arthroplasty procedure. The nurse notes swelling and redness of the affected extremity, and the patient complains of pain of 7 on a scale of 0 to 10. The patient has an order for an ice bag to the region.
4 Which of the following assessment findings is a contraindication for use of cold therapy?
1 A patient with acute inflammation
2 A patient with impaired circulation
3 A patient with severe pain
4 A patient suffering trauma within the past 24 hours |
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Definition
| 2; Rationale: A patient with a preexisting condition that impairs circulation would be at greater risk for injury because of the vasoconstrictive action of cold applications. |
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Term
5 What is a major concern with the prolonged application of moist heat?
1 Maceration
2 Cramping
3 Erythema
4 Dermatitis |
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Definition
| 1; Rationale: Moisture in combination with heat increases the risk of developing macerated skin. |
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Term
6 Performing which of the following actions would be inappropriate when applying moist heat therapy to a patient?
1 Performing a neurovascular assessment before heat application
2 Using a low setting on the microwave to heat the compress
3 Checking affected joint ROM after application
4 Removing compress before 20 minutes has passed |
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Definition
| 2; Rationale: Use of microwaves to heat compresses places the patient at risk from injury because of the uneven heating that occurs. In addition, placing objects such as moist towels into a microwave may be a violation of safety and fire regulations of the facility. |
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Term
| 7 The application of ______________________ would achieve the most effective deep penetrating heat. Fill in the blank. |
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Definition
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Term
| 8 Assessment findings of _______________ skin would be an indication of prolonged exposure to cold from a cold gel pack. Fill in the blank. |
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Definition
| Chilled, mottled, or bluish; Rationale: Mottled, reddened, or bluish purple skin are indications of prolonged exposure to cold. |
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Term
9 A patient has an order for heat application following a muscle strain to the back. Which nursing intervention would be the priority for the prevention of injury in this situation?
1 Frequently assessing the setting on the heat delivery system
2 Placing a plastic wrap over the compress for better penetration
3 Frequently assessing the area where the heat is being applied
4 Encouraging the patient to increase his oral fluid intake |
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Definition
| 3; Rationale: Frequent assessment of the area receiving heat therapy must be done to prevent breakdown of the skin. |
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Term
Mrs. Jones, a 62-year-old, white female, is 3 days post-op following a left total knee replacement. She has been receiving IV fluids of D5 NS solution at 83 mL/hr via an EID. Mrs. Jones has a 20-g 1-inch Insyte IV device in her L midcephalic. When getting report, the nurse finds out she has been c/o nausea and is unable to eat. Her blood work reveals she is mildly dehydrated, but her VS are stable. After calling her surgeon, Mrs. Jones is to continue her IV fluids for 2 more days. Her IV site is without signs/symptoms of IV-related complications and had been restarted yesterday.
1 Mrs. Jones is due for her next bag of IV fluids. Place in order the steps to change the IV bag.
a Remove spike from old IV bag.
b Label new IV bag with date, time, and time of completion.
c Close roller clamp on old IV tubing.
d Check for air in tubing.
e Regulate flow rate.
f Insert spike into new IV bag.
g Remove new IV bag from refrigerator at least 1 hour before hang time. |
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Definition
| g, c, a, f, d, e, b; Rationale: Medication must be removed from refrigerator before infusion. Cold IV fluids can cause arrhythmias and bubbles in tubing. Closing roller clamp prevents fluid from leaking from tubing. Removing spike from old IV tubing maintains sterility and prevents tubing from running dry. Inserting spike into new IV bag ensures no break in therapy and maintains sterility. Air in tubing can cause emboli and be fatal to patient. Regulating flow rate ensures that correct rate of fluid is given. Labeling bag provides for accuracy when assessing right patient right medication; ensures that fluid is running on time. |
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Term
Mrs. Jones, a 62-year-old, white female, is 3 days post-op following a left total knee replacement. She has been receiving IV fluids of D5 NS solution at 83 mL/hr via an EID. Mrs. Jones has a 20-g 1-inch Insyte IV device in her L midcephalic. When getting report, the nurse finds out she has been c/o nausea and is unable to eat. Her blood work reveals she is mildly dehydrated, but her VS are stable. After calling her surgeon, Mrs. Jones is to continue her IV fluids for 2 more days. Her IV site is without signs/symptoms of IV-related complications and had been restarted yesterday.
2 Thirty minutes after hanging her new 1 L bag of IV fluids, Mrs. Jones rings her call bell. On entering her room the nurse notices that her IV bag is empty and she is complaining of shortness of breath and is dyspneic. The nurse's assessment reveals bilateral crackles in lung bases, tachycardia, and increased urinary output. What should she suspect is happening?
1 Fluid volume deficit
2 Fluid volume overload
3 Obstructed IV catheter
4 Air emboli |
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Definition
| 2; Rationale: The IV bag has only been hanging for 30 minutes and is empty at a rate of 83 mL/hr, which would place patient at risk for fluid overload. Signs and symptoms indicate fluid overload. |
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Term
Mrs. Jones, a 62-year-old, white female, is 3 days post-op following a left total knee replacement. She has been receiving IV fluids of D5 NS solution at 83 mL/hr via an EID. Mrs. Jones has a 20-g 1-inch Insyte IV device in her L midcephalic. When getting report, the nurse finds out she has been c/o nausea and is unable to eat. Her blood work reveals she is mildly dehydrated, but her VS are stable. After calling her surgeon, Mrs. Jones is to continue her IV fluids for 2 more days. Her IV site is without signs/symptoms of IV-related complications and had been restarted yesterday.
3 Nursing interventions for Mrs. Jones's condition would include which of the following? Select all that apply.
1 Slow infusion.
2 Check for kinks in IV tubing.
3 Place her in high-Fowler's position.
4 Remove IV device. |
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Definition
| 1, 3; Rationale: IV fluid should continue, but at a slower rate. Placing patient in High fowler's will improve her breathing. Kinks in IV tubing would cause fluid to decrease flow rate or not infuse at all; therefore patient would not experience fluid overload. IV device should not be removed in the event diuretics need to be given, |
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Term
4 Which of the following symptoms are indicative of phlebitis?
1 Tenderness, pitting edema, dyspnea, cough
2 Chest pain, cyanosis, hypotension, weak pulse
3 Headache, nausea, diarrhea, chills
4 Pain, erythema, induration, swelling |
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Definition
| 4; Rationale: Signs and symptoms of phlebitis do not include respiratory, cardiac or GI presentations, but they do include the local symptoms of erythema and pain. |
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Term
5 A patient is receiving a blood transfusion of PRBC following a total hip replacement. The nurse checks the vital signs 30 minutes after beginning the transfusion and finds an oral temperature of 101° F, pulse 100 bpm, and a respiratory rate of 20. What is the nurse's first priority?
1 Notify the physician.
2 Stop the transfusion and begin the NSS infusion.
3 Notify the Blood Bank immediately.
4 Wait 30 minutes and repeat the vital signs.
5 Administer acetaminophen (Tylenol) 650 mg by mouth. |
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Definition
| 2; Rationale: If a transfusion reaction is suspected based on an elevated temperature, pulse, or complaints of itching or presences of hives, the priority nursing intervention is to STOP the blood transfusion but maintain IV access. |
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Term
6 Considerations for selecting an IV catheter for a patient include which of the following?
1 Selecting the longest catheter with a larger gauge
2 Selecting the longest catheter with the smallest gauge
3 Selecting the shortest catheter with a larger gauge
4 Selecting the shortest catheter with the smallest gauge |
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Definition
| 4; Rationale: Based on INS standards of practice, the smallest device and smallest gauge possible to give the prescribed therapy should be used. |
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Term
7 Which is the correct anatomical tip location for a PICC line?
1 Inferior vena cava
2 Midaxillary
3 Antecubital fossa
4 Superior vena cava |
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Definition
| 4; Rationale: According to the INS, optimal tip placement for a central line is the SVC. A PICC is placed in the arm via the antecubital fossa or upper arm; therefore it would be advanced to the SVC. |
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Term
8 A patient returning from surgery has an order for 1000 mL D5NS to infuse at 100 mL/hr. The drop factor on the patient's infusion tubing is 10 gtts/mL. What would be the correct infusion rate?
1 34 gtts/min
2 10 gtts/min
3 60 gtts/min
4 17 gtts/min |
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Definition
4; Rationale: Based on calculations:
10060×101=16.667;round to 17gtts/min. |
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Term
9 Partial PN can only be administered through a CVAD.
1 True
2 False |
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Definition
| 2 (False); Rationale: Partial PN can be administered through either a peripheral device or a central venous device since the osmolarity is less then 600 mOsm/L. Total PN must be given through a central device because the osmolarity is greater than 600 mOsm/L. |
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