Fundamentals Final 2017 Flashcards


Set Details Share
created 6 years ago by BrookeBewley
1,752 views
updated 6 years ago by BrookeBewley
Subjects:
nursing fundamentals
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:

1

A home health nurse is performing a home assessment for safety. Which of the following
comments by the patient would indicate a need for further education?

"When it is cold outside in the winter, I can warm my car up in the garage."

2

The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social
services to address the patient's health care needs?

The electricity was turned off 2 days ago.

3

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients?

. 65° F to 75° F

4

A homeless adult patient presents to the emergency department. The nurse obtains the
following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory
rate 12. Which of the vital signs should be addressed immediately?

Temperature

5

The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection
bag and disposes of the urine, the next step is to

Remove gloves and dispose of in garbage

6

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to

Assess and monitor the patient

7

The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication?

The patient states, "I will finish the antibiotic in ten days."

8

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to

Growing ability to explore and oral activity

9

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of

a bicycle helmet.

10

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points?

Adolescents need information about the effects of beer on the liver.

11

When is a patients temperature usually lowest if at normal levels, with their circadian rhythm?

Between 1-4am

12

A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. During the health history, which of these questions should the nurse prioritize?

. “What medications are you currently taking?”

13

The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to prevent the spread of infection is to

Wash their hands between each interaction with children

14

The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a localized inflammatory response, the nurse should assess for which of these signs and symptoms?

Edema, redness, tenderness, and loss of function

15

Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response?

Rest, ice, compression, and elevation

16

The nurse is caring for a group of medical-surgical patients. The patient most at risk for developing an infection is the patient who

Is recovering from a right total hip arthroplasty

17

The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is priority in this procedure?

Maintain aseptic technique

18

The nurse is caring for a patient who is susceptible to infection. Which of the following nursing interventions will assist in decreasing the risk of infection?

Teaching the patient to select nutritious foods

19

A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which of these interventions would be most appropriate for the nurse to provide?

Don gloves and other appropriate personal protective equipment

20

Localized Infection:

Patient experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site.

21

Systemic Infection:

An infection that affects the entire body instead of just a single organ and can become fatal if undetected

22

The posterior hypothalamus helps control temperature by

Causing vasoconstriction.

23

Of the following mechanisms of heat loss by the body, identify the mechanism that transfers heat away by using air movement?

Convection

24

The patient has a temperature of 105.2° F. The nurse is attempting to lower his temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. The nurse is attempting to lower the patient’s temperature through the use of

Conduction

25

When focusing on temperature regulation of newborns and infants, the nurse understands that

Newborns need to wear a cap to prevent heat loss

26

The nurse is working the night shift on a surgical unit and is making 4 AM rounds. She notices that the patient’s temperature is 96.8° F (36° C), whereas at 4 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

Realize that this is a normal temperature variation

27

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). His last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). The nurse should

Wait an hour and recheck the patient’s temperature.

28

The nurse is caring for a patient who has an elevated temperature. The nurse understands that

Hyperthermia occurs when the body cannot reduce heat production.

29

The patient is restless with a temperature of 102.2° F (39° C). One of the first things the nurse should do is

Place the patient on oxygen.

30

The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?

Assessing changes in body temperature

31

The patient requires routine temperature assessment but is confused and easily agitated and has a history of seizures. The nurse’s best option would be to take his temperature

Tympanically.

32

The patient is being admitted to the emergency department following a motor vehicle accident. His jaw is broken, and he has several broken teeth. He is ashen, and his skin is cool and diaphoretic. To obtain an accurate temperature, the nurse uses which of the following routes?

Rectal

33

The nurse is caring for an infant and is obtaining the patient’s vital signs. The best site for the nurse to obtain the infant’s pulse would be the _____ artery.

Brachial

34

The patient is found to be unresponsive and not breathing. To determine the presence of central blood circulation and circulation of blood to the brain, the nurse checks the patient’s _____ pulse.

Carotid

35

The nurse needs to obtain a radial pulse from a patient. To obtain the correct measure, what must the nurse do?

Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist.

36

The patient’s blood pressure is 140/60. The nurse realizes that this equates to a pulse pressure of

80

37

Which statement is true of the ovulation phase?

Body temperature is at previous baseline levels or higher.

38

To provide patient care of the highest quality, nurses utilize an evidence-based practice approach because evidence-based practice is

A guide for nurses in making clinical decisions.

39

In caring for patients, it is important for the nurse to realize that evidence-based practice is

Dependent on patient values and expectations.

40

The first step in evidence-based practice is to ask a clinical question. In doing so, the nurse needs to realize that in researching interventions, the question

May be easier if in PICO format.

41

In collecting the best evidence, the gold standard for research is

The randomized controlled trial (RCT).

42

The nurse is developing a PICO question related to whether her patient’s blood pressure is more accurate while measuring with the patient’s legs crossed versus with the patient’s feet flat on the floor. With P being the population of interest, I the intervention of interest, C the comparison of interest, and O the outcome, the nurse determines that this is

A true PICO question regardless of placement of elements.

43

Note that a well-designed PICO question does not have to follow the sequence of P, I, C, and O. The aim is to ask a question that contains as many of the PICO elements as possible.

Studies phenomena that are difficult to quantify.

44

The nurse has used her PICO question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more support staff than is available at this time. What is the nurse’s best option?

Conduct a pilot study to develop evidence to support the change.

45

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation for patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. What type of research is the nurse conducting?

Qualitative research

46

In conducting a research study, the researcher must guarantee that any information the subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team. This concept is known as

Confidentiality.

47

When evaluating quality improvement (QI) programs in relation to evidence-based practice (EBP), it is easy to note that

When implementing EBP projects, it is important to review QI data.

48

The hospital’s quality improvement committee has identified a problem on one of the units. In using the PDSA method to help determine ways to deal with the issue, the committee decides to do a literature review. This is an example of quality improvement

Combined with evidence-based practice.

49

The hospital quality improvement committee has noted that the incidence of needlestick injuries on a particular unit has increased. When faced with issues, the committee applies the PDSA model, a formal model for exploring and resolving quality concerns. Because the committee is multidisciplinary in nature, and few members are nurses, it is imperative that the committee first

Plan

50

An argument for passing “universal health care” legislation is that it would help fulfill the Healthy People 2020 goal of

Eliminating health disparities in America.

51

To increase quality and years of healthy life, Healthy People 2020 focuses on four areas. One of those areas is

Creating social and physical environments that promote good health.

52

According to the World Health Organization, what is the best definition for “health”?

Involving the total person and environment

53

The health care model that utilizes Maslow’s hierarchy as its base is the _____ Model.

Basic Human Needs

54

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood sugars. During the admission process, the nurse asks the patient about her employment status and displays a nonjudgmental attitude. Why does the nurse do this?

A person’s compliance is affected by economic status.

55

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. In doing so, the nurse is fostering the concept of

Passive health promotion.

56

The nurse is working in a clinic that is designed to provide health education and immunizations. As such, this clinic is designed to provide

Primary prevention.

57

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. She is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. What level of preventive care is this patient receiving?

Secondary prevention

58

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. What are these examples of?

Tertiary prevention

59

The National Coalition for Cancer Survivorship has defined a cancer survivor as a person who has

Had cancer until he or she dies.

60

When working with cancer survivors, the nurse must understand that cancer survivors

Seek a balance between independence and interdependence.

61

The nurse is caring for a cancer survivor who has been hospitalized in the intensive care unit (ICU) for an unrelated and stable problem. The ICU has posted visiting hours, but some of the patient’s family is from out of town and would like to see her even though it is not time. The patient has also voiced a desire to see her family. The nurse allows the family to visit even though it is not the “official” visiting time. Why would the nurse do this?

Believes that the visit will help relieve psychological stress

62

The nurse is caring for a young woman with breast cancer. The stress between the woman and her husband is obvious, as is anxiety among the children. What is the nurse’s best action in this situation?

Help find or develop an educational program for the patient and her husband.

63

The nurse is caring for a patient diagnosed with cancer. The family of the patient asks the nurse for information. What should the nurse do?

Offer information about the different resources available.

64

The patient has lung cancer and voices concerns about his cancer treatment. He wants to know how chemotherapy will affect his sexuality. What is the nurse’s best reply?

“Sexual changes are common with cancer therapy. Let me get someone who can answer your questions.”

65

The nurse is caring for a patient who has successfully undergone cancer therapy and will be discharged home soon. The patient is concerned about going home and not knowing what to do. The nurse reassures the patient, telling him that

He will be part of a team that will provide any support and care that he may need.

66

Nurses and other health care providers need to become more vigilant in recognizing cancer survivors and attempting to link them with the support and resources that they require because

Many survivors are discharged with no survivor plan.

67

The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as

Osmosis.

68

The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?

Calcium of 17.5 mg/dL

69

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect?

Abdominal distention

70

The nurse would not expect full compensation to occur for which acid-base imbalance?

Respiratory alkalosis

71

A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother’s purse. The nurse knows that the child is at greatest risk for which acid-base imbalance?

Respiratory acidosis

72

Which organ system is responsible for compensation of respiratory acidosis?

Renal

73

The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect?

pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L

74

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?

Potassium imbalance

75

If obstructed, which component of the urination system would cause peristaltic waves?

Ureters

76

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding?

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding?

77

Critical thinking characteristics include

Considering what is important in a given situation.

78

Which of these patient scenarios is most indicative of critical thinking?

Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past

79

Professional nurses are responsible for making clinical decisions to

Take immediate action when a patient’s condition worsens.

80

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making?

Improves a plan of care while thinking back on interventions performed

81

A nursing instructor needs to evaluate students’ abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor’s needs?

Concept mapping

82

Concept mapping

A scientific knowledge base

83

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following?

Using the nursing process

84

The critical thinking skill of evaluation in nursing practice can be best described as

Reviewing the effectiveness of nursing actions.

85

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

Explore other options for pain relief.

86

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by

Asking for an orientation to the unit.

87

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse

Completes a comprehensive database.

88

A nurse using the problem-oriented approach to data collection will first

Focus on the patient’s presenting situation.

89

After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make?

Ask the nursing assistant to record the patient’s vital signs before administering medications.

90

Subjective data include

A patient’s feelings, perceptions, and reported symptoms.

91

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that

The patient is apprehensive about discharge.

92

Which of the following methods of data collection is utilized to establish a patient’s nursing database?

Which of the following methods of data collection is utilized to establish a patient’s nursing database?

93

To gather information about a patient’s home and work surroundings, the nurse will need to utilize which method of data collection?

Perform a thorough nursing health history.

94

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should

Consider cultural differences during this assessment.

95

After setting the agenda during a patient-centered interview, what will the nurse do?

Conduct a nursing health history.

96

Components of a nursing health history include

Patient expectations.

97

One purpose of using standard formal nursing diagnoses in practice is to

Distinguish the nurse’s role from the physician’s role.

98

Which diagnosis below is NANDA-I approved?

Acute pain

99

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as

Diagnostic reasoning.

100

The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function labs are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Diagnosis

101

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process?

Diagnosis

102

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by

Reassessing the patient.

103

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by

Turning side to back to side with assistance every 2 hours.

104

The following statements are on a patient’s nursing care plan. Which of the following statements is written as an outcome?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

105

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements?

The patient will feed self at all mealtimes today without complaints of shortness of breath.

106

A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Involve the son in the plan of care as much as possible.

107

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications?

Patient will have one soft, formed bowel movement by end of shift.

108

In which step of the nursing process does the nurse provide nursing care interventions to patients?

Implementation

109

The nurse defines a clinical guideline or protocol as a

Document that assists the clinician in making decisions and choosing interventions for specific health care problems or conditions.

110

Before implementing any intervention, the nurse uses critical thinking to

Determine whether an intervention is correct and appropriate for the given situation.

111

The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache. After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse

Administers the Tylenol.

112

Which of the following is a nursing intervention?

Provide assistance while the patient walks in the hallway twice this shift with crutches.

113

A patient visiting with family members in the waiting area tells the nurse that his stomach is not feeling good. Before intervening, what should the nurse do?

Ask the patient to return to his room so the nurse can inspect his abdomen.

114

In which step of the nursing process does the nurse determine if the patient’s condition has improved and whether the patient has met expected outcomes?

Evaluation

115

A nurse is getting ready to discharge to home a patient who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the patient’s plan of care, what does the nurse need to do?

Evaluate whether patient goals and outcomes have been met.

116

The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

Absence of skin breakdown

117

A goal for a patient with a diagnosis of Ineffective coping is to demonstrate effective coping skills. Which of these patient behaviors indicates that interventions performed to meet this outcome have been successful?

States he feels better after talking with his family and friends

118

An acquaintance of a nurse asks for a nonmedical approach for excessive worry and work stress. The most appropriate CAM therapy that the nurse can recommend is

Meditation

119

The therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness is _____ medicine.

Allopathic

120

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following?

Maturational and sociocultural factors

121

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention?

Tertiary

122

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below.

Sensory peaceful words

123

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating “No way, I’m not crazy.” The best response the nurse can give is which of the following?

“Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness.”

124

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will

Reassess patient’s stress-related symptoms and compare with expected outcomes.

125

An adult male reports new-onset seizurelike activity. An EEG and a neurology consultant’s report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurse’s next best action would be to

Obtain history of any recent life stressors.

126

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to

Identify limits and scope of work responsibilities.

127

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to

Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

128

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism?

Denial

129

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?

Ask the patient to rate the level of pain.

130

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient’s blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

“What would you like to try to alleviate your pain?”

131

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

Meaning of pain

132

The nurse anticipates administering an opioid fentanyl patch to which patient?

A 50-year-old patient with prostate cancer

133

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

Relaxation and guided imagery

134

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?

“I feel less anxiety about the possibility of overdosing.”

135

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?

“We should work together to create a regular schedule of medications that does not allow for breakthrough pain.”

136

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.” What type of pain does the nurse document that the patient is having at this time?

Visceral pain

137

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?

The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

138

The nurse recognizes that which of the following is a modifiable contributor to a patient’s perception of pain?

Anxiety and fear

139

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include

Alteration in level of consciousness.

140

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is

Pressure.

141

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?

The patient has fecal incontinence.

142

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer?

Healing stage III pressure ulcer

143

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage

II.

144

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?

Granulation

145

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by

Primary intention.

146

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by

Secondary intention.

147

Which nursing observation would indicate that a wound healed by secondary intention?

Scarring can be severe.

148

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing?

The incision has a mass, bluish in color.

149

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?

Complaint by patient that something has given way

150

A patient has developed a decubitus ulcer. What laboratory data would be important to gather?

Serum albumin

151

Which of the following would be the most important piece of assessment data to gather with regard to wound healing?

Pulse oximetry assessment

152

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased

Protein.

153

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes

Débridement of the wound.

154

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question?

Irrigate with hydrogen peroxide.

155

The nurse is precepting a student nurse and explains that perioperative nursing care occurs

Before, during, and after surgery.

156

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient’s laboratory tests and allergies. In which perioperative nursing phase would this work be completed?

Preoperative

157

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as

Emergency.

158

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse’s best next step?

Assess for the presence of anxiety, pain, or fatigue.

159

The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, the nurse understands that

The patient’s illness may require teaching of new hygiene practices.

160

The nurse is caring for a patient who refuses “AM care.” When asked why, the patient tells the nurse that she always bathes in the evening. The nurse should

Defer the bath until evening and pass on the information to the next shift.

161

When providing hygiene for an elderly patient, it is important for the nurse to closely assess the skin. This is because as the patient ages

Less frequent bathing may be required.

162

The nurse is bathing a patient and notices movement in the patient’s hair. The nurse should

Use gloves or a tongue blade to inspect the hair.

163

When assessing a patient’s skin, the nurse needs to know that

Moisture on the skin can lead to skin maceration.

164

The nurse is caring for a patient who is immobile. The nurse is aware that the patient is at risk for Impaired skin integrity because

Pressure reduces circulation to affected tissue.

165

The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. The nurse realizes that patients with these conditions

Have decreased pain sensation and increased risk of skin impairment.

166

The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should

Assess all surfaces exposed to the cast for pressure areas.

167

Of the following disorders, which is caused by a virus?

Plantar warts

168

When assessing a patient’s feet, the nurse notices that the toenails are thick and separated from the nail bed. The nurse is aware that this condition is caused by

Fungi.

169

The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because

Foot ulcers are the most common precursor to amputation.

170

The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. The nurses understands that this is important for the patient because

Foot ulcers are the most common precursor to amputation.

171

The nurse is caring for an elderly patient with Alzheimer’s disease who is ambulatory but requires total assistance with his activities of daily living (ADLs). The nurse notices that his skin is dry and wrinkled. The nurse should

Reduce the number of baths per week if possible.

172

The nurse knows that most nutrients are absorbed in which portion of the digestive tract?

Duodenum

173

Which of the following is not a function of the large intestine?

Absorbing nutrients

174

The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because

Mastication triggers the digestive system to begin peristalsis.

175

nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?

Grape and walnut chicken salad sandwich on whole wheat bread

176

A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that

Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.

177

A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement?

Raising the head of the bed

178

Which patient is most at risk for increased peristalsis?

A 21-year-old patient with three final examinations on the same day

179

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate?

“Do you take iron supplements?”

180

Which physiological change can cause a paralytic ileus?

Surgery for Crohn’s disease and anesthesia

181

Fecal impactions occur in which portion of the colon?

Rectum

182

The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient?

A 70-year-old patient with stool incontinence

183

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation?

Use a mobility device to place the patient on a bedside commode.

184

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation?

The patient reports eliminating a soft, formed stool.

185

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

Presence of blood in the stool

186

The nurse should question which order?

A Kayexalate enema for a patient with hypokalemia

187

A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important?

Removing all of the patient’s metallic jewelry

188

In which nursing care model is the RN usually appointed the position of group leader?

Team nursing

189

Which organizational structure approach has fewer directors with managers accountable 24 hours for staff, budget, and day-to-day management?

Decentralized management

190

A staff member verbalizes his satisfaction in working on a particular nursing unit because he appreciates the freedom of choice and responsibility for the choices. This nurse highly values which element of decentralized decision making?

Autonomy

191

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. The nurse manager is providing a learning opportunity in this situation through

Staff education.

192

A nurse is making a home visit and discovers that a patient’s wound infection has gotten worse. After cleaning and re-dressing the wound, what should the nurse do?

Notify the health care provider of the findings before leaving the home.

193

Which of these assessments of a patient who is 1 day post surgery to repair a hip fracture requires immediate nursing intervention?

Patient reports severe pain 30 minutes after receiving pain medication.