1. When describing patient education approaches, the nurse educator would ex- plain that informal teaching is an approach that a. follows formalized
... [Show More] plans b. has standardized content c. often occurs one-to-one d. addresses group needs C. Informal teaching is individualized one on one teaching which represents the majori- ty of patient education done by nurses that occurs when an intervention is explained or a question is answered. Group needs are often the focus of formal patient education courses or classes. Informal teaching does not necessarily follow a specific formalized plan. It may be planned with specific content, but it is individualized responses to patient needs. Formal teaching involves the use of a curriculum/course plan with standardized content. 2. A patient expresses a strong C. Cognitive theorists believe that atten- interest in returning to their work, family, and hobbies af- ter having a stroke. Which theory type would the nurse use to develop a plan of care for the best results of this patient's motivation style? a. field b. biological c. cognitive d. sociologic 3. The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all that apply) a. an older woman with hy- pertension b. a young man with a body mass index of 42 c. a young many who has tion, relevance, confidence, and satisfaction (ARCS) are the conditions that, when in- tegrated, motivate someone to learn. Field theorists place significance on how achieve- ment, power, the need for affiliation, and avoidance motives influence individual be- havior. Sociologic theories are not involved in motivation. C, D, E, F clients with poor nutrition, fatigue, and mul- tiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circula- tion have a higher incidence of frostbite. just consumed six martinis d. an older man who smokes a pack of cigarettes a day e. a young woman who is anorexic f. a young woman who is di- abetic 4. Which statement made by a nurse represents the need for further education regard- ing pain management in old- er adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients c. older adults are at greatest risk for under treated pain d. older clients have a differ- ent pain mechanism and do not feel it as much 5. The nurse is working at a first aid booth for a spring training game on a hot day. D There is no evidence to support the idea that older adult clients perceive pain any different- ly than younger clients. The other statements are accurate regarding older clients and pain. C The spectator shows signs of heat stroke, A spectator comes in, report- which is a medical emergency. The spectator ing that he is not feeling well. should be transported to the ED ASAP. The Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pres- sure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Low- ering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment a. admin tylenol 650 mg oral- ly b. encourage rest, and re- assess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink 6. The client is receiving an IV of 60 mEq of potassi- um chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What inter- vention does the nurse per- form first? a. assess for a blood return b. notify the physician c. document the finding d. stop the IV infusion 7. A nurse is caring for an older adult client who lives alone. Which economic situ- ation presents the most seri- ous problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider bene- fits d. social security as the ba- sis of income D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be success- ful. The solution could be diluted (less potas- sium) and the rate could be slowed once it is determined that the needle is in the vein. D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs 8. Controlling pain is important to promoting wellness. Unre- lieved pain has been associ- ated with a. prolonged stress re- sponse and a cascade of A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response caus- harmful effects system wide. es the endocrine system to release exces- b. decreased tumor growth and longevity c. large tidal volumes and de- creased lung capacity d. decreased carbohydrate, protein, and fat destruction 9. Which intervention in a client with dehydration in- duced confusion is most likely to relieve the confu- sion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position sive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased en- docrine activity in turn initiates a number of metabolic processes, in particular, accelerat- ed carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and in- creased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth and longevi- ty are not associated with unrelieved pain. Decreased carbs, protein, and fat are not associated with pain or stress response. A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can re- duce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depend- ing on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema. d. Measuring intake and out- put every four hours 10. Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cog- nitive impairment d. younger adult client re- ceiving hypertonic IV fluid 11. A nurse is caring for sever- al clients. Which client does the nurse assess most care- fully for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure us- ing a salt substitute c. client taking a thiazide di- uretic for hypertension d. client taking non-steroidal anti-inflammatory drugs dai- ly 12. An older adult client pre- sents with signs and symp- toms related to dig toxici- ty. Which age related change may have contributed to this problem? a. decreased renal blood C Older adults, because they have less to- tal body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and can- not obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration B Many salt substitutes are composed of potas- sium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potas- sium. NSAIDs promote the retention of sodi- um but not potassium. A Decreased renal blood flow and reduced glomerular filtration can result in slower med- ication excretion time, potentially leading to toxic drug accumulation. Aging results in de- creased total body water and gastrointesti- nal motility and an increase in the ratio of flow b. increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass d. increased total body water 13. A client is being treated for dehydration. Which state- ment made by the client indi- cates understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of wa- ter or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat or drink. 14. The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assess- ment one hour ago. Which in- tervention by the nurse is the priority? a. assess the client's respira- tory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure adipose tissue to lean body mass, but is not related to dig toxicity. D Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess flu- id loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration. A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assess- ment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement. d. call the health care provider 15. The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5 16. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effec- tive? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, includ- ing steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers 17. When a client is assessed, which behavior best indi- cates that he or she is expe- riencing changes associated with acute pain? a. inability to concentrate C 60/40 (desired/have) C Clients on restricted sodium diets generally should avoid processed, smoked, and pick- led foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium. A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility 18. A nurse is caring for several clients at risk for overhydra- tion. The nurse assesses the older client with which find- ing first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently 19. The client with a stroke was admitted to a medical-surgi- cal unit. Which tasks does the nurse delegate to the unlicensed assistive person- nel? A) Assess level of con- sciousness. B) Evaluate the pulse oxime- try reading. C) Assist the client with meals. D) Complete the nursing care plan. 20. Interrelated concepts to the professional nursing role a nurse manager would con- sider when addressing con- more with acute pain, before any physiologic or behavioral adaptation has occurred. C Blood replacement therapy involves intra- venous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from inter- stitial and intracellular spaces into the plas- ma volume. An older adult may not have suffi- cient cardiac or renal reserve to manage this extra fluid. C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client. D The interrelated concepts to the profession- al role of a nurse include health promotion, cerns about the quality of pa- leadership, technology/informatics, quality, tient education include: A) adherence. B) developmental level. C) motivation. D) technology. 21. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility 22. An older adult client is in physical restraints. Which in- tervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the re- straints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing re- straints every 2 hours. collaboration, and communication. Adher- ence, culture, developmental level, family dy- namics, and motivation are considered in- terrelated concepts to patient attributes and preference. D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teach- ing to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced abili- ty to generate heat. Impaired cognition is a risk factor. Recreational or occupational ex- posure is a risk factor. Temperature extremes are risk factors for impaired thermoregula- tion. D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assess- ing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints. 23. The nurse is assessing a client with a long-term histo- ry of arthritic pain. Assess- ment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pres- sure medication. B) Administer a drug to low- er the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medica- tion. 24. The nurse is assigned to care for the following four clients who have the poten- tial for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy 25. Before surgery, the nurse ob- serves the client listening to C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normal- ly causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best inter- vention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out. B Populations at highest risk for inadequate pain treatment include older adults, minori- ties, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting. B music on the radio. Based on this observation, the nurse may try which nonpharma- cologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimula- tion B) Imagery C) Radiofrequency ablation D) Hypnosis Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stim- uli. 26. What interrelated constructs A facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural di- versity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversi- ty, self-awareness, cultural skill, and cultural knowledge 27. The emphasis on under- standing cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cul- tural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by address- ing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. D Culture is an essential aspect of health care because of increasing diversity. Disability en- titlements refer to defined benefits for eli- gible mental or physically disabled benefi- ciaries in relation to housing, employment, C) litigious society. D) increasing global diversi- ty. 28. The patient's laboratory re- port today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indi- cates that heart rhythm is regular. What is the most im- portant nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precau- tions due to potential mus- cle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and con- fusion. and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable infor- mation being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit. C Hypokalemia can cause postural hypoten- sion and bilateral muscle weakness, espe- cially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of con- sciousness, or seizures. 29. A nurse is assessing clients for fluid and electrolyte im- balances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiv- ing intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfon- amide antibiotic 30. The nurse accidentally ad- ministers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What ac- tion must the nurse be pre- pared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Nar- can). 31. Which action does the nurse teach a client to reduce the risk for dehydration? A) Avoiding the use of glyc- erin suppositories to man- age constipation B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hypona- tremia. D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first inter- vention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxy- gen saturation decreases. Intubation may oc- cur if the client does not respond to the Nar- can, and respiratory depression becomes a respiratory arrest. Naloxone may be repeat- ed, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms. B Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when con- B) Maintaining a daily oral in- take approximately equal to daily fluid loss C) Restricting sodium intake to no greater than 4 g/day D) Maintaining an oral intake of at least 1500 mL/day 32. A client is taking furosemide (Lasix) and becomes con- fused. Which potassium lev- el does the nurse correlate with this condition? A) 2.9 mEq/L B) 5.0 mEq/L C) 6.0 mEq/L D) 3.8 mEq/L 33. The most appropriate mea- sure for a nurse to use in as- sessing core body tempera- ture when there are suspect- ed problems with thermoreg- ulation is a(n) A) rectal thermometer. B) tympanic membrane sen- sor. C) temporal thermometer scan. D) oral thermometer. 34. A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to ques- tions. Which intervention will ditions result in greater than usual fluid loss through perspiration or ventilation. A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations. A The most reliable means available for as- sessing core temperature is a rectal temper- ature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment. B Mild hypothermia is manifested by shiver- ing, slurred speech, poor muscular coordi- nation, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur the nurse prepare for this client FIRST? A) Continuous arteriove- nous rewarming B) Dry clothing and warm blankets C) Peritoneal lavage with warmed normal saline D) Administration of warmed IV fluids 35. The Joint Commission fo- cuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objec- tive? A) Performing range-of-mo- tion exercises on the client three times each day B) Assessing the client's respirations when adminis- tering opioids C) Delegating to the nursing assistant to give the client a complete bath daily D) Ensuring that the client is eating 100% of the meals served to him or her 36. What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a fami- ly member remain with the slowly by removing wet clothing and provid- ing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia. B It is important for the nurse to assess respira- tions of the client when administering opioids because of the possibility of respiratory de- pression. The other interventions may or may not be necessary in the care of the client and do not focus on safety. D Advanced age and multiple illnesses, partic- ularly those that result in alterations in sensa- tion, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in re- straints to prevent move- ment without assistance D) Providing assistance to the client in getting out of the bed or chair 37. The nurse is caring for four clients. Which client assess- ment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision 38. The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are with- in the scope of nursing prac- tice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehy- drated client. C) Use sterile technique prevent falls. The client should not be re- strained or maintained on bedrest without adequate indication. Although family mem- bers are encouraged to visit, their presence around the clock is not necessary at this point. B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as in- creased heart rate, increased blood pres- sure, increased respirations, sweating, rest- lessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restless- ness with tachycardia is the most indicative. C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physi- cian. when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%. 39. Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pres- sure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness 40. The nursery nurse identi- fies a newborn at signifi- cant risk for hypothermic al- teration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight. 41. The nurse is assessing a patient's functional ability. Which activities most close- ly match the definition of functional ability? A) Healthy individual, col- lege educated, travels fre- quently, can balance a checkbook A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vo- calization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations. D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be mal- nourished. An infant born at term is not con- sidered at significant risk. A well nourished infant is not at significant risk. C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and commu- nity; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option. B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volun- teers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed 42. Which action demonstrates that the nurse understands the purpose of the Rapid Re- sponse Team? A) Documenting all changes observed in the client and maintaining a postoperative flow sheet B) Monitoring the client for changes in postoperative status such as wound infec- tion C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic D) Notifying the physician of the client's increase in restlessness after medica- tion change 43. An older client just returned from surgery and is rating C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which re- sponds to client arrests, it intervenes rapidly for those who are beginning to decline clini- cally. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status af- ter a medication change would not be consid- ered activities of the Rapid Response Team. B,C,D,E pain as "8" on a 0 to 10 scale. Meperidine, propoxyphene, and codeine are Which medications are un- safe choices for treatment of severe pain in this older not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine 44. An emergency department (ED) nurse gives report on a client who is being trans- ferred to the medical-surgi- cal floor. Because of an iden- tified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This state- ment represents which part of the SBAR hand-off? A) Situation B) Recommendation C) Background D) Assessment 45. Understanding classifica- tions of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branch- es sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is con- sidered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted. B The ED nurse is giving recommendations to the medical-surgical floor nurse about inter- ventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, back- ground, or assessment. D Nociceptive pain refers to the normal func- tioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throb- bing. Neuropathic pain is pathologic and re- sults from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or periph- eral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chron- ic pain is constant and unrelenting such as C) neuropathic pain. D) nociceptive pain. 46. The new nurse is caring for a client with a high temper- ature. Which action should the nurse perform FIRST? A) Obtaining a fan from cen- tral supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin 47. A patient has been new- ly diagnosed with hyperten- pain associated with cancer. Mixed pain syn- drome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate. C sion. The nurse assesses the Adults learn best when given information need to develop a collab- orative plan of care that includes a goal of adher- ing to the prescribed regi- men. When the nurse is plan- ning teaching for the patient, which is the most important initial learning goal? A) The patient will demon- strate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. they can understand that is tailored to their learning styles and needs. Verbalizing an un- derstanding is important; however, the nurse will first need to teach the patient. C) The patient will select the type of learning materials they prefer. D) The patient will verbal- ize an understanding of the importance of following the regimen. 48. When reviewing the purpos- es of a family assessment, the nurse educator would identify a need for further teaching if the student re- sponded that family assess- ment is used to gain an un- derstanding of the family. A) development. B) function. C) structure. D) political views. 49. The client was given 15 mg of morphine IM for postsur- gical pain. When the nurse checks the client for pain re- lief 1 hour later, the client is sleeping and has a respira- tory rate of 10 breaths/min. What is the nurse's first ac- tion? A) Administering oxygen by nasal cannula B) Documenting the findings and continuing to monitor C) Arousing the client by calling his or her name D An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is im- portant to nurses for the provision of quality health care. A family assessment provides an understanding of family development, func- tion, and structure. C Many clients experience some degree of res- piratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respira- tion is increased spontaneously, no further intervention is required. D) Administering naloxone (Narcan) IV push 50. The physician orders Lanox- in(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient? A) 8 mL B) 7.5 mL C) 7 mL D) 5.5 mL 51. The nurse is admitting an older adult with decompen- sated congestive heart fail- ure. The nursing assess- ment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's or- der? A) KCl 20 mEq PO two times per day B) Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr B B A patient with decompensated heart fail- ure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an addition- al load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, be- cause furosemide increases potassium ex- cretion. Oxygen administration is appropriate in this situation of near pulmonary edema C) Oxygen via face mask at 8 from ECV excess. L/min D) Furosemide (Lasix) 20 mg PO now 52. The priority nursing inter- vention for a patient sus- pected to be hypothermic would be to: A) hydrate with intravenous B The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is im- (IV) fluids. B) remove wet clothes. C) assess vital signs. D) provide a warm blanket. 53. The nurse admitting a pa- tient to the emergency de- partment on a very hot sum- mer day would suspect hy- perthermia when the patient demonstrates: A) slow capillary refill. B) red, sweaty skin. C) low pulse rate. D) decreased respirations. 54. Why does the nurse always ask the client his or her pain level after taking routine vital signs? A) To follow McCaffery's guidelines on pain manage- ment B) To ensure that pain as- sessment occurs on a regu- lar basis C) To determine the need for more frequent vital sign measurement D) To determine whether pain is influencing blood pressure and heart rate portant, but the wet clothes should be re- moved first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy. B With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respi- ration rate with hyperthermia. The heart rate increases with hyperthermia. With hypother- mia there is slow capillary refill. B Making pain the fifth vital sign allows more frequent and accurate assessment, which can contribute to better pain management. 55. 55. The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? A) Examine dependent body areas. B) Notify the physician. C) Document the finding and continue to monitor. D) Assess turgor on the client's forehead. 56. The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which D Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician. C A client who undergoes a TURP is at risk for bleeding during the first 24 hours after assessment finding requires surgery. Passage of small blood clots and immediate action by the nurse? A) Having the urge to void continuously while the catheter is inserted B) Passing small blood clots after catheter removal C) Having bright red drainage with multiple blood clots D) Experiencing urinary fre- quency after catheter re- moval 57. Which finding puts a client at greatest risk for wound in- fection? tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the catheter is re- moved. However, the presence of bright red blood with clots indicates arterial bleeding and should be reported to the provider. C A compromised immune system puts a client at greatest risk for infection. Although all the A) Presence of a deep wound other options might increase the client's sus- B) Coexisting medical condi- tions C) Immune compromised status D) Severely reddened skin 58. The nurse is assessing a client with an early on- set of multiple sclerosis (MS). Which clinical manifes- tations does the nurse ex- pect to see? A) Nystagmus & Diplopia B) Hyperresponsive reflexes C) Excessive somnolence D) Heat intolerance 59. The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention re- lated to this assessment? A) Increase the client's fluid intake. B) Consult with the health care provider. C) Reassess the client in 3 days. D) Document the finding per protocol. 60. While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing inter- vention? ceptibility, the one with the greatest potential impact is being immune compromised. A Early signs and symptoms of MS include changes in motor skills, vision, and sensa- tion. The other manifestations are later signs of MS. B A score of 11 or less on the Braden Scale indicates severe risk for pressure ulcer devel- opment in terms of decreased sensory per- ception, exposure to moisture, decreased in- dependent activity, decreased mobility, poor nutrition, and chronic exposure to friction and shear. The nurse needs to consult with the health care provider to relay this information and to obtain more aggressive skin protec- tion measures than are currently provided. D Pacing activities throughout the day con- serves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while ad- A) Completing all nursing care in the evening when the patient is more rested B) Completing all nursing care in the morning so the patient can rest the remain- der of the day C) Limiting visitors, thus pro- moting the maximal amount of hours for sleep D) Prioritization and admin- istration of nursing care throughout the day 61. A diabetic client has numb- ness and reduced sensation. Which intervention does the nurse teach this client to pre- vent injury? A) "Use a bath thermome- ter to test the water tempera- ture." B) "Examine your feet daily using a mirror." C) "Wear white socks in- stead of colored socks." D) "Rotate your insulin injec- tion sites." 62. Which client does the nurse assess to be at greatest risk for pressure ulcer develop- ment? A) Client who requires assis- tance with ambulation B) Incontinent client with equate sleep is important, an increase in the number of hours slept will not resolve the fa- tigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation. A Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury. B Being immobile and being incontinent are two significant risk factors for the develop- ment of pressure ulcers. Clients with pneu- monia and hypertension do not have specific risk factors. The client who needs assistance with ambulation might be at moderate risk if limited mobility C) Client with hypertension on multiple medications D) Client who has pneumo- nia 63. The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail old- er patient; the nursing as- sistant understands the in- struction when she agrees to: he or she does not move about much, but having two risk factors makes the last option the person at highest risk. C The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent heal- A) bathe and dry the skin vig- ing; however, offering snacks is indicated to orously to stimulate circula- tion. B) limit intake of fluid and of- fer frequent snacks. C) turn the patient at least every 2 hours. D) keep the head of the bed elevated 30 degrees. 64. The client with type 2 di- abetes has recently been changed from the oral antidiabetic agents gly- buride (Micronase) and met- formin (Glucophage) to gly- buride-metformin (Glucov- ance). The nurse includes which information in the teaching about this medica- tion? A) "Glucovance is more ef- fective than glyburide and metformin." increase healing particularly if they are pro- tein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline. C Glucovance is composed of glyburide and metformin. It is given to enhance the conve- nience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate. B) "Your diabetes is improv- ing and you now need only one drug." C) "Glucovance contains a combination of glyburide and metformin." D) "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents." 65. The nurse administers 6 A units of regular insulin and 10 units NPH insulin at 7 AM. NPH is an intermediate-acting insulin with an At what time does the nurse assess the client for prob- lems related to the NPH in- sulin? A) 4 PM B) 11 PM C) 8 AM D) 8 PM 66. The nurse is caring for a client who is immobile from a recent stroke. Which inter- vention does the nurse im- plement to prevent compli- cations in this client? A) Teach the client to touch and use both sides of the body. B) Apply sequential com- pression stockings. C) Instruct the client to turn the head from side to side. D) Position the client with the unaffected side down. onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late. B To avoid complications of immobility, such as deep vein thrombosis, the nurse applies sequential compression stockings or pneu- matic compression boots. Efforts are made to mobilize the client as much as possible, and the client should be repositioned frequently. The other interventions will not prevent com- plications of immobility. 67. The nurse is caring for a client who has experienced a stroke. Which nursing in- tervention for nutrition does the nurse implement to pre- vent complications from cra- nial nerve IX impairment? A) Place the client in high Fowler's position. B) Verbalize the placement of food on the client's plate. C) Order a clear liquid diet for the client. D) Turn the client's plate around halfway through the meal. 68. Which statement indicates that the client needs more teaching about mucositis? A) "I will use a soft-bristled toothbrush to prevent trau- ma." B) "I will rinse my mouth with water after every meal." C) "I should use an alco- hol-based mouth rinse to kill bacteria." D) "I cannot use floss be- cause it may irritate my gums." 69. A young woman is be- ing treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the high- est priority instruction for A Cranial nerve IX, the glossopharyngeal nerve, controls the gag reflex. Clients with impairment of this nerve are at great risk for aspiration. The client should be in high Fowler's position and should drink thickened liquids if swallowing difficulties are present. The client would not have vision problems. Turning the plate around would not prevent a complication, nor would limiting the client's diet to clear liquids. C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, lead- ing to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Inter- ventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis. C The client should use a second form of birth control because penicillin seems to re- duce the effectiveness of estrogen-contain- the nurse to give this client? A) "You may experience an irregular heartbeat while on the drug." B) "Watch for blood in your urine while taking this drug." C) "Use a second form of birth control while on the drug." D) "You will experience in- creased menstrual bleeding while on this drug." 70. The nurse prepares to teach a patient recovering from a myocardial infarction (MI) about combination durg therapy based on "best prac- tice" for controlling hyper- tension. Which drugs does the nurse include in the teaching plan? SELECT ALL THAT APPLY!!! [Show Less]