Nursing Care for Older Adults: Best Practices and Considerations, Exams of Nursing

Download Nursing Care for Older Adults: Best Practices and Considerations and more Exams Nursing in PDF only on Docsity! 2024 HESI RN Fundamental Exam New Recent Version Best Studying Material with All Questions and Answers In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B.Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels. ----------- Correct Answer ----------- Check the bath water temperature. During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A. Listen and show interest as the client expresses these feelings B. Reinforce that this behavior means they were not true friends C. Ask the healthcare provider for a psychiatric consult D. Continue with the assessment and tell the client not to worry ---------- Correct Answer ------------ Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses these feelings While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. ---------- Correct Answer --- --------- Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. ---------- Correct Answer ------------ Flush the tube with water The NGT should be flushed before, after, and in-between each medication In completing a client's preoperative routine, the nurse finds that the operative permitis not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A.Witness the client's signature to the permit. B.Answer the client's questions about the surgery. C.Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D.Reassure the client that the surgeon will answer any questions before the anesthesia is administered. ----------- Correct Answer ----------- Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. An older client who had abdominal surgery 3 days earlier was given a barbituratefor sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Requested that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate. ----------- Correct Answer ----------- Assist the client to walk to the bathroom and do not leave the client alone. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A."You may not have enough energy before long to hold a big party." B."Do you mean to say that you want to plan your funeral and wake?" C." Planning a party and thinking about all your friends sounds like fun." D."You should be thinking about spending your last days with your family." ----------- Correct Answer ----------- " Planning a party and thinking about all your friends sounds like fun." A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility. ----------- Correct Answer ----------- Talk with the client about her feelings related to her own death. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A.Low serum albumin level B.Low serum transferrin level C.High hemoglobin level D.High cholesterol level ----------- Correct Answer ----------- Low serum albumin level The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A.14 B.16 C.17 D.28 ----------- Correct Answer ----------- 16 The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A."Fill your lungs with air through your mouth and then compress the inhaler." B."Compress the inhaler while slowly breathing in through your mouth." C."Compress the inhaler while inhaling quickly through your nose." D."Exhale completely after compressing the inhaler and then inhale." ----------- Correct Answer ----------- Compress the inhaler while slowly breathing in through your mouth." The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A.Steak, baked beans, and a salad B.Broiled fish, green beans, and an apple C.Pork chops, macaroni and cheese, and grapes D.Avocado salad, milk, and angel food cake ----------- Correct Answer ----------- Broiled fish, green beans, and an apple The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A.Stay with the client while the client is standing. B.Record the findings on the graphic sheet in the chart. C.Keep the blood pressure cuff on the same arm. D.Record changes in the client's pulse rate. ----------- Correct Answer ----------- Stay with the client while the client is standing. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A.Determine how the client feels about changing the dressing. B.Ask the client to describe the procedure in writing. C.Seek a family member's evaluation of the client's ability to change the dressing. D.Observe the client change the dressing unassisted. ----------- Correct Answer ----------- Observe the client change the dressing unassisted. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A.Dilute each of the medications with sterile water prior to administration. B.Mix the medications in one syringe before opening the feeding tube. C.Administer water between the doses of the two liquid medications. D.Withdraw any fluid from the tube before instilling each medication. ----------- Correct Answer ----------- Administer water between the doses of the two liquid medications. The nurse is teaching a client how to perform progressive muscle relaxation techniquesto relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A.Instruct the client to add regular exercise as a daily routine. B.Determine if the client has been keeping a sleep diary. C.Encourage the client to continue the routine until sleep is achieved. D.Ask the client to describe the routine he is currently following. ----------- Correct Answer ----------- Ask the client to describe the routine he is currently following. The nurse is teaching an obese client, newly diagnosed with arteriosclerosis,about reducing the risk of a heart attack or stroke. Which health promotionbrochure is most important for the nurse to provide to this client? A."Monitoring Your Blood Pressure at Home" B."Smoking Cessation as a Lifelong Commitment" C."Decreasing Cholesterol Levels Through Diet" D."Stress Management for a Healthier You" ----------- Correct Answer ----------- "Decreasing Cholesterol Levels Through Diet" The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A.Document that the client responds to painful stimulus. B.Observe the client's response to verbal stimulation. C.Place the client on seizure precautions for 24 hours. D.Report decorticate posturing to the health care provider ----------- Correct Answer ------ ----- Document that the client responds to painful stimulus. A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A.Pulse characteristics B.Open airway C.Entrance and exit wounds D.Cervical spine injury ----------- Correct Answer ----------- Pulse characteristics The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A.Perform range-of-motion exercises to prevent contractures. B.Decrease the client's fluid intake to prevent diarrhea. C.Massage the client's legs to reduce embolism occurrence. D.Turn the client from side to back every shift. ----------- Correct Answer ----------- Perform range-of-motion exercises to prevent contractures. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A.The cuff wraps around the girth of the leg. B.The UAP auscultates the popliteal pulse with the cuff on the lower leg. C.The client is placed in a prone position. D.The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm --- -------- Correct Answer ----------- The UAP auscultates the popliteal pulse with the cuff on the lower leg. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL ----------- Correct Answer ----------- 0.8 mL The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A.Place the client in a high Fowler position. B.Help the client assume a left side-lying position. C.Measure the tube from the tip of the nose to the umbilicus. D.Instruct the client to swallow after the tube has passed the pharynx. E.Assist the client in extending the neck back so the tube may enter the larynx. ----------- Correct Answer ----------- Place the client in a high Fowler position. Instruct the client to swallow after the tube has passed the pharynx. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A.Left brachial vein B.Right cephalic vein C.Dorsal side of the right wrist D.Right upper extremity ----------- Correct Answer ----------- Right cephalic vein C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure. ----------- Correct Answer ----------- Calmly reassure the client that the discomfort will be temporary. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C.Insert an indwelling urinary catheter D. Instruct client in the use of adult diapers. ----------- Correct Answer ----------- Maintain standard precautions. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chainof infection? A.Mode of transmission B.Portal of entry C.Reservoir D.Portal of exit ----------- Correct Answer ----------- Mode of transmission A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client. ----------- Correct Answer ------- ---- Review the schedule of outdoor breaks with the client. A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse dofirst? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device. ----------- Correct Answer ----------- Turn off the intermittent suction device. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill. ----------- Correct Answer -------- --- Decrease intake of fluids after the evening meal. A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. -- --------- Correct Answer ----------- Assess the client's medical record to determine the client's normal bowel pattern. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A.Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription foran antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings. ----------- Correct Answer ----------- Compare the current reading with the client's previously documented blood pressure readings. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A.Americans with Disabilities Act of 1990 B.ANA Code of Ethics with Interpretative Statements C.ANA's Scope and Standards of Nursing Practice D.Patient's Bill of Rights of 1990 ----------- Correct Answer ----------- ANA's Scope and Standards of Nursing Practice During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning forschool. Which assessment data should the nurse obtain in response to the mother's report? A.The occurrence of any episodes of sleep apnea B.The child's blood pressure, pulse, and respirations C.Length of rapid eye movement (REM) sleep that the child is experiencing D.Description of the family's home environment ----------- Correct Answer ----------- Description of the family's home environment During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. ----------- Correct Answer ----------- Ask the client to talk about specific concerns. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly. ---- ------- Correct Answer ----------- Remind the client to walk carefully down the stairs until reaching a lower floor. A female client with frequent urinary tract infections (UTIs) asks the nurse to explainher friend's advice about drinking a glass of juice daily to prevent future UTIs. Whichresponse is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C.Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics. ----------- Correct Answer ---- ------- Cranberry juice stops pathogens' adherence to the bladder. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may needa higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity. -- --------- Correct Answer ----------- The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping. ----------- Correct Answer ----------- Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence. ----------- Correct Answer ----------- If informed consent is withheld from a client, health care providers could be found guilty of negligence. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. ----------- Correct Answer ----------- Put bed rails up on the side of bed opposite from the nurse. Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Requested the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions. ----------- Correct Answer -------- --- Speak directly to the client, with an interpreter translating. Which client is most likely to be at risk for spiritual distress? A.Roman Catholic woman considering an abortion B.Jewish man considering hospice care for his wife C.Seventh-Day Adventist who needs a blood transfusion D.Muslim man who needs a total knee replacement ----------- Correct Answer ----------- Roman Catholic woman considering an abortion Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C.Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour. ----------- Correct Answer ----------- Dorsiflex and plantarflex the feet 10 times each hour. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D.Encourage frequent ambulation in the hallway. ----------- Correct Answer ----------- Encourage frequent ambulation in the hallway. Which nonverbal action should the nurse implement to demonstrate active listening? A.Sit facing the client. B.Cross arms and legs. C.Avoid eye contact. D.Lean back in the chair. ----------- Correct Answer ----------- Sit facing the client. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A.Self-care deficit B.Functional incontinence C.Fluid volume deficit D.High risk for infection ----------- Correct Answer ----------- High risk for infection Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?A.White blood cell count B. Albumin C. Calcium D. Sodium ----------- Correct Answer ----------- Sodium Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A.Place the client in a side-lying position. B.Pull the auricle upward and outward. C.Hold the dropper 6 cm above the ear canal. D.Place a cotton ball into the inner canal. E.Pull the auricle down and back. ----------- Correct Answer ----------- Place the client in a side-lying position. Pull the auricle upward and outward. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A.Encourage the client to see the clinic's grief counselor. B.Determine if the client has a family history of suicide attempts C.Inquire about whether the life partner was suffering from AIDS. D.Consult with the health care provider about the client's need for antidepressant medications. ----------- Correct Answer ----------- Encourage the client to see the clinic's grief counselor. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A."How will this affect your present sexual activity?" B."How active is your current sex life?" C."How has your sex life changed as you have become older?" D."Tell me about your sexual needs as an older adult." ----------- Correct Answer ---------- - "How will this affect your present sexual activity?" During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? A. Place the stethoscope bell at random points on the posterior chest B. Use the stethoscope bell over the valvular areas of the anterior chest C. Move the diaphragm of the stethoscope over the left anterior chest D. Position the diaphragm of the stethoscope over Erb's point on the chest ---------- Correct Answer ------------ Use the stethoscope bell over the valvular areas of the anterior chest Abnormal heart sounds are best heard with the bell of the stethoscope (which picks up lower-pitched sounds) and placed over the valvular areas of the anterior chest A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. ---------- Correct Answer ------------ Reposition the client on her side The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment. ---------- Correct Answer ------------ The client voluntarily signed the form The nurse signs the consent form to witness that the client voluntarily signs the consent, that the client's signature is authentic, and that the client is otherwise competent to give consent After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals. ---------- Correct Answer ------------ Determine the etiology of the problem D. Rashes in the axillary, groin, and skin fold regions ---------- Correct Answer ------------ Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes, skin breakdown, and ulcer development Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. ---------- Correct Answer ------------ Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A. Genetic and familial health disorders B. Chronic health problems C. Reason for seeking care D. Undetected disorders ---------- Correct Answer ------------ Genetic and familial health disorders A genogram used during the the health assessment process identifies genetic and familial health disorders The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus B. Hypothalamus C. Frontal Lobe D. Parietal lobe ---------- Correct Answer ------------ Frontal lobe The frontal lobe of the cerebrum controls higher mental activities such as memory, intellect, language, emotions, and personality A client with chronic kidney disease selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CKD. ---------- Correct Answer ------------ Commend the client for selecting a high biologic value protein Foods such as eggs and milk are high biologic value proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies B. Blood specimens not collected because client no longer wants blood tests performed C. Healthcare provider notified of client's refusal to have blood specimens collected for testing D. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified ---------- Correct Answer ------------ Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative form The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions B. Advise client to increase intake of oral fluids C. Rotate the suction catheter to obtain any remaining secretions D. Re-oxygenate the client before attempting to suction again ---------- Correct Answer -- ---------- Re-oxygenate the client before attempting to suction again Suctioning should NOT be continued for longer than ten to fifteen seconds at a time, since the client's oxygenation is compromised during the time of this procedure, therefore oxygenation takes priority here The way you practice your profession of nursing should be guided by standards of nursing care and which of the following ---------- Correct Answer ----------- Nurse Practice Act The standards of nursing care are administered by the: ---------- Correct Answer ---------- - American Nurse Association (ANA) Nurse practice acts are administered by your: ---------- Correct Answer ----------- Individual state A nurse who can obtain histories, conduct physical examinations, order laboratory and diagnostic tests, interpret results, diagnose disorders, and treat patients has what nursing credentials? ---------- Correct Answer ----------- Nurse Practitioner The easiest way to participate in research is to: ---------- Correct Answer ----------- Be a good consumer of research. The purpose of evidence-based practice is to: ---------- Correct Answer ----------- Improve patient outcomes. Which of the following is an example of health promotion? ---------- Correct Answer ------- ---- Assisting a patient in stopping smoking. The effect of illness on a family unit depends on several factors, including: ---------- Correct Answer ----------- Which of the family members is effected. One of the goals of "Healthy People 2020" is to decrease the incidence of obese adults age 20 and older to no more than: ---------- Correct Answer ----------- 30% When describing disease development, which disease stage is described as producing generally mild, non-specific signs and symptoms> ---------- Correct Answer ----------- Prodromal The Code of Ethics for Nurses provides information that's necessary for the practicing nurse to: ---------- Correct Answer ----------- Uses her professional skills in providing the most effective holistic care possible. Which of the following is a type of unintentional tort? ---------- Correct Answer ----------- Malpractice. The Patient Self-Determination Act of 1990 states that: ---------- Correct Answer ----------- Hospitals must make information about advanced directives available to all patients. Which part of the medical record can be used as evidence in court? ---------- Correct Answer ----------- Entire record. When obtaining a health history from a patient, ask first about: ---------- Correct Answer - ---------- Biographic data. Expected outcomes are defined as: ---------- Correct Answer ----------- Goals the patient should reach as a result of planned nursing interventions. The primary source of assessment information is: ---------- Correct Answer ----------- The patient. What are three components to a proper patient outcome? ---------- Correct Answer ------- ---- Realistic, nurse centered, optimistic. When developing a therapeutic nurse-patient relationship, during what phase do you review the patient's surgical history? ---------- Correct Answer ----------- Pre-interaction When suctioning a patient, you should: ---------- Correct Answer ----------- Oxygenate the patient's lungs before and after suctioning. To help the patient achieve maximal ventilation, use: ---------- Correct Answer ----------- An incentive spirometer. Which tube permits speech through the upper airway? ---------- Correct Answer ----------- Fenestrated tube. When performing chest physiotherapy, which of the following uses gravity to promote drainage of secretions? ---------- Correct Answer ----------- Postural drainage When giving a back massage, which stroke uses alternating kneading and stroking of the patient's back and upper arms? ---------- Correct Answer ----------- Petrissage When performing personal hygiene on a female patient, it's important to wash the genital area in what direction? ---------- Correct Answer ----------- Front to back Which of the following is the correct position to perform mouth care on a comatose patient? ---------- Correct Answer ----------- Side-lying When providing morning care to a patient, which of the following is the correct direction for washing the patient's eye? ---------- Correct Answer ----------- Inner canthus to outer canthus. Exercises performed without any effort by the patient are called: ---------- Correct Answer ----------- Passive ROM exercises Your patient can't move his right arm toward the midline, so you document this as impaired: ---------- Correct Answer ----------- Adduction. Which patient position requires the head of the bed to be elevated 45 degrees? ---------- Correct Answer ----------- Fowler's Which gait should you teach a patient who can bear weight on both legs? ---------- Correct Answer ----------- Four point The main function of the skin includes: ---------- Correct Answer ----------- Protection, sensory perception, and temperature regulation. Which type of wound closes by primary intention? ---------- Correct Answer ----------- Surgical incision Which wound bed color indicates normal, healthy granulation tissue? ---------- Correct Answer ----------- Red Which intervention is most appropriate for preventing excessive heel pressure? ---------- Correct Answer ----------- Suspending the heels by placing a pillow under the calves Which condition is characteristic of REM sleep? ---------- Correct Answer ----------- Paralysis of the muscles. Which part of the brain regulates NREM sleep? ---------- Correct Answer ----------- Basal forebrain What are questions to ask when taking a sleep history? ---------- Correct Answer ---------- - 1)How many hours of sleep do you normally get per night? 2)What types of medications do you take before bed? 3)What is your bedtime routine? 4)What type of work do you do? A patient may be assessed for narcolepsy sleep disorder if the deep sleep attacks occur for which of the following time periods? ---------- Correct Answer ----------- A period of up to 20 minutes. Which medication is used to reverse the effects of narcotic overdose? ---------- Correct Answer ----------- Naloxone Thermotherapy causes which effect? ---------- Correct Answer ----------- Vasodilation Massage promotes increased circulation and softening of connective tissues. It also has which effect? ---------- Correct Answer ----------- Eases muscle spasms. Through metabolism, energy is extracted from which nutrients? ---------- Correct Answer ----------- Carbohydrates, proteins, and fats. Essential nutrients are supplied to the body by: ---------- Correct Answer ----------- Food in many different combinations. Which GI hormone stimulates gastric secretions and motility? ---------- Correct Answer -- --------- Gastrin In which phase of digestion does the stomach secrete the digestive juices HCI and pepsin? ---------- Correct Answer ----------- Cephalic A patient complains of lower abdominal pressure, and you note a firm mass extending above the symphysis pubis. You suspect: ---------- Correct Answer ----------- Distended bladder Although the male and female urinary systems function in the same way, there's a difference in the length of the: ---------- Correct Answer ----------- Urethra In a healthy adult, what's the normal range of bladder capacity? ---------- Correct Answer ----------- 500 to 600ml The left ureter is slightly longer than the right ureter because the: ---------- Correct Answer ----------- Left kidney is higher than the right. What role does the epiglottis play in swallowing? ---------- Correct Answer ----------- Closes to prevent aspiration An adhesive-backed ostomy opening should be how much larger than the stoma? ------- --- Correct Answer ----------- 1/8" Which GI hormone stimulates gastric secretion and motility? ---------- Correct Answer ---- ------- Gastrin