Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions) 2024-2025 Edition.Grade A+, Exams of Nursing

Download Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions) 2024-2025 Edition.Grade A+ and more Exams Nursing in PDF only on Docsity! Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions) 2024-2025 Edition. Distinction Guaranteed ___ are accepted as truths and are based on values and beliefs. - ANSAssumptions ___ are the words or phrases that identify, define, and establish structure and boundaries for ideas generated about a particular phenomena. - ANSConcepts ___ have different purposes and are sometimes classified by levels of abstraction or the goals. - ANSTheories ___ is considered to be the mother of psychiatric nursing. - ANSHildegard Peplau ___ is the end product of a system. - ANSoutput ___ nursing practice helps nurses to design and implement nursing interventions that address individual and family responses to health problems. - ANSTheory-based ___ offer well-grounded rationales for how and why nurses perform specific interventions and for predicting patient behaviors and outcomes. - ANSTheories ___ research determines how accurately a theory describes a nursing phenomenon. - ANSTheory-testing ___ research uses logic to explore relationships between phenomena. - ANSTheory- generating ___ serves as the foundation for the art and science of nursing. - ANSTheory ___ theories are more limited in scope and less abstract. - ANSMiddle-range ___ theories continue to advance nursing knowledge through nursing research. - ANSMiddle-range ___ theories help shape and define your practice. - ANSGrand ___ theories help you provide specific care for individuals and groups of diverse populations and situations. - ANSPractice (**) A nurse is caring for a patient with respiratory problems. which assessment finding indicates a late sign of hypoxia? a. elevated blood pressure b. increased pulse rate c. restlessness d. cyanosis - ANSANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. DIF:Understand (comprehension)REF:877 (**) A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis." - ANSANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis. DIF:Apply (application)REF:872 | 892 | 896 (**) The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis - ANSANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema. DIF:Apply (application)REF:882 (**) The nurse suspects the patient has increased after load. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. pulse oximeter b. oxygen cannula c. blood pressure cuff d. yankauer suction tip catheter - ANSANS: C DIF:Apply (application)REF:882 (**)The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation - ANSANS: D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5- year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax. DIF:Analyze (analysis)REF:895 *A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?* A. Encouraging use of an overhead trapeze for positioning and transfer. B. Frequent family visits C. Assisting the patient to a wheelchair once per day D. Ensuring that there is an order for physical therapy - ANS*Answer: A* Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living. *A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.)* A. "I usually go swimming with my family at the YMCA 3 times a week." B. "I need to ask my doctor if I should have a bone mineral density check this year." C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill." E. "My lactose intolerance should not be a concern when considering my calcium intake." - ANS*Answer: A, B, C* Rationale: Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that. *A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:* A. Decreased peristalsis B. Decreased heart rate C. Increased blood pressure D. Increased urinary output - ANS*Answer: A* Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. *A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply.)* A. Bruising B. Pale yellow urine C. Bleeding gums D. Coffee ground-like vomitus E. Light brown stool - ANS*Answer: A, C, D* Rationale: Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums. *A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:* A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus - ANS*Answer: C* Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative. *An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)* A. B/P = 128/84 B. Respirations 26/min on room air C. HR 114 D. Crackles over lower lobes heard on auscultation E. Pain reported as 3 on scale of 0 to 10 after medication - ANS*Answer: B, C, D* Rationale: Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. *An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?* A. Loss of appetite B. Gum soreness C. Difficulty swallowing D. Left-ankle joint stiffness - ANS*Answer: D* Rationale: Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures. *The effects of immobility on the cardiac system include which of the following? (Select all that apply.)* A. Thrombus formation B. Increased cardiac workload C. Weak peripheral pulses D. Irregular heartbeat E. Orthostatic hypotension - ANS*Answer: A, B, E* Rationale: The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation. *The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)* A. Initial patient measurement is made around the calves B. Inflation pressure averages 40 mm Hg C. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve. D. Stockings are removed every 2 hours during application. E. Yellow light indicates SCD device is functioning. - ANS*Answer: B & C* Rationale: The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning. 1. A patient needs to learn to use a walker. Which domain is required for learning this skill? A. Affective domain B. Cognitive domain C. Attentional domain D. Psychomotor domain - ANSD. Psychomotor domain Pg. 339 Using a walker requires the integration of mental and muscular activity. 1. The five rights of delegation include (Select all that apply.) a. Right task. b. Right circumstances. c. Right monetary compensation. d. Right person. e. Right direction. f. Right opinion. g. Right supervision. - ANSANS: A, B, D, E, G The five rights of delegation are right task, circumstances, person, direction, and supervision. 1. The nurse and a new nurse in orientation are caring for a patient with pneumonia. Which statement by the new nurse will indicate a correct understanding of this condition? a. "An infectious disease like pneumonia may not pose a risk to others." b. "We need to isolate the patient in a private negative-pressure room." c. "Clinical signs and symptoms are not present in pneumonia." d. "The patient will not be able to return home." - ANSANS: A Infections are infectious and/or communicable. Infectious diseases may not pose a risk for transmission to others, although they are serious for the patient. Pneumonia is not a communicable disease—a disease that is transmitted directly from one individual to the next, so there is no need for isolation. A private negative-air pressure room is used for tuberculosis, not pneumonia. Clinical signs and symptoms are present in pneumonia. Frequently, patients with pneumonia do return home unless there are extenuating circumstances. 1. The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all that apply.) a. Wear an N95 respirator when entering the patient's room. b. Maintain airflow rate greater than 12 air exchanges/hr. c. Place in special room with negative-pressure airflow. d. Open drapes during the daytime. e. Listen to the patient's interests. f. Place dried flowers in a plastic vase. - ANSANS: B, D, E This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges/hr, and all air is filtered through a HEPA filter. Isolation disrupts normal social relationships with visitors and caregivers. Take the opportunity to listen to a patient's concerns or interests. Open drapes or shades and remove excess supplies and equipment. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms. All health care personnel wear an N95 respirator every time they enter the room for patients, and a private room with negative airflow is required for patients on airborne precautions. 1. Two pt deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? 1. Keep a journal 2. Participate in a unit meeting to discuss feelings about the pt deaths 3. Ask the nurse manager to assign you to less difficult pts 4. Review the policy and procedure manual on proper care of pts after death - ANS1. Answer: 2. By connecting and meeting with staff colleagues, the nurse can talk about the experiences of caring for dying patients and learn that her feelings are likely shared by others. A journal is helpful but not the best way to relieve stress. A policy and procedure manual will not help the nurse examine and understand the nature of the stress. Asking for a different assignment is no guarantee that another stressful experience will develop. 1. Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from pt's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a pt's assessment data - ANS1. Answer: 1, 2, 3. Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step 1.) The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis. - ANS1.) Ans: 2 This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses. 10. A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. E. Goal setting. - ANSA. Data collection. . C. Data interpretation This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis. 10. A nurse is checking a pt's intravenous line and, while doing so, notices how the pt bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Pt's level of function. 2. Pt's willingness to perform self-care. 3. Pt's level of consciousness. 4. Pt's health management values. - ANS10. Answer: 1. Observing a patient perform activities physical, socially, psychologically and developmentally assesses their level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values. 10. A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail she sent stating that it had to be discarded. The staff nurse dress code is not being adhered to, and the staff lounge is not kept neat and tidy as she requested in the same e-mail. Several staff nurses deny having received the e-mail. After evaluating this situation, one way the nurse manager could resolve the issue is to a. Include the findings on each staff member's annual evaluation. b. Close the staff lounge. c. Enforce a stricter dress code. d. Place a hard copy of announcements and unit policies in each staff member's mailbox. - ANSD single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error. 11. A nurse begins the night shift being assigned to five pts. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A pt care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all pts, so she begins rounds on the pt who has recently asked for a pain medication. As the nurse begins to approach the pt's room, a nurse stops her in the hallway to ask about another pt. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. RN's years of experience 5. Competency of pt care technician - ANS11. Answer: 1, 2, 3. Many factors within the health care environment affect your ability to set priorities, including model for delivering care, a nursing unit's workflow routine, staffing levels, and interruptions from other care providers. Available resources (e.g., policies and procedures) also affect priority setting. The nurse's years of experience is not part of the environment. 11. A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old pt from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the pt? (Select all that apply.) 1. The nurse asks the pt to rate his pain on a scale of 0 to 10. 2. The nurse asks the pt what caused his fall. 3. The nurse asks the pt if he has had pain in his back in the past. 4. The nurse assesses the pt's lower-limb strength. 5. The nurse asks the pt what pain medication is most effective in managing his pain. - ANS11. Answer: 1, 4. Validation of assessment data is the comparison of data with another source to determine data accuracy. The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient's lower limb strength. Asking the patient what caused his fall and asking about past back pain would offer the nurse new information about the patient. 11. Fill in the Blank. A nurse administered an antibiotic 30 minutes ago and returns to the pt's room to determine if the pt is having any unexpected symptoms. This is an example of assessing for a(n) ___________________. - ANS11. Answer: Adverse Reaction. An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. 11. Fill in the Blank. When a nurse tries to understand a pt's and family caregiver's perspective of why a pt is falling at home, the nurse applies the intellectual standard of _________________________ to understand all viewpoints. - ANS11. Answer: Broad. The intellectual standard of 'broad' covers multiple viewpoints. 11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? a. Review the procedure with the patient. b. Position the patient comfortably. c. Maintain surgical aseptic technique. d. Gather available supplies. - ANSANS: C You maintain surgical aseptic technique at the patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and sterile dressing changes) because patients with disease processes of the immune system are at particular risk for infection. These diseases include leukemia, AIDS, lymphoma, and aplastic anemia. These disease processes weaken the defenses against an infectious organism. Reviewing the procedure with the patient, positioning the patient, and gathering the supplies are all important steps in the procedure but are not the priority in the procedure since the patient already has a compromised immune response. 11. When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? A. Telling B. Analogy C. Demonstration D. Simulation - ANSB. Analogy Pg. 349 Analogies use familiar images when teaching to help explain complex information. 12. A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar? - ANSA, C, and E Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias. 12. A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? A. How to use an inhaler during an asthma attack B. The need to avoid people who smoke to prevent asthma attacks C. Where to purchase a medical alert bracelet that says she has asthma D. The importance of maintaining a healthy diet and exercising regularly - ANSA. How to use an inhaler during an asthma attack It is important to start with essential life-saving information when teaching people because they usually remember what you tell them first. 12. A nursing student is reporting during hand-off to the registered nurse (RN) assuming her pt's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane with out difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during night - ANS12. Answer: 3, 4. The goal for improving activity tolerance will require an outcome that is a measure of changes in activity tolerance, such as no shortness of breath during exercise or walking a set distance. 12. A pt who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an 3. Eliminates need to create an individualized care plan for the pt 4. Delivers evidence-based interventions for stage II pressure ulcer 5. Summarizes the various approaches used for the practice concern or problem - ANS13. Answer: 1, 2, 4. Even though a standardized clinical practice guideline offers evidence based solutions for clinical excellence that nurses can quickly and easily apply in practice, a nurse remains accountable for individualizing even standardized interventions when necessary. A guideline is not a summary of various approaches used by clinicians for a practice issue; it is a summary of the most relevant evidence based information. 13. A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing? A. Simulation B. Restoring health C. Coping with impaired function D. Health promotion and illness prevention - ANSD. Health promotion and illness prevention Health promotion and illness prevention are the focus when nurses provide information to help patients improve their health and avoid illness. 13. A nursing student is reporting during hand-off to the RN assuming her pt's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 . Which intervention is a dependent intervention? 1. Reporting hand-off at change of shift 2. Ambulating pt down hallway 3. Sleep hygiene 4. IV fluid administration - ANS13. Answer: 4. Administering IV fluids required a physician's order. The other three interventions are independent nursing activities. 13. In which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.) 1. The nurse thinks back about a personal experience before administering a medication subcutaneously. 2. The nurse uses a pain-rating scale to measure a pt's pain. 3. The nurse explains a procedure step by step for giving an enema to a pt care technician. 4. The nurse gathers data on a pt with a mobility limitation to identify a nursing diagnosis. 5. A nurse offers support to a colleague who has witnessed a stressful event. - ANS13. Answer: 1,2,4. Reflection, using a pain rating scale to be precise and specific, and nursing assessment (the first step of the nursing process) are examples of critical thinking skills. Explaining a procedure based on policy is not critical thinking - however performing a procedure following policy is basic critical thinking. Offering support to a colleague is an important way to assist another in managing stress but is not a critical thinking skill. 13. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to take a temperature c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol - ANSANS: C A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. This is the only teaching point that directly influences risk. Teaching the patient how to take a temperature can help the patient assess if there is a fever, but it is not related to decreasing the individual's risk for infection. Teaching the patient about fall prevention or about the effects of alcohol does not decrease the risk of infection. 14. Which of the following nursing diagnoses is stated correctly? (Select all that apply.) A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools. - ANSB, D The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic. 14. 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 action will the nurse take to prevent the spread of infection? a. Position the patient comfortably on the stretcher. b. Explain the procedure for dressing change to the patient. c. Review the medication list that the patient brought from home. d. Don gloves and other appropriate personal protective equipment. - ANSANS: D Localized infections are most common in the skin or with mucous membrane breakdown. Wear gloves and other personal protective equipment as appropriate when examining or providing treatment to localized infected areas to create a protective barrier. Positioning the patient, explaining the procedure, and reviewing the medication list are all tasks that need to be completed, but they do not prevent the spread of infection. 14. A nurse enters a 72-year-old pt's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the pt lives alone and notices bruising on the pt's leg. When watching the pt walk, the nurse notes that she has an unsteady gait and leans to one side. The pt admits to having fallen in the past. The nurse identifies the pt as having the nursing diagnosis of Risk for Falls. This scenario is an example of: 1. Inference. 2. Basic critical thinking. 3. Evaluation. 4. Diagnostic reasoning. - ANS14. Answer: 4. Diagnostic reasoning begins when you interact with a patient or make physical or behavioral observations. An expert nurse sees the context of a patient situation (e.g., Patient lives alone, has fallen in past, observes patterns and themes and makes a diagnostic decision. 14. A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: A. A teaching plan. B. A learning objective. C. Reinforcement of content. D. Enhancing the children's self-efficacy. - ANSB. A learning objective. Pg. 338 A learning objective describes what the learner will do after the teaching session. 14. A nurse reviews all possible consequences before helping a pt ambulate such as how the pt ambulated last time; how mobile the pt was before admission to the health care facility; or any current clinical factors affecting the pt's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? 1. Critical thinking 2. Managing an adverse event 3. Exercising self-discipline 15. Match the concepts for a critical thinker on the right with the application of the term on the left. a. Anticipate how a pt might respond to a treatment. ___ 1. Truth seeking b. Organize assessment on the basis of pt priorities. ___ 2. Open-mindedness c. Be objective in asking questions of a pt. ___ 3. Analyticity d. Be tolerant of the pt's views and beliefs. ___ 4. Systematicity - ANS15. Answer: 1 c, 2 d, 3a, 4 b. 15. The nurse enters the room of an 82-year-old pt for whom she has not cared previously. The nurse notices that the pt wears a hearing aid. The pt looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) 1. Listen attentively to the pt's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the pt's fatigue. - ANS15. Answer: 1, 2, 4. Approaches for collecting an older adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patient- directed eye gaze. Leaning forward, not backward shows interest in what the patient has to say. 16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priorityaction will the nurse take to decrease the potential for a health care-associated infection? a. Use local anesthetic on reddened areas. b. Use nonallergenic tape on dressings. c. Use a chlorhexidine wash. d. Use filtered water. - ANSANS: C The Centers for Disease Control and Prevention (CDC) recommends the use of chlorhexidine (CHG) bathing for patients in intensive care units, patients who are scheduled for surgery, and all patients with invasive central line catheters as part of MRSA reduction efforts. Using local anesthetics, nonallergenic tape, and filtered water does not affect the cause of a health care-associated infection by, for example, decreasing microbial counts like a CHG bath. 17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care-associated infection will the nurse report? a. Vector b. Exogenous c. Endogenous d. Suprainfection - ANSANS: B An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras. A vector transmits microorganisms and is usually a type of insect or organism. Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. 18. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? a. Reusing the patient's graduated receptacle to empty the drainage bag. b. Allowing the drainage bag port to touch the graduated receptacle. c. Emptying the urinary drainage bag at least once a shift. d. Irrigating the catheter infrequently. - ANSANS: B Allowing the urinary drainage bag port to touch contaminated items (graduated receptacle) may introduce bacteria into the urinary system and contribute to a urinary tract infection. The urinary drainage bag should be emptied at least once a shift. Patients should have their own receptacle for measurement to prevent cross- contamination. Repeated catheter irrigations increase the chance so irrigating infrequently will be beneficial in reducing the risk. 19. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection? a. Uses surgical aseptic technique to suction an airway b. Uses a clean technique for inserting a urinary catheter c. Uses a cleaning stroke from the urinary meatus toward the rectum d. Uses a sterile bottled solution more than once within a 24-hour period - ANSANS: B Using clean technique (medical asepsis) to insert a urinary catheter would place the patient at risk for a health care-associated infection. Urinary catheters need to be inserted using sterile technique, which is also referred to as surgical asepsis. Surgical aseptic technique (also called sterile technique) should be used when suctioning an airway because it is considered a sterile body cavity. Washing from clean to dirty (urinary meatus toward rectum) is correct for decreasing infection risk. Bottled solutions may be used repeatedly during a 24-hour period; however, special care is needed to ensure that the solution in the bottle remains sterile. After 24 hours, the solution should be discarded. 2. A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster. - ANSAns: D A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment) 2. A 62-year-old pt had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the pt's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) 1. Assess condition of skin before making the call 2. Rely on the nurse specialist to know the type of surgery the pt likely had 3. Explain the pt's response emotionally to the repeated leaking of stool 4. Describe the type of bag being used and how long it lasts before leaking 5. Order extra colostomy bags currently being used - ANS2. Answer: 1, 3, 4. The nurse should have as much information available before making the call to the nurse specialist. It is also important for the nurse to interpret and explain the problem. In addition it is important to explain the patient's perspective. Assuming the nurse specialist knows the extent of the surgery is not appropriate. 2. A nurse assesses a pt who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern - ANS2. Answer: 4. The nurse's assessment covers health perception and health management pattern, which is a patient's self report of how he or she manages their health and their knowledge of preventive health practices. The coping stress tolerance pattern would include questions focused on how the patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient's language adequacy, memory and decision making ability. 2. A nurse has seen many cancer pts struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping pts focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1. Creativity. 2. Fairness. 3. Clinical reasoning. 4. Applying ethical criteria. - ANS2. Answer: 4. The use of ethical criteria for nursing judgment allows a nurse to focus on a patient's values and beliefs. Clinical decisions are then just, faithful to the patient's choices, and beneficial to the patient's well-being. 2. The nurse administers a tube feeding via a pt's nasogastric tube. This is an example of which of the following? 1. Physical care technique Utilize clean gloves (medical asepsis) to remove contaminated dressings and sterile supplies, including gloves and dressings (surgical asepsis-sterile technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not necessary when removing soiled dressings. Donning clean gloves to dress a sterile wound would contaminate the sterile supplies. Utilizing clean supplies for a sterile dressing would not help in decreasing the number of microbes at the incision site. 23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? a. Washing hands after removing gloves b. Disinfecting endoscopes in the workroom c. Removing gloves to transfer the endoscope d. Placing the endoscope in a container for transfer - ANSANS: C Standard precautions are used to prevent and control the spread of infection. Transferring contaminated equipment without the protection of gloves can assist in the spread of microbes to inanimate objects and to the person doing the transfer; therefore, the nurse must intervene. Utilizing gloves, washing hands, covering contaminated supplies during transfer, and disinfecting equipment in the appropriate way in the appropriate places utilize principles of basic medical asepsis and standard precautions and can break the chain of infection. 24. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? a. Teaches the patient about good nutrition b. Dons gloves when wearing artificial nails c. Disposes an uncapped needle in the designated container d. Wears eyewear when emptying the urinary drainage bag - ANSANS: D Standard precautions include the wearing of eyewear whenever there is a possibility of a splash or splatter, like when emptying the urinary drainage bag. Teaching the patient about good nutrition is positive but does not apply to standard precautions. Standard precautions apply to contact with blood, body fluid (except sweat), nonintact skin, and mucous membranes from all patients. Artificial nails are not worn when using standard precautions. Any needles should be disposed of uncapped, or a mechanical safety device is activated for recapping. 25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? a. Contact b. Droplet c. Standard d. Protective environment - ANSANS: C Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes of all patients. Contact precautions apply to individuals with infections that can be transmitted by direct or indirect contact. Protective environment precautions apply to individuals who have undergone transplantations and gene therapy. Droplet precautions focus on diseases that are transmitted by large droplets. 26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a. The nurse is responsible for providing a safe environment for the patient. b. Different scopes of practice allow modification of procedures. c. Allowing the water to run is a waste of resources and money. d. This is a key step in the procedure for washing hands. - ANSANS: A The nurse is responsible for providing a safe environment for the patient. The effectiveness of infection control practices depends on conscientiousness and consistency in using effective aseptic technique by all health care providers. After washing hands, turn off a handle faucet with a dry paper towel, and avoid touching the handles with your hands to assist in preventing the transfer of microorganisms. Wet towels and hands allow the transfer of pathogens from faucet to hands. The principles and procedures for washing hands are universal and apply to all members of health care teams. Being resourceful and aware of the cost of health care is important, but taking shortcuts that may endanger an individual's health is not a prudent practice. 27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? a. Wash hands with an antimicrobial soap and water. b. Clean hands with wipes from the bedside table. c. Use an alcohol-based waterless hand gel. d. Wipe hands with a dry paper towel. - ANSANS: A The Centers for Disease Control and Prevention (CDC) recommends that when hands are visibly soiled, one should wash with a non-antimicrobial soap or with antimicrobial soap. Cleaning hands with wipes or using waterless hand gel does not meet this standard. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands. Wiping hands with a dry paper towel will occur after the nurse has washed both hands. 28. The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next? a. Inform the health care provider and recruit another nurse to assist. b. Rinse and dry hands, and begin assisting the health care provider. c. Extend the handwashing procedure to 5 minutes. d. Repeat handwashing using antiseptic soap. - ANSANS: D The inside of the sink and the edges of the sink, faucet, and handles are considered contaminated areas. If the hands touch any of these areas during handwashing, repeat the handwashing procedure utilizing antiseptic soap. There is no need to inform the health care provider or be relieved of this assignment. If the hands are contaminated when touching the sink, drying hands and proceeding with the procedure could possibly contaminate and contribute to increased microbial counts during the procedure, resulting in infection for the patient. Extending the time for washing the hands (although this is what will happen when the procedure is repeated) is not the focus. The focus is to repeat the whole hand hygiene procedure utilizing antiseptic soap. 29. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? a. Sending to central sterile for cleaning and sterilization b. Sending to central sterile for cleaning and disinfection c. Sending to central sterile for cleaning and boiling d. Sending to central sterile for cleaning - ANSANS: A Surgical instruments need to be cleaned and sterilized. Disinfecting, boiling, or cleaning is not utilized on critical items that will be reused on patients in the hospital environment. Items that are used on sterile tissue or in the vascular system present a high risk of infection if they become contaminated with bacteria. 3. A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis. - ANSD. Identifying the medical diagnosis instead of the patient's response to the diagnosis. Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis. 3. A nurse is caring for a complicated pt 3 days in a row. The nurse attends an interdisciplinary conference to discuss the pt's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) 1. Is willing to challenge other members' ideas because the nurse disagrees with their rationale 2. Shows competence in how to monitor pts' clinical status and inform the physician of critical changes 3. Asks a more experienced nurse to attend the conference 5. Your experiences in caring for other pts with similar problems - ANS3. Answer: 1, 3, 4. There are many sources of data for an assessment, including the patient through interview, observations, and physical exam; family members or significant others, health care team members like a physical therapist, the medical record which includes x ray results and the scientific and medical literature. 30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? a. The family member places the used dressings in a plastic bag. b. The family member saves part of the dressing because it is clean. c. The family member removes gloves and gathers items for disposal. d. The family member wraps the used dressing in toilet tissue before placing in trash. - ANSANS: A Contaminated dressings and other infectious, disposable items should be placed in impervious plastic or brown paper bags and then disposed of properly in garbage containers. Gloves should be worn during this process. Parts of the dressing should not be saved, even though they may seem clean, because microbes may be present. 31. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions b. A patient with tuberculosis in airborne precautions c. A patient with MRSA infection in contact precautions d. A patient with a lung transplant in protective environment precautions - ANSANS: A A patient with Clostridium difficile should be on contact precautions, not droplet; therefore, the nurse will see this patient first to correct the precautions. All the rest are on correct precautions. Patients with tuberculosis belong in airborne precautions; patients with MRSA infection belong in contact precautions; and patients with lung transplants belong in protective environment precautions. 32. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? a. Shaking hands b. Performing treatments c. Opening the refrigerator d. Working on a computer - ANSANS: B Patients and family members should perform hand hygiene before and after treatments and when coming in contact with body fluids. Shaking hands does not require washing of hands before and after. Washing hands before and after opening the refrigerator and using the computer is not required. 33. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? a. Apply a new mask. b. Reapply the mask after it air-dries. c. Change the mask when relieved by next shift. d. Do not change the mask if the nurse is comfortable. - ANSANS: A After the mask is worn for several hours, it can become moist. The mask should be changed as soon as possible because moisture does not provide a barrier to microorganisms and is ineffective. Waiting to change the mask, air-drying it, or wearing it because it is comfortable does not support the principles of infection control. 34. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? a. Place the patient in a room with negative airflow. b. Wear a gown, gloves, face mask, and goggles for interactions with the patient. c. Transport the patient safely and quickly when going to the radiology department. d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. - ANSANS: D Contact precautions are a type of isolation precaution used for patients with illness that can be transmitted through direct or indirect contact. Patients who are on contact precautions should have dedicated equipment wherever possible. This would mean, for example, that one blood pressure cuff and one stethoscope would stay in the room with the patient and would be used for that patient only. A gown and gloves may be required for interactions with a patient who is on contact precautions. A face mask and goggles are not part of contact precautions. A room with negative airflow is needed for patients placed on airborne precautions; it is not necessary for a patient on contact precautions. When a patient on contact precautions needs to be transported, the patient should wear clean gown, and hands cleaned, and the infectious material is contained or covered. 35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? a. Instruct assistive personnel to use soap and water rather than sanitizer. b. Wear an N95 respirator when entering the patient room. c. Place the patient on droplet precautions. d. Teach the patient cough etiquette. - ANSANS: A Clostridium difficile is a spore-forming organism that can be transmitted through direct and indirect patient contact. Because Clostridium difficile is a spore-forming organism, hand sanitizer is not effective in preventing its transmission. Hands must be washed with soap and water to prevent transmission. This organism is not transmitted via the droplet route; therefore, droplet precautions are not needed. An N95 respirator is used primarily for patients with airborne illness, especially tuberculosis. While all patients should be taught cough etiquette, this action is not specifically related to the patient having Clostridium difficile. 36. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk? a. Diphtheria b. Hepatitis B c. Clostridium difficile d. Methicillin-resistant Staphylococcus aureus - ANSANS: B Bloodborne pathogens such as those associated with hepatitis B and C are most commonly transmitted by contaminated needles. Clostridium difficile and MRSA are spread by contact. Diphtheria is spread by droplets when one is within 3 feet of the patient. 37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b. Immediately wash the site with soap and running water, and seek guidance from the manager. c. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. d. Delay washing of the site until the nurse is finished providing care to the patient. - ANSANS: B After getting splashed with blood from a patient who has a known bloodborne pathogen, it is important to cleanse the site immediately and thoroughly with soap and running water and notify the manager for guidance on next steps in the process. Removing the blood with an alcohol swab, delaying washing, and doing nothing because the splash was to intact skin could possibly spread the blood within the room and could spread the infection. Contain contamination immediately to prevent contact spread. 38. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? a. Placing the scalpel in a needle safe container b. Testing the patient and offering treatment to the nurse c. Removing sterile gloves and disposing of in kick bucket d. Providing a medical evaluation of the nurse to the manager - ANSANS: B Follow-up for risk of infection begins with patient testing. Patients should be tested for HIV and hepatitis B and C. Testing of the nurse is dependent on the results of patient testing; if the patient is positive for one of these infections, the nurse will be started on testing and treatment. Removing sterile gloves and placing sharps in appropriate containers are always part of the perioperative process and are not the process for postexposure. A confidential medical evaluation is provided to the nurse, not the manager. 39. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles. 2. Perform hand hygiene, leave room, and close door. 3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside of mask. your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal though process of thinking back about a situation. 4. The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes? A. Provide information using a lecture B. Use simple words to promote understanding C. Develop topics for discussion that require problem solving D. Complete an extensive literature search focusing on eating disorders - ANSC. Develop topics for discussion that require problem solving Adolescents learn best when they are able to use problem solving to help them make choices. 4. Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned pt? 1. Knowing the source of the guideline 2. Reviewing evidence used to develop guideline 3. Individualizing how to apply clinical guideline for a pt 4. Explaining to a pt the purpose of the guideline - ANS4. Answer: 3. Individualizing patient care is still the important principle for implementing care, even when a clinical guideline is used. Explaining any interventions in a guideline to the patient is important but not the most critical factor in implementing care. Reviewing the source of the guideline and applicable evidence will not directly benefit a patient. 40. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission 2. An infectious agent or pathogen 3. A susceptible host 4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir a. 3, 2, 4, 1, 5, 6 b. 1, 3, 5, 4, 6, 2 c. 4, 2, 1, 6, 3, 5 d. 2, 4, 6, 1, 5, 3 - ANSANS: D For spread of infection, the chain has to be uninterrupted with an infectious agent, a reservoir and portal of exit, a mode of transmission, a portal of entry, and a susceptible host. The nurse manager is evaluating the chain of infection to determine actions that could be implemented to influence the spread of infection in the intensive care unit. Understanding the spread of infection and directing actions toward those steps have the potential to decrease infection in the setting. 5 rights of successful delegation - ANSright task, right, circumstances, right person, right direction/communication, right supervision/evaluation. 5. A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely - ANSC. Insufficient number of cues It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume. 5. A 72-year-old male pt comes to the health clinic for an annual follow-up. The nurse enters the pt's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the pt's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format 3. Back channeling 4. A problem-oriented approach - ANS5. Answer: 4. This is an example of a problem focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine nature of the patient's pain and other presenting symptoms. 5. A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient's ability to perform the examination? A. The patient will verbalize the steps involved in breast self-examination within 1 week. B. The nurse will explain the importance of performing breast self-examination once a month. C. The patient will perform breast self-examination correctly on herself before the end of the teaching session. D. The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society. - ANSC. The patient will perform breast self-examination correctly on herself before the end of the teaching session. Return demonstration provides an excellent source of feedback and reinforcement to evaluate learning. 5. A nurse is visiting a pt in the home and is assessing the pt's adherence to medications. While talking with the family caregiver, the nurse learns that the pt has been missing doses. The nurse wants to perform interventions to improve the pt's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this pt? (Select all that apply.) 1. Reviewing the family caregiver's availability during medication administration times 2. Making a judgment of the value of improved adherence for the pt 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the pt missing specific medicines 5. Reviewing the therapeutic actions of the medications - ANS5. Answer: 2, 4. Tips for making good clinical decisions during implementation include: Making a judgment of the value of the consequence to the patient, Review all possible consequences associated with each nursing action, determine the probability of all possible consequences and review the set of all possible nursing interventions for a patient's problems. 5. A nurse on a busy medicine unit is assigned to four pts. It is 10 AM. Two pts have medications due and one of those has a specimen of urine to be collected. One pt is having complications from surgery and is being prepared to return to the operating room. The fourth pt requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the pt group? (Select all that apply.) 1. Consider availability of assistive personnel to obtain the specimen 2. Combine activities to resolve more than one pt problem 3. Analyze the diagnoses/problems and decide which are most urgent based on pts' needs 4. Plan a family conference for tomorrow to make decisions about resources the pt will need to go home 5. Identify the nursing diagnoses for the pt going home - ANS5. Answer: 1,2,3. Analyzing urgency of problems helps in prioritization as does considering the resources that are available (such as assistive personnel) to complete patient care activities. Deciding on how to combine activities is good time management. Holding a family conference is a good idea but in this case would be too late to be beneficial to the patient. The nurse must identify nursing diagnoses for all patients in order to determine priorities. 5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) a. Private room 2. Adequacy 3. Discipline 4. Thinking independently - ANS6. Answer: 3. Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline. 6. The nurse and the student nurse are caring for two different patients on the medical- surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) a. Dispose of supplies to prevent the spread of microorganisms. b. Wash hands before entering and leaving both of the patients' rooms. c. Be consistent in nursing interventions since there is only one difference in the precautions. d. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e. Have patients in airborne precautions wear a mask during transportation to other departments. f. Check the working order of the negative-pressure room for the airborne precaution patient on admission and at discharge. - ANSANS: A, B, D, E Washing hands, properly disposing of supplies, applying knowledge of the disease process, and having patients in airborne precautions wear a mask during transfer are all principles to follow when caring for patients in isolation. Multiple differences are evident among these types of isolation, including the type of room used for the patient and what the nurse wears while caring for the patient. It is important to check the working order of a negative-pressure room before admitting a patient to the room, each shift the patient is in the room, and if and when the device alarms. Checking the working order of the negative-pressure rooms at discharge is not necessary. 6. The nurse asks a pt, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a pt-centered interview? 1. Orientation 2. Working phase 3. Data validation 4. Termination - ANS6. Answer: 2. The gathering of information is the working phase of a patient-centered interview. 6. The nurse enters a pt's room and finds that the pt was incontinent of liquid stool. B/c the pt has recurrent redness in the perineal area, the nurse worries about risk of the pt developing a pressure ulcer. The nurse cleanses the pt, inspects the skin, and applies a barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity - ANS6. Answer: 2, 3. The call to the specialist is a referral and an indirect care measure on the patient's behalf. Cleansing of the skin is an example of direct care. Application of a skin barrier is an independent measure and it is not an instrumental activity of daily living. 6. The nurse is providing an education session to an adult community group about the effects of smoking on infection. Which information is most important for the nurse to include in the educational session? a. Smoke from tobacco products clings to your clothing and hair. b. Smoking affects the cilia lining the upper airways in the lungs. c. Smoking can affect the color of the patient's fingernails. d. Smoking tobacco products can be very expensive. - ANSANS: B A normal defense mechanism against infection in the respiratory tract is the cilia lining the upper airways of the lungs and normal mucus. When a patient inhales a microbe, the cilia and mucus trap the microbe and sweep them up and out to be expectorated or swallowed. Smoking may alter this defense mechanism and increase the patient's potential for infection. Smoking can be expensive, the smell does cling to hair and clothing, and the tar within the smoke can alter the color of a patient's nails. This information can be included in the education but does not constitute the most important point. 7. A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? A. Disturbed Sleep Pattern evidenced by frequent awakening B. Disturbed Sleep Pattern related to family caregiving responsibilities C. Disturbed Sleep Pattern related to need to improve sleep habits D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested - ANSD. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor. 7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? a. "When was the last time you visited your primary health care provider?" b. "Has this condition affected your eating habits in any way?" c. "What medications are you currently taking?" d. "Are you able to sleep at night?" - ANSANS: C Antibiotics and oral contraceptives can disrupt normal flora in the vagina, causing an overgrowth of Candida albicans in that area. It is important to ask the patient about current medications to obtain information that may assist with diagnosis. The body contains normal flora (microorganisms) that live on the surface of skin, saliva, oral mucosa, gastrointestinal tract, and genitourinary tract. The normal flora of the vagina causes vaginal secretions to achieve a low pH, inhibiting the growth of many microorganisms. Visiting the primary health care provider is important for the patient's health maintenance but is not the priority. Learning about the patient's eating and sleeping habits will assist in the plan of care but is not the priority. 7. A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The pt is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the pt's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish pts understood how overeating affects their health." - ANS7. Answer: 3. This is the only assessment approach that is not biased or showing judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient based on personal stereotypes and biases. 7. A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called: 1. Reflection. 2. Perseverance. 3. Intuition. 4. Problem solving - ANS7. Answer: 1. The mother had difficulty the first time breast feeding. The nurse relied on reflection to consider her previous actions, review what was successful and the opportunities for improvement. The nurse has not yet problem solved but might do so after reflection and anticipating the patient's next clinic visit. 7. During the implementation step of the nursing process, a nurse reviews and revises a pt's plan of care. Place the following steps of review and revision in the correct order. ______, ______, ______, _____ 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. - ANS8. Answer: 4, 3, 1, 5, 2. The correct order of the steps of the scientific method are: 1. Identifying the problem, 2. Collecting data, 3. Formulating a question or hypothesis, 4. Testing the question or hypothesis, and 5. Evaluating results of the test or study. 8. The nurse is caring for a school-aged child who has injured the right leg after a bicycle accident. Which signs and symptoms will the nurse assess for to determine if the child is experiencing a localized inflammatory response? a. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells b. Chest pain, shortness of breath, and nausea and vomiting c. Dizziness and disorientation to time, date, and place d. Edema, redness, tenderness, and loss of function - ANSANS: D The body's cellular response to an injury is seen as inflammation. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. Systemic signs of inflammation include fever, malaise, and anorexia, as well as enlarged lymph nodes and increased white blood cells. Chest pain, shortness of breath, and nausea and vomiting are signs and symptoms of a cardiac alteration. Dizziness and disorientation to time, date, and place may indicate a neurologic alteration. 8. Which type of interview question does the nurse first use when assessing the reason for a pt seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4. Confirmation - ANS8. Answer: 2. The best interview question for determining initially the reason a patient is seeking healthcare is by asking an open ended question that allows the patient to tell their story. This is also a more patient-centered approach. Probing questions are done after data are gathered to seek more in depth information. Problem oriented and confirmation are not types of interview question. 9. Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Impaired Skin Integrity related to physical immobility B. Fatigue related to heart disease C. Nausea related to gastric distention D. Need for improved Oral Mucosa Integrity related to inflamed mucosa E. Risk for Infection related to surgery - ANSA. Impaired Skin Integrity related to physical immobility C.Nausea related to gastric distention The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet. 9. A nurse changed a pt's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the pt discomfort. Today he gives the pt an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The pt reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Select all that apply.) 1. Clinical inference 2. Basic critical thinking 3. Complex critical thinking 4. Experience 5. Reflection - ANS9. Answer: 3,4. The nurse relies on experience and the ability to adapt a procedure such as a dressing change (complex critical thinking) to make it successful. 9. A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Pt has a heart rate of 78 beats/min and regular. 4. Pt has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F). 6. Pt states, "I'm worried that I won't be able to return to work when I planned." - ANS9. Answer: 1, 4, 5. Tender skin around the wound, drainage from the surgical wound, and a temperature of 101° indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 and regular are normal assessment findings. A patient's expressed concern about returning to work is a patient's subjective response about a separate issue and insufficient to form a pattern. 9. A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? A. Describing difficulties a family member has had in taking insulin B. Expressing the importance of learning the skill correctly C. Being able to see and understand the markings on the syringe D. Having the dexterity needed to prepare and inject the medication - ANSB. Expressing the importance of learning the skill correctly Pg. 348-349 Patients are ready to learn when they understand the importance of learning and are motivated to learn. 9. An 82-year-old pt who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals Outcomes 1. _____ Pt will ambulate independently in 3 days 2. _____ Pt will be injury free for 1 month. 3. _____ Pt will achieve 5-lb weight gain in 1 month. 4. _____ Pt will achieve pain relief by discharge. a. Pt has fewer nonverbal signs of discomfort w/i 24 hrs. b. Pt increases calorie intake to 2500 daily. c. Pt walks 20 feet using a walker in 24 hrs. d. Pt identifies barriers to remove in the home w/i 1 wk. - ANS9. Answer: 1c, 2d, 3b, 4a. In each case the outcome is a measurable behavior or perception that reflects goal achievement. 9. Match the category of direct care on the left with the specific direct care activity on the right. 1. Counseling ___ 2. Lifesaving measure ____ 3. Physical care technique ___ 4. Activity of daily living ____ a. Assisting pt with oral care b. Discussing a pt's options in choosing palliative care c. Protecting a violent pt from injury d. Using safe pt handling during positioning of a pt - ANS9. Answer: 1b, 2c, 3d, 4a. 9. Which interventions utilized by the nurse will indicate the ability to recognize a localized inflammatory response? a. Vigorous range-of-motion exercises b. Turn, cough, and deep breathe c. Orient to date, time, and place d. Rest, ice, and elevation - ANSANS: D Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. One sign of the inflammatory response, C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions - ANSB, D A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a.States feels better after talking with family and friends b.Consumes high-carbohydrate foods when stressed c.Dislikes the support group meetings d.Spends most of the day in bed - ANSA A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a."An evaluation helps you determine whether all nursing interventions were completed." b."During evaluation, you determine when to downsize staffing on nursing units." c."Nurses use evaluation to determine the effectiveness of nursing care." d."Evaluation eliminates unnecessary paperwork and care planning." - ANSC A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms several times looking for equipment and supplies. This nurse could benefit from practicing better _____ skills. a. Clinical decision-making b. Organizational c. Evaluation d. Interpersonal communication - ANSB A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a."Evaluative measures are multiple-page documents used to evaluate nurse performance." b."Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c."Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d."Evaluative measures are objective views for completion of nursing interventions." - ANSB A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination - ANSANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship. A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. aortic and mitral b. mitral and tricuspid c. aortic and pulmonic d. mitral and pulmonic - ANSAs the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time. DIF:Apply (application)REF:874 A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend - ANSANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self- confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient. A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? A. Patient weight B. Asking patient to identify three low-sodium foods to eat for lunch C. A calorie count of food D. Patient description of how food selections are made - ANSB A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? Select all that apply. A. Checked the IV infusion rate B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change D. Inspected the condition of the IV dressing at the site E. Checked clarity of IV solution - ANSA, D A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a.Assessment b.Planning c.Implementation d.Evaluation - ANSD A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? management of asthma medications. Identify appropriate evaluative indicators for self- management for this patient. Select all that apply. A. Quality of life B. Patient satisfaction C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications - ANSA, C, D A nurse is assigned to care for the following patients who all need vital signs taken right now. Which of these patients is most appropriate for the nurse to delegate vital sign measurement to nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from cardiac catheterization d. Patient returning from hip replacement surgery - ANSA A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues - ANSANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown. DIF:Understand (comprehension)REF:877 A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a.Observations of wound healing b.Daily blood pressure measurements c.Findings of respiratory rate and depth d.Completion of nursing interventions e.Patient's subjective report of feelings about a new diagnosis of cancer - ANSA, B, C, E A nurse is caring for a group of patients. Which patient should the nurse see first? a. a patient with hypercapnia wearing an oxygen mask b. a patient with a chest tube ambulating with the chest tube unclamped c. a patient with thick secretions being tracheal suctioned first and then orally d. a patient with a new tracheostomy and tracheostomy obturator at the bedside - ANSANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged. DIF:Analyze (analysis)REF:902 A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions - ANSANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat. DIF:Analyze (analysis)REF:879-880 A nurse is caring for a patient who is depressed because her children have gone away to college. Which type of loss is experienced by the patient? a. Perceived b. Situational c. Conditional d. Maturational - ANSd A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina - ANSANS: C Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle. DIF:Apply (application)REF:883 A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask - ANSANS: A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non-rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min. DIF:Apply (application)REF:903 A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia - ANSANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. DIF:Apply (application)REF:878 A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a.Assist-control (AC) b.Pressure support ventilation (PSV) A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a.1, 5, 2, 4, 3 b.2, 1, 5, 4, 3 c.4, 3, 1, 5, 2 d.5, 4, 5, 1, 2 - ANSB A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6 - ANSANS: C The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline. DIF:Understand (comprehension)REF:907-911 A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. pulse 75 b. pulse 80 c. O2 saturation 91% d. O2 saturation 88% - ANSANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%. DIF:Apply (application)REF:911 A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a.Health status b.Health behavior c.Psychological self-control d.Health service utilization - ANSB A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers - ANSANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction. DIF:Apply (application)REF:875-876 A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a. Intimate b. Personal c. Social d. Public - ANSANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing. A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good. - ANSANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message. A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a.It is given yearly. b.It is given in a series of four doses. c.It is safe for children allergic to eggs. d.It is safe for adults with acute febrile illnesses. e.The nasal spray is given to people over 50. f.The inactivated flu vaccine is given to people over 50. - ANSANS: A, F Annual (yearly) flu vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia. DIF:Apply (application)REF:890-891 A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. right ventricle, left ventricle, left atrium b. left atrium, right ventricle, left ventricle c. right ventricle, left atrium, left ventricle d. left atrium, left ventricle, right ventricle - ANSANS: C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery A nurse uses SBAR during hand-offs. The purpose of SBAR is to a. Use common courtesy. b. Establish trustworthiness. c. Promote autonomy. d. Standardize communication. - ANSANS: D When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, a risk of miscommunication arises. Accurate communication is essential to prevent errors. SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others. A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group - ANSANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. A nursing assistant reports seeing a reddened area on the patient's hip while bathing the patient. The nurse should a. Go to the patient's room to assess the patient's skin. b. Document the finding per the nursing assistant's report. c. Request a wound nurse consult. d. Ask the nursing assistant to apply a dressing over the reddened area. - ANSA A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR - ANSANS: A In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation. A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Reflection. - ANSA A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate - ANSANS: A A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load. DIF:Understand (comprehension)REF:879 A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. myocardial contractility x myocardial blood flow b. ventricular filling time/diastolic filling time c. stroke volume x heart rate d. preload/afterload - ANSANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output. DIF:Understand (comprehension)REF:875 A patient has inadequate stroke volume related to decreased preload. which treatment does the nurse prepare to administer? a. diuretics b. vasodilators c. chest physiotherapy d. intravenous (IV) fluids - ANSANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem. DIF:Apply (application)REF:875 A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit - ANSANS: B A patient with impaired verbal communication has defining characteristics such as an inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending. Hopelessness implies that the patient has no hope for the future. Hearing loss is not a nursing diagnosis. Just because a patient has garbled speech does not mean that a hearing loss has occurred; a physical problem such as a stroke could cause the garbled speech. Self-care deficit does not apply in this situation because this usually relates to bathing, grooming, etc. A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. - ANSANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient. A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status." - ANSANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing. DIF:Apply (application)REF:884 A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. increase in diastolic filling time b. decrease in hemoglobin level c. decrease in cardiac output d. increase in stroke volume - ANSANS: C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected. DIF:Understand (comprehension)REF:875 A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong. - ANSANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe. 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? a. Responsibility b. Autonomy c. Accountability d. Authority - ANSANS: B Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions. Authority refers to legitimate power to give commands and make final decisions specific to a given position. A staff nurse delegates a task to a nursing assistant, knowing that the assistant has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the nursing assistant should have known how to perform such a simple task. This nurse is demonstrating lack of a. Responsibility. b. Autonomy. c. Authority. d. Accountability. - ANSD A theory also consists of interrelated ___ that help describe or label phenomena. - ANSconcepts A young child begins wetting the bed again after the parents bring home a new baby sister. Which ego-defense mechanism is used by the child? a. Regression b. Conversion c. Identification d. Compensation - ANSa According to Hildegard Peplau, nurses help patients reduce anxiety by converting it into ___. - ANSconstructive actions According to Hildegard Peplau, what are the four phases that characterize the nurse- patient interpersonal relationship? - ANS(1) preorientation (2) orientation (3) working phase (4) resolution According to the Dorothea Orem's ___ theory, a nurse continually assesses a patient's ability to perform self-care and intervenes as needed to ensure that the patients meet physical, psychological, sociological, and developmental needs. - ANSself-care deficit nursing According to which theorist, nurses help a patient cope with or adapt to changes in physiological, self-concept, role function, and interdependence domains? - ANSRoy According which theorist do nurses develop therapeutic relationships with patients that are respectful, empathetic, and non-judgmental? - ANSHildegard Peplau After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a.Eliminate headache from the nursing care plan. b.Direct the nursing assistive personnel to ask if the headache is relieved. c.Reassess the patient's pain level in 30 minutes. d.Revise the plan of care. - ANSC After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? Reflection-in-action Reassessment Reprioritizing Reflection-on-action - ANSD An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print. - ANSANS: B Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired. As a system, the nursing process has what four components? - ANS(1) input (2) output (3) feedback (4) content Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination - ANSANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and b. Primary nursing c. Team nursing d. Case management - ANSANS: D What is unique about case management is that clinicians, as individuals or as part of a collaborative group, oversee the management of patient groups with specific case types and usually are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care. DIF: Remember REF: 276 In which nursing care model is the RN usually appointed the position of group leader? a. Total patient care b. Primary nursing c. Team nursing d. Case management - ANSANS: C In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, licensed vocational nurses, and nurse assistants or technicians. Total patient care involves an RN being responsible for all aspects of care for one or more patients. Primary nursing places RNs at the bedside more, assuming responsibility for a caseload of patients over time. This model, however, does not require an all-RN staff as is required for total patient care. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. DIF: Remember REF: 276 Kolcaba's theory of caring was based on the works of ___. - ANSNightingale Magnet recognition - ANSoperated by the American nurses credential center, has a practice environment that is dynamic, autonomous, collaborative, and positive for nurses. Nurse executive - ANSresponsibilities include philosophy of care, purpose of nursing unit, how staff works with patients and families, standards of care. Nurse/physician collaborative practice - ANSthe process between nurse and physician Nurses develop ___ to explain the relationship among variables by testing the theory through research and applying it in practice. - ANStheories Nurses use ___ theories to anticipate the outcomes of nursing interventions. - ANSprescriptive Nurses use ___ to provide direction in how to use the nursing process. - ANStheory Nurses who make the best communicators a. Develop critical thinking skills. b. Like different kinds of people. c. Learn effective psychomotor skills. d. Maintain perceptual biases. - ANSANS: A Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques and communication involves more than psychomotor skills. Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators. Often used synonymously with paradigm is the term ___. - ANSconceptual framework Organizational skills - ANSeffective use time, being well organized and prepared Phenomena may be ___ or ___. - ANStemporary or permanent Phenomena may be ___ or permanent. - ANStemporary Phenomena may be temporary or ___. - ANSpermanent Primary nursing - ANS24 hour responsibility for planning, directing, and evaluating patient care, associate nurse provides care when the primary nurse is off duty. Priority setting - ANShigh priority(immediate threat to patient survival), intermediate(non-emergency, non-life threatening), low priority(actual or potential problems not directly related to patients illness) Purposes of the Nursing Outcomes Classification (NOC) include which of the following? Select all that apply. A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings C. To establish health care reimbursement guidelines D. To identify nursing interventions for linked nursing diagnoses E. To define measurement procedures for outcomes - ANSA, B, E Shared governance- - ANScommittees chaired by senior clinical staff that establish and maintain care standards Team communication - ANSan enriching professional environment where staff member respect one another's ideas, share information, and keeping one another informed. Team nursing - ANSan RN leads a team of other nurses and NAP's, team members provide direct patient care under the RN. The ___ allows nurses to understand and explain what nursing *is*, what nursing *does*, and *why* nurses do what they do. - ANSnursing metaparadigm The ___ of nursing is based on data obtained from current research. - ANSscience The ___ of nursing stems from a nurse's experience and the unique caring relationship that a nurse develops with a patient. - ANSart The ___ provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a discipline. - ANSdomain The --------is a closed-loop communication technique used to evaluate patient understanding and retention of material. - ANSTeach Back Method Pg. 351 Teach-back is a closed loop communication technique that assesses patient retention of the information imparted during a teaching session. The chart lists the patient's daughter as having medical durable power of attorney for the patient. How does this impact the patient's care? a. The daughter is an attorney and plans to sue to the nursing staff and hospital for malpractice after the patient's death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient's daughter must be consulted before asking the patient to consent to medical procedures. d. The patient's daughter will translate medical terminology used by health care providers when communicating with the patient. - ANSb The female patient grieves the loss of her child to adoption and finds it difficult to cope because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. to determine peripheral extremity circulation b. to determine oxygenation requirements c. to determine cardiac dysrhythmias d. to determine ventilation status - ANSANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output. The nurse is caring for a patient who generally copes well after losing a child many years ago but becomes despondent each year on the anniversary of the death. Which is the best statement by the nurse? "That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction." "What happens to you is understandable and common in people who have lost loved ones." "I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time." "The fact that you reacted so strongly is concerning to me. This could be the beginning of some psychological issues." - ANSb The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a.Ask the nursing assistive personnel if the wound looks better. b.Document the progress of wound healing as "better" in the chart. c.Measure the wound and observe for redness, swelling, or drainage. d.Leave the dressing off the wound for easier access and more frequent assessments. - ANSC The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a.Wait and change the dressing at 1800 as ordered. b.Revise the plan of care and change the dressing now. c.Reassess the dressing and the wound in 2 hours. d.Discontinue the plan of care for wound care. - ANSB The nurse is caring for a patient who has just been diagnosed with amyotrophic lateral sclerosis (ALS). Which assessment findings justify the diagnosis of ineffective denial related to fear of loss of body function and death for the patient? (Select all that apply.) a. The patient attempts to hide shortness of breath from the nurse. b. The patient has fallen twice after insisting that a walker is not needed. c. The patient uses a gastrostomy tube for nutrition when unable to swallow. d. The patient attends support group meetings for families and patients with ALS. e. The patient insists that an uneven sidewalk caused a fall rather than leg weakness. - ANSa b e The nurse is caring for a patient who has just passed away. Which is the priority action of the nurse? Ask the family to leave the room so that postmortem care can be provided. Have the patient's family members sign consent forms for organ donation. Remove all drainage tubes and IV lines in case an autopsy is to be performed. Provide postmortem care in a manner consistent with religious or cultural beliefs. - ANSd The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions - ANSANS: B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider. DIF:Apply (application)REF:896 The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion - ANSANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output. DIF:Apply (application)REF:875 The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged." - ANSANS: B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax. DIF:Apply (application)REF:899 | 922 | 926 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? a.Staff documentation of turning the patient every 2 hours b.Presence of redness only on the heels of the patient c.Patient's eating 100% of all meals d.Absence of skin breakdown - ANSD DIF:Understand (comprehension)REF:879 The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately. - ANSANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues. The nursing metaparadigm includes what four concepts? - ANS(1) person (2) health (3) environment/situation (4) nursing The original ___ theories served as springboards for the development of the more modern middle-range theories. - ANSgrand The original grand theories served as springboards for the development of the more modern ___ theories. - ANSmiddle-range The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which ego-defense mechanism is used by the patient? a. Conversion b. Dissociation c. Compensation d. Reimbursement - ANSb The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression - ANSB Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future. The patient develops an inability to swallow after many years of emotional abuse. The physicians can find no medical reason for the patient's dysphagia. Which ego-defense mechanism is used by the patient? a. Displacement b. Dissociation c. Compensation d. Conversion - ANSd The patient grieves the security of a solid supportive marriage after the spouse has an affair. Which type of loss was experienced by the patient? a. Actual b. Perceived c. Situational d. Maturational - ANSB Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements. The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. peripheral edema b. basilar crackles c. chest pain d. cyanosis - ANSANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion. DIF:Apply (application)REF:878 The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. stimulation of chemical receptors in the aorta b. reduction of arterial oxygen saturation levels c. requirement of elastic recoil lung properties d. enhancement of accessory muscle usage - ANSANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. DIF:Understand (comprehension)REF:872 The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning - ANSANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction. DIF:Apply (application)REF:878 The patient is frustrated after being treated poorly by providers due to lack of health insurance. Which type of factor is causing the stress for the patient? a. Rational b. Situational c. Maturational d. Sociocultural - ANSd Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Situational factors include work-related stress. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Rational factors are not a cause of stress. The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? Explain that as long as the heart is beating, the patient is still alive. Provide a private area for the family to discuss organ donation options. Inform the family that the organs will be harvested when he is off the ventilator. Stress the importance of leaving the patient on the ventilator to harvest the corneas. - ANSb spouse is exhausted and overwhelmed so readiness for enhanced comfort is not appropriate. The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations. - ANSANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique. The twenty-first century is considered the era of ___. - ANStheory utilization The young child cries and tries to run away when after being told that a flu shot is to be administered. Which term best describes the psychological reaction of the child? A. Primary appraisal B. Ineffective denial C. Adventitious crisis D. Developmental Crisis - ANSa When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Ineffective denial is not indicated as the child realized the injection would be administered shortly and became upset. An adventitious crisis is a major disaster such as an earthquake or fire. A developmental crisis is when new coping strategies are needed to deal with stages of maturation such as getting married or having a child. Theories use ___ to communicate meaning. - ANSconcepts Theorists use ___ to communicate the general meaning of the concepts of a theory. - ANSdefinitions Time management - ANSinvolves learning how, when, and where to use your time, using to-do lists, estimating time needed to perform activities, and setting goals. Total patient care - ANSRN is responsible for all aspects of care, the RN works directly with the patient, family, and other health care team members. True or False. A grand theory does not provide guidance for specific nursing interventions. - ANSTrue True or False. A grand theory provides guidance for specific nursing interventions. - ANSFalse. A grand theory does not provide guidance for specific nursing interventions. True or False. Nursing is both an art and a science. - ANSTrue True or False. The nursing process is a system. - ANSTrue True or False. The nursing process is a theory. - ANSFalse. The nursing process is not a theory. True or False. The nursing process is not a theory. - ANSTrue Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea - ANSANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. DIF:Understand (comprehension)REF:878 Use of resources - ANSusing other health care team members, equipment and supplies What are the five historical eras of knowledge development in nursing? - ANS(1) curriculum era (2) research era (3) graduate education era (4) theory era (5) theory utilization era What are the three types of definitions? - ANS(1) theoretical definitions (2) conceptual definitions (3) operational definitions What are two other terms for shared theory? - ANS(1) borrowed theory (2) interdisciplinary theory What does AJN stand for? - ANSAmerican Journal of Nursing What does EBP stand for? - ANSevidence-based practice What is another term for practice theories? - ANSsituation-specific theories What is another term for situation-specific theories? - ANSpractice theories What is the focus of Nightingale's grand theory? - ANSthe patient's environment What is the focus on Roy's grand theory? - ANSadaptation What is the major concept of Madeleine Leininger's theory? - ANScultural diversity What is the name of Dorothea Orem's grand theory? - ANSSelf-Care Deficit Nursing Theory What is the name of Florence Nightingale's theory? - ANSEnvironmental Theory What is the name of Hildegard Peplau's theory? - ANSInterpersonal theory What is the term for a pattern of beliefs used to describe the domain of a discipline? - ANSparadigm What is the term for the "taken-for-granted" statements that explain the nature of the concepts, definitions, purpose, relationships, and structure of a theory? - ANSassumptions What is the term for the perspective or territory of a profession or discipline? - ANSdomain When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?" - ANSANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them. Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent's will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record.