Nursing Diagnostics: Preventing Falls and Pressure Ulcers, Managing Pain and Infections, Exams of Nursing

Download Nursing Diagnostics: Preventing Falls and Pressure Ulcers, Managing Pain and Infections and more Exams Nursing in PDF only on Docsity!

Fundamentals Final Exam Questions and

Answers 2024 LATEST UPDATE ASSURED

A+

An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? a. I'll take my time getting up from the bed or chair. b. I should dim the lighting outside to decrease the glare in my eyes. c. I'll leave my throw rugs in place so that my feet won't touch the cold tile. d. I should wear my favorite smooth bottom socks to protect my feet when walking around. - SOLUTION I'll take my time getting up from the bed or chair. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? a) Keep all side rails down at all times. b) Encourage patient to remain in bed most of the shift. c) Place patient in room away from the nurses' station if possible. d) Assist patient into and out of bed every 4 hours or as tolerated. - SOLUTION Assist patient into and out of bed every 4 hours or as tolerated A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient after the fall? a) Identifying factors interfering with goal achievement b) Counseling the nursing assistive personnel on duty when the patient fell c) Removing the fall risk sign from the patient's door because the patient has suffered a fall d) Requesting that the more experienced charge nurse complete the documentation about the fall - SOLUTION Identifying factors interfering with goal achievement A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old

b. 20/20 vision c. Urinary continence d. Orthostatic hypotension - SOLUTION Orthostatic hypotension During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? a) The patient is oriented. b) The patient takes a hypnotic. c) The patient walks only 2 miles a day. d) The patient recently became widowed. - SOLUTION The patient takes a hypnotic. The nurse is creating a plan of care for a patient diagnosed with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit? a. Body image disturbance b. Impaired socialization c. Risk for falls d. Fear - SOLUTION Risk for falls A nurse is caring for a young adult. Which goal is priority? a) Maintain peer relationships. b) Maintain family relationships. c) Maintain parenteral relationships. d) Maintain recreational relationships. - SOLUTION Maintain family relationships. A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? a) One who is pregnant. b) One who has excessive risks. c) One who has unlimited access to health care. d) One who uses nontraditional healing practices. - SOLUTION One who has excessive risks. A nurse is teaching a community group of school-aged parents about safety. The proper fitting of which safety item is most important for the nurse to include in the teaching session? a) A bicycle helmet

b) Soccer shin guards c) Swimming goggles d) Baseball sliding shorts - SOLUTION A bicycle helmet The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? a) Frequent injuries related to poor psychomotor coordination b) Recognizing common signs and symptoms of the schizophrenia c) Failing grades and changes in dress may indicate substance abuse d) The importance of the use seat belts whenever riding in the backseat of a car - SOLUTION Frequent injuries related to poor psychomotor coordination The nurse is discussing threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? a) Smoking just to control stress is not good for my body. b) Our campus is safe; we leave our dorms unlocked all the time. c) If I have only two drinks, I can still be the designated driver. d) I am young, so I can work nights and go to school with 2 hours' sleep. - SOLUTION Smoking just to control stress is not good for my body. The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? a) Are you able to hear the tornado sirens in your area? b) Are you able to read your favorite book? c) Are you able to taste spices like before? d) Are you able to open a jar of pickles? - SOLUTION Are you able to hear the tornado sirens in your area? The nurse is monitoring for risks for injury identified in the health care environment. Which finding will alert the nurse that these safety risks are occurring? a) Tile floors, cold food, scratchy linen, and noisy alarms b) Dirty floors, hallways blocked, medication room locked, and alarms set c) Carpeted floors, ice machine empty, unlocked supply cabinet, and nurse call system in reach

d) Wet floors unmarked, failure to use lift for patient, and alarms not functioning properly - SOLUTION Wet floors unmarked, failure to use lift for patient, and alarms not functioning properly Which activity will increase the need for the nurse to monitor for equipment- related accidents? a) Using a patient-controlled analgesic pump b) Making an entry in a computer-based documentation record c) Using a plastic measuring device to accurately measure urine d) Removing medications from a manual medication-dispensing device - SOLUTION Using a patient-controlled analgesic pump An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a) Positions patient's buttocks close to the front of wheelchair seat. b) Backs wheelchair into elevator, leading with large rear wheels first. c) Places locked wheelchair on same side of bed as patient's weaker side. d) Unlocks wheelchair for easy maneuverability when patient is transferring. - SOLUTION Backs wheelchair into elevator, leading with large rear wheels first. The nurse is preparing to move a patient to a wheelchair. Which action indicates the nurse is following recommendations for safe patient handling? a) Mentally reviews the transfer steps before beginning. b) Uses own strength to transfer the patient. c) Focuses solely on body mechanics. d) Bases decisions on intuition. - SOLUTION Mentally reviews the transfer steps before beginning The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group about the most important thing to do to prevent the spread of infection. Which information did the nurse share with the preschool workers? a) Encourage preschool children to eat a nutritious diet. b) Suggest that parents provide a multivitamin to the children. c) Clean the toys every afternoon before putting them away. d) Wash their hands between each interaction with children. - SOLUTION Wash their hands between each interaction with children.

The nurse is admitting a patient with an infectious disease process. Which question will be most appropriate for a nurse to ask about the patient's susceptibility to this infectious process? a. Do you have a spouse? b. Do you have a chronic disease? c. Do you have any children living in the home? d. Do you have any religious beliefs that will influence your care? - SOLUTION Do you have a chronic disease? The nurse is caring for a patient diagnosed with C. difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? a) Appropriate disposal of contaminated items in biohazard bags b) Monthly in-services about contact precautions c) Mandatory cultures on all patients d) Proper hand hygiene techniques - SOLUTION Proper hand hygiene techniques The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action 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. - SOLUTION Use a chlorhexidine wash. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a) Touching clean protective eyewear b) Standing with hands above waist area c) Accepting sterile supplies from the surgeon d) Staying with the sterile table once it is open - SOLUTION Touching clean protective eyewear 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. - SOLUTION Repeat handwashing using antiseptic soap. 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. - SOLUTION Wash hands with an antimicrobial soap and water. 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. - SOLUTION Immediately wash the site with soap and running water and seek guidance from the manager. A nurse is following safety principles to reduce the risk of needlestick injury. Which actions will the nurse take? (Select all that apply.) a) Recap the needle after giving an injection. b) Remove needle and dispose in sharps box. c) Never force needles into the sharp's disposal. d) Use clearly marked sharps disposal containers. e) Use needleless devices whenever possible. - SOLUTION -Never force needles into the sharp's disposal. -Use clearly marked sharps disposal containers. -Use needleless devices whenever possible.

A nurse is preparing to perform a complete physical examination on a fragile, older-adult patient diagnosed with bilateral basilar pneumonia. Which position will the nurse use to facilitate the patient's breathing? a. Prone b. Sims' c. Supine d. Lateral recumbent - SOLUTION Supine A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow's hierarchy of needs is the nurse promoting when the family is encouraged to visit? a) First level b) Second level c) Third level d) Fourth level - SOLUTION Third level Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute. According to Maslow's hierarchy of needs, which patient need should the nurse address first? a) Self-esteem b) Physiological c) Self-actualization d) Love and belonging - SOLUTION Physiological A nurse is using Maslow's hierarchy of needs to prioritize care. Place the levels in order of basic priority to highest priority that the nurse will follow.1. Physiological2. Self-esteem

3. Self-actualization
4. Safety and security
5. Love and belonging a) 4, 1, 2, 3, 5 b) 1, 4, 5, 3, 2 c) 4, 5, 3, 2, 1 d) 1, 4, 5, 2, 3 - SOLUTION 1, 4, 5, 2 , 3

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a) Anxiety b) Not eating c) Mental health d) Not seeing family members - SOLUTION Not eating A nurse is engaged in therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? a) Interpersonal communication to change negative self-talk to positive self- talk b) Small group communication to present information to an audience of children c) Electronic communication to communicate with the health care provider d) Intrapersonal communication to build strong teams - SOLUTION Electronic communication to communicate with the health care provider A nurse is caring for a postoperative mastectomy patient. Which action is a priority for increasing self-awareness? a. Solving problems for the patient before developing insight b. Using communication skills to clarify family and patient expectations c. Telling the patient that it will be fine because many others have survived d. Rotating nursing personnel in the patient's care, so the patient can talk to many people - SOLUTION Using communication skills to clarify family and patient expectations The patient is having a difficult time dealing with an AIDS diagnosis. The patient states, ―It's not fair. I'm totally isolated from God and my family because of this. Even my father hates me for this. He won't even speak to me.‖ What should the nurse do? a. Tell the patient to move on and focus on getting better. b. Use therapeutic communication to establish trust and caring. c. Assure the patient that the father will accept this situation soon. d. Point out that the patient has no control and that he or she must face the consequences. - SOLUTION Use therapeutic communication to establish trust and caring. While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. the nurse

disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a) Tell the patient to just focus on the leg and cast right now. b) Document the sleep patterns and information in the patient's chart. c) Explain that a more thorough assessment will be needed next shift. d) Ask the patient about usual sleep patterns and the onset of having difficulty resting. - SOLUTION Ask the patient about usual sleep patterns and the onset of having difficulty resting. The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using? a) Cognitive b) Interpersonal c) Psychomotor d) Judgmental - SOLUTION Interpersonal The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? a) Cognitive b) Interpersonal c) Psychomotor d) Judgmental - SOLUTION Psychomotor A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a) Refusing the assignment b) Asking for an orientation to the unit c) Admitting lack of knowledge and going home d) Assuming that patient care will be the same as on the other units - SOLUTION Asking for an orientation to the unit Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that requires epinephrine therapy? a) The patient will identify the main ingredients in several foods. b) The patient will list the side effects of epinephrine. c) The patient will learn about food labels.

d) The patient will administer epinephrine. - SOLUTION The patient will administer epinephrine. During a school physical examination, the nurse reviews the patient's current medical history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies? a) Clubbing b) Pale nasal mucosa c) Yellow nasal discharge d) Puffiness of nasal mucosa - SOLUTION Pale nasal mucosa The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a) Perioperative b) Preoperative c) Intraoperative d) Postoperative - SOLUTION Preoperative The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? a) Public health nursing b) Community-based nursing c) Community health nursing d) Vulnerable population nursing - SOLUTION Public health nursing A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice? a) Nursing theory can direct how a nurse uses the nursing process. b) Nursing theory requires the nursing process to develop knowledge. c) Nursing theory with the nursing process has a minor role in professional nursing. Nursing theory combined - SOLUTION Nursing theory can direct how a nurse uses the nursing process. Which action indicates the nurse is using the nursing process in patient care?

a) Generates nursing knowledge for use in nursing practice. b) Conceptualizes an aspect of nursing to predict nursing care. c) Develops nursing care as a specific, distinct phenomenon. d) Delivers nursing care using a systematic approach. - SOLUTION Delivers nursing care using a systematic approach. Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process - SOLUTION Using the nursing process The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a) Completes a comprehensive database. b) Identifies pertinent nursing diagnoses. c) Intervenes based on priorities of patient care. d) Determines whether outcomes have been achieved. - SOLUTION Completes a comprehensive database. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient reports feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a) Assessment b) Diagnosis c) Implementation d) Evaluation - SOLUTION Assessment Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. What types of foods do you think caused your upset stomach b. How many bowel movements a day have you had? c. Are you able to get to the bathroom in time

d. What medications are you currently taking? - SOLUTION How many bowel movements a day have you had? The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process? a) Assessment b) Diagnosis c) Planning d) Implementation - SOLUTION Planning A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? a) Assessment b) Planning c) Implementation d) Evaluation - SOLUTION Implementation Which action should the nurse take first during the initial phase of implementation? a) Determine patient outcomes and goals. b) Prioritize patient's nursing diagnoses. c) Evaluate interventions. d) Reassess the patient. - SOLUTION Reassess the patient. 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 - SOLUTION Evaluation A novice 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. - SOLUTION Nurses use evaluation to determine the effectiveness of nursing care. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors. - SOLUTION -Determine whether outcomes or standards are met. -Document results of goal achievement. -Use self-reflection and correct errors. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a) Do you feel like you need to go to the bathroom? b) Are you able to walk to the bathroom by yourself? c) When was the last time you took your medicine? d) Do you have a safety rail in your bathroom at home? - SOLUTION Do you feel like you need to go to the bathroom? The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action? a) The patient may void uncontrollably during the procedure. b) Local trauma sometimes promotes excessive urine incontinence. c) Anesthetics can decrease bladder contractility and cause urinary retention. d) The patient will not interrupt the procedure by asking to go to the bathroom. - SOLUTION Anesthetics can decrease bladder contractility and cause urinary retention. A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a) 55 years old b) 20/20 vision c) Urinary continence

d) Orthostatic hypotension - SOLUTION Orthostatic hypotension A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? a) Blood pressure sitting 120/64; blood pressure 140/70 standing b) Blood pressure sitting 126/64; blood pressure 120/58 standing c) Blood pressure sitting 130/60; blood pressure 110/60 standing d) Blood pressure sitting 140/60; blood pressure 130/54 standing - SOLUTION Blood pressure sitting 130/60; blood pressure 110/60 standing A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a) Thermometer b) Elastic stockings c) Blood pressure cuff d) Sequential compression devices - SOLUTION Blood pressure cuff The nurse is caring for a group of patients. Which task may the nurse delegate to the unlicensed assistive personnel (UAP)? a) Administer a back massage to a patient with pain. b) Assessment of pain for a patient reporting abdominal pain. c) Administer patient-controlled analgesia for a postoperative patient. d) Assessment of vital signs in a patient receiving epidural analgesia. - SOLUTION Administer a back massage to a patient with pain. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling? a) Use at least three people. b) Have the patient reach for the opposite side rail when turning. c) Move the top part of the patient's torso and then the bottom part. d) Do not use pillows after turning. - SOLUTION Use at least three people. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? a) Provide the patient with a writing board each shift. b) Obtain an interpreter for the patient as soon as possible. c) Assist the patient in performing swallowing exercises each shift.

d) Ask the family to provide a sitter to always remain with the patient. - SOLUTION Provide the patient with a writing board each shift. A patient who recently had a stroke is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care? a) Teach the patient about special assistive devices. b) Make the patient talk as much as possible. c) Obtain an order for antidepressant medications. d) Place a consult for a home health nurse. - SOLUTION Teach the patient about special assistive devices. A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. Status unchanged, doing well. b. Patient seems to be in pain and states, ―I feel uncomfortable. c. Left knee incision 1 inch in length without redness, drainage, or edema. d. Patient is hard to care for and refuses all treatments and medications. Family is present. - SOLUTION Left knee incision 1 inch in length without redness, drainage, or edema. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a) Disorientation b) Poor judgment c) Slower reaction time d) Loss of language skills - SOLUTION Slower reaction time The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? a) Should be postponed because it may cause embarrassment. b) Should be unnecessary because the patient is uncircumcised. c) Should be done by the patient. d) Should be done by the nurse. - SOLUTION Should be done by the patient.

A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? a) Cleansing from back to front b) Washing using a circular motion c) Cleansing from pubic area to rectum d) Cleansing upward from rectum to pubic area - SOLUTION Cleansing from pubic area to rectum The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take? a) Leave the foreskin alone because there is little chance of infection. b) Retract the foreskin for cleansing and allow it to return on its own. c) Retract the foreskin and return it to its natural position when done. d) Leave the foreskin retracted after cleansing the penis. - SOLUTION Retract the foreskin and return it to its natural position when done. Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.) a) A patient with rectal and genital surgical dressings b) A patient with urinary and fecal incontinence c) A circumcised male who is ambulatory d) A patient who has an indwelling catheter e) A bariatric patient - SOLUTION -A patient with rectal and genital surgical dressings -A patient with urinary and fecal incontinence -A patient who has an indwelling catheter -A bariatric patient An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b. Tape an occlusive moisture barrier pad to the patient's skin. c. Apply a skin protective ointment after perineal care. d. Massage the skin with light kneading pressure. - SOLUTION Apply a skin protective ointment after perineal care. Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes? a) Do not place slippers on the patient's feet.

b) Trim the patient's toenails daily. c) Report sores on the patient's toes. d) Check the brachial artery. - SOLUTION Report sores on the patient's toes. old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding? a) Assess the patient as thoroughly as possible. b) Explain to the patient that breast tenderness is normal at her age. c) Tell the patient that redness is not a cause for concern and is quite common. d) Inform her that redness is the precursor to normal unilateral breast enlargement. - SOLUTION Assess the patient as thoroughly as possible A patient continues to report post surgical incision pain at a level of 9 out of 10 after pain medicine is given. the next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a) Explore other options of pain relief b) Discuss the surgical procedure and reason for the pain. c) Explain to the patient that nothing else has been ordered. d) Offer to notify the health care provider after morning rounds are completed. - SOLUTION Explore other options of pain relief A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache - SOLUTION Disruption of tissue integrity A patient recovering from a leg fracture after a fall report having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority? a) Assist the patient to walk in the room with crutches. b) Obtain a walker for the patient. c) Consult physical therapy. d) Administer pain medication. - SOLUTION Administer pain medication.

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a) I will only need to be on this pain medication. b) I feel less anxiety about the possibility of overdosing. c) I can receive the pain medication as frequently as I need to. d) I need the nurse to notify me when it is time for another dose. - SOLUTION I feel less anxiety about the possibility of overdosing. 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. - SOLUTION Don gloves and other appropriate personal protective equipment. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and needs a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind? a) Patients who appear unkempt place little importance on hygiene practices. b) Personal preferences determine hygiene practices and are unchangeable. c) The patient's illness may require teaching of new hygiene practices. d) All cultures value cleanliness with the same degree of importance. - SOLUTION The patient's illness may require teaching of new hygiene practices. The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve? a) Prevention of plantar warts b) Prevention of foot fungus c) Prevention of neuropathy d) Prevention of amputation - SOLUTION Prevention of amputation

A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management? a. This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication. b. I need to reassess the patient's pain 1 hour after administering oral pain medication. c. It wasn't time for the patient's medication, so when it was requested, I gave a placebo. d. The patient is sleeping, so I pushed the PCA button. - SOLUTION I need to reassess the patient's pain 1 hour after administering oral pain medication A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a) Give pain medications around the clock. b) Administer pain medication before any activity. c) Give pain medication after the pain is a 7/10 on the pain scale. d) Administer pain medication only when nonpharmacological measures have failed. - SOLUTION Give pain medications around the clock. The nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best evidence-based practice regarding clinical guidelines for low back pain. What is the best database for the nurse to access? a) MEDLINE b) EMBASE c) PsycINFO d) Agency for Healthcare Research and Quality (AHRQ) - SOLUTION Agency for Healthcare Research and Quality (AHRQ) A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, ―The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.‖ Which type of pain does the nurse document the patient is having currently? a) Superficial pain b) Idiopathic pain c) Chronic pain d) Visceral pain - SOLUTION Visceral pain

A nurse is providing medication education to a patient who just started been prescribed ibuprofen. Which information will the nurse include in the teaching session? a. Ibuprofen helps to depress the central nervous system to decrease pain perception. b. Ibuprofen reduces anxiety, which will help you cope with your pain. c. Ibuprofen binds with opiate receptors to reduce your pain. d. Ibuprofen inhibits the development of inflammation. - SOLUTION Ibuprofen inhibits the development of inflammation. The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child? a) Use the FACES scale. b) Check to see what previous nurses have charted. c) Ask the parents if they think their child is in pain. d) Have the child rate the level of pain on a 0 to 10 pain scale. - SOLUTION Use the FACES scale. A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a) Patient drinks 1 to 2 glasses of wine every night. b) Patient smokes 2 packs of cigarettes a day. c) Patient occasionally uses marijuana. d) Patient takes antianxiety medications. - SOLUTION Patient drinks 1 to 2 glasses of wine every night. The patient has a calculated body mass index (BMI) of 34. How will the nurse classify this finding? a) Normal weight b) Underweight c) Overweight d) Obese - SOLUTION Obese A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom. Which action should the nurse take initially? a) Ask for at least two other assistive personnel to come to the room. b) Medicate the patient to alleviate discomfort while ambulating. c) Review the patient's activity orders.

d) Offer the patient a walker. - SOLUTION Review the patient's activity orders. The nurse is creating a plan of care for an obese patient who is experiencing fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Sensibly reducing daily calorie intake c. Running 30 minutes every morning d. Stopping smoking immediately - SOLUTION Sleeping on two to three pillows at night A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a) Precontemplation b) Contemplation c) Preparation d) Action - SOLUTION Contemplation Which assessment finding is consistent with the diagnosis of malnutrition? a) Moist lips b) Pink conjunctivae c) Spoon-shaped nails d) Not easily plucked hair - SOLUTION Spoon-shaped nails The nurse will anticipate inserting a Coudé catheter for which patient? a) An 8-year-old male undergoing anesthesia for a tonsillectomy b) A 24-year-old female who is going into labor c) A 56-year-old male admitted for bladder irrigation d) An 86-year-old female admitted for a urinary tract infection - SOLUTION A 56-year-old male admitted for bladder irrigation The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What action indicates the nurse is aware of appropriate hydraulic life use? a) Places a horseshoe-shaped base on the opposite side from the chair.

b) Removes straps before lowering the patient to the chair. c) Hooks longer straps to the bottom of the sling. d) Attaches short straps to the bottom of the sling. - SOLUTION Hooks longer straps to the bottom of the sling. A patient at risk for skin impairment can sit up in a chair. How long should the nurse schedule the patient to sit in the chair? a) 2 hours or less at any one time b) For a total of least than 3 hours daily c) No longer than 30 minutes out of every hour d) Until the patient expresses being uncomfortable - SOLUTION 2 hours or less at any one time A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a. Reassess the patient and situation. b. Revise the turning schedule to increase the frequency. c. Delegate turning to the nursing assistive personnel. d. Apply medication to the area of skin that is broken down. - SOLUTION Reassess the patient and situation. The wound care nurse is monitoring a patient with a Stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record? a) Stage I pressure ulcer b) Healing Stage II pressure ulcer c) Healing Stage III pressure ulcer d) Stage III pressure ulcer - SOLUTION Healing Stage III pressure ulcer The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a) Stage I b) Stage II c) Stage III d) Stage IV - SOLUTION Stage II Which laboratory data will be important for the nurse to monitor when a patient develops a pressure ulcer?

a) Vitamin E b) Potassium c) Prealbumin d) Sodium - SOLUTION Prealbumin Upon entering the room of a patient with a healing Stage III pressure ulcer, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What action should the nurse give priority to? a. Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results b. Notifying the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR) c. Consulting the wound care nurse about the change in status and the potential for infection d. Conferring with the charge nurse about the change in status and the potential for infection - SOLUTION Completing a head-to-toe assessment, including current treatment, vital signs, and laboratory results The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse expect to be increased after collaboration with the dietitian? a) Fat b) Protein c) Vitamin E d) Carbohydrate - SOLUTION Protein The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous with a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. I am so weak and tired. I just want to feel better. b. I been thinking I will be ready to go home early next week. c. I really need a bath and linen change right; I feel so awful. d. I am hoping there will be something good to eat for my dinner tonight. - SOLUTION I really need a bath and linen change right; I feel so awful. The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? a) Low-air-loss

b) Air-fluidized c) Lateral rotation d) Standard mattress - SOLUTION Air-fluidized The nurse notes that a patient has a black pressure ulcer on the left hip. Which event will the nurse anticipate when planning care for this patient? a) Increased monitoring of the wound condition b) Documenting the wound's status daily c) Surgical debridement of the wound d) Increased drainage from wound - SOLUTION Surgical debridement of the wound The nurse caring for a patient with a healing Stage III pressure ulcer notes that the wound is clean and granulating. Which health care provider's order will the nurse question? a) Use a low-air-loss therapy unit. b) Irrigate with Dakin's solution. c) Apply a hydrogel dressing. d) Consult a dietitian. - SOLUTION Apply a hydrogel dressing. The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis should the nurse add to the care plan? a) Readiness for enhanced nutrition b) Impaired physical mobility c) Impaired skin integrity d) Chronic pain - SOLUTION Impaired skin integrity When a comatose patient develops a Stage II pressure ulcer, the nurse includes the nursing diagnosis of Risk for infection to the care plan. Which is the best goal for this patient? a) The patient will state what to look for regarding an infection. b) The patient's family will demonstrate specific care of the wound site. c) The patient's family members will wash their hands when visiting the patient. d) The patient will remain free of odorous or purulent drainage from the wound. - SOLUTION The patient will remain free of odorous or purulent drainage from the wound. As prescribed, the nurse leaves the pressure ulcer open to air and does not apply a dressing. Which stage of ulcer did the nurse appropriately treat?

a) A Stage I b) A Stage II c) A Stage III d) A Stage IV - SOLUTION Stage I 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) Asking the nursing assistive personnel if the wound looks better b) Documenting the progress of wound healing as better‖ in the chart c) Measuring the wound and observe for redness, swelling, or drainage d) Leaving the dressing off the wound for easier access and more frequent assessments - SOLUTION Measuring the wound and observe for redness, swelling, or drainage A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? a) Effective hand hygiene b) Saline wound irrigation c) Appropriate use of gloves d) When eye protection is needed - SOLUTION Effective hand hygiene The nurse is preparing to administer an injection into the deltoid muscle of an adult patient weighing approximately 160 lb. Which needle size and length will the nurse choose? a) 18 gauge ´ 1 1/2 inch b) 23 gauge ´ 1/2 inch c) 25 gauge ´ 1 inch d) 27 gauge ´ 5/8 inch - SOLUTION 25 gauge ´ 1 inch The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse's action? a) Reduced kidney functioning b) Reduced esophageal stricture c) Increased gastric motility d) Increased liver mass - SOLUTION Reduced kidney functioning What is the nurse's priority action to protect a patient from medication error? a) Reading medication labels at least 3 times before administering b) Administering as many of the medications as possible at one time