Nursing fundamentals test bank, Exams of Nursing

Download Nursing fundamentals test bank and more Exams Nursing in PDF only on Docsity! Nursing fundamentals test bank Q & A 2024 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." - ✔a. "An infectious disease like pneumonia may not pose a risk to others." The patient and the nurse are discussing the vector transmitted Rickettsia rickettsii— Rocky Mountain spotted fever. Which patient statement to the nurse indicates understanding regarding the mode of transmission for this disease? a. "When camping, I will use sunscreen." b. "When camping, I will drink bottled water." c. "When camping, I will wear insect repellent." d. "When camping, I will wash my hands with hand gel." - ✔c. "When camping, I will wear insect repellent." 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. - ✔d. 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?" - ✔b. "Do you have a chronic disease?" The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5° F, and the WBC is 10,500/mm3. Which action should the nurse take first? a. Plan to change the surgical dressing during the shift. b. Utilize SBAR to notify the primary health care provider. c. Reevaluate the temperature and white blood cell count in 4 hours. d. Check to see what solution was used for skin preparation in surgery. - ✔b. Utilize SBAR to notify the primary health care provider. 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. - ✔b. Smoking affects the cilia lining the upper airways in the lungs. 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? - ✔c. "What medications are you currently taking?" 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 - ✔d. Edema, redness, tenderness, and loss of function 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 - ✔d. Rest, ice, and elevation The nurse is caring for a group of medical-surgical patients. Which patient is most at risk for developing an infection? a. A patient who is in observation for chest pain. b. A patient who has been admitted with dehydration. c. A patient who is recovering from a right total hip surgery. d. A patient who has been admitted for stabilization of heart problems. - ✔c. A patient who is recovering from a right total hip surgery. The nurse is caring for a patient diagnosed 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. - ✔c. Maintain surgical aseptic technique. ✔c. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing 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 - ✔c. Removing gloves to transfer the endoscope 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. - ✔d. Wears eyewear when emptying the urinary drainage bag. 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 - ✔c. Standard 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. - ✔a. The nurse is responsible for providing a safe environment for the patient. 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. - ✔a. Wash hands with an antimicrobial soap and water. 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 - ✔d. Repeat handwashing using antiseptic soap 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 - ✔a. Sending to central sterile for cleaning and sterilization 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 - ✔a. The family member places the used dressings in a plastic bag. The nurse is caring for a group of patients. For which patient will the nurse question the form of precautions being used? 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 - ✔a. A patient with Clostridium difficile in droplet precautions The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse to emphasize washing hands before and after what form of contact? a. Shaking hands b. Performing treatments c. Opening the refrigerator d. Working on a computer - ✔b. Performing treatments 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. - ✔a. Apply a new mask. 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 - ✔d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only The nurse is caring for a patient who has cultured positive for C. 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 - ✔a. Instruct assistive personnel to use soap and water rather than sanitizer. 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. C. difficile d. Methicillin-resistant Staphylococcus aureus - ✔b. Hepatitis B 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. - ✔b. Immediately wash the site with soap and running water and seek guidance from the manager. 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 - ✔b. Testing the patient and offering treatment to the nurse . 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. 6. Dispose of all contaminated supplies and equipment in designated receptacles. a. 3, 1, 4, 5, 6, 2 b. 1, 4, 5, 3, 6, 2 c. 1, 4, 5, 3, 2, 6 b. Wash hands before entering and leaving both of the patients' rooms. 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. A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? a. Eccentric tension and isotonic contraction b. Eccentric tension and isometric contraction c. Concentric tension and isotonic contraction d. Concentric tension and isometric contraction - ✔a. Eccentric tension and isotonic contraction A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient's medical record? a. Scoliosis b. Arthritis c. Osteomalacia d. Osteogenesis - ✔a. Scoliosis A nurse is caring for a patient who is experiencing some symptoms related to arthritis. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? a. This will affect synovial fluid. b. This will affect the body systemically. c. This involves mostly non-weight-bearing joints. d. This involves an increased risk for impaired weight bearing - ✔d. This involves an increased risk for impaired weight bearing The nurse providing care to a bedridden patient raises the height of the bed. What is the rationale for the nurse's action? a. Narrows the nurse's base of support. b. Allows the nurse to bring feet closer together. c. Prevents a shift in the nurse's base of support. d. Shifts the nurse's center of gravity farther away from the base of support. - ✔c. Prevents a shift in the nurse's base of support. A nurse is following the no-lift policy when working to prevent personal injury from twisting. Which type of personal back injury is the nurse most likely trying to prevent? a. Thoracic b. Cervical c. Lumbar d. Sacral - ✔c. Lumbar The nurse is caring for a patient in the emergency department with an injured shoulder. Which type of joint will the nurse assess? a. Fibrous b. Synovial c. Synergistic d. Cartilaginous - ✔b. Synovial The nurse is caring for a patient with inner ear problems. Which goal is the priority? a. Maintain balance. b. Maintain proprioception. c. Maintain muscle strength. d. Maintain body alignment - ✔a. Maintain balance. A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? a. Swimming, jogging, and bicycling b. Tightening or tensing of muscles without moving body parts c. Quadriceps set exercises and contraction of the gluteal muscles d. Push-ups, hip lifting, pushing feet against a footboard on the bed - ✔a. Swimming, jogging, and bicycling An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? a. Tendon b. Ligament c. Synergistic muscle d. Antagonistic muscle - ✔b. Ligament A nurse is developing an exercise plan for a middle-aged patient. In which order will the nurse instruct the patient to execute the plan, beginning with the first step? 1. Design the fitness program. 2. Assemble equipment. 3. Assess fitness level. 4. Monitor progress. 5. Get started. a. 5, 1, 3, 2, 4 b. 1, 2, 3, 5, 4 c. 2, 5, 3, 1, 4 d. 3, 1, 2, 5, 4 - ✔d. 3, 1, 2, 5, 4 The nurse gives instructions to a nursing assistive personnel (NAP) regarding exercise for a patient. Which action by the NAP indicates a correct understanding of the directions? a. Determines the patient's ability to exercise. b. Teaches the patient how to do the exercises. c. Reports the patient got dizzy after exercising. d. Advises the patient to work through the pain. - ✔c. Reports the patient got dizzy after exercising. The nurse is starting an exercise program in a local community as a health promotion project. Which information will the nurse include in the teaching session? a. A cool-down period lasts about 5 to 10 minutes. b. The purpose of weight training is to bulk up muscles. c. Resistance training is appropriate for warm-up and cool-down periods. d. Aerobic exercise should be done 3 to 5 times per week for about 20 minutes - ✔a. A cool-down period lasts about 5 to 10 minutes. The patient is eager to begin an exercise program with a 2-mile jog. The nurse instructs the patient to warm up. The patient does not want to waste time with a "warm-up." Which information will the nurse share with the patient? a. The warm-up in this case can be done after the 2-mile jog. b. The warm-up prepares the body and decreases the potential for injury. c. The warm-up allows the body to readjust gradually to baseline functioning. d. The warm-up should be performed with high intensity to prepare for the coming challenge. - ✔b. The warm-up prepares the body and decreases the potential for injury. 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. - ✔c. Hooks longer straps to the bottom of the sling. 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. - ✔a. Mentally reviews the transfer steps before beginning. A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene? a. Mechanical lifts are in a locked closet. b. Algorithms for patient handling are available. c. Ergonomic assessment protocols are being followed. d. A no-lift policy is in place with adherence by all staff. - ✔a. Mechanical lifts are in a locked closet. The patient is brought to the emergency department with possible injury to the left shoulder. Which area will the nurse assess to best determine joint mobility? a. The patient's gait b. The patient's range of motion c. The patient's ethnic influences d. The patient's fine-motor coordination - ✔b. The patient's range of motion The nurse is evaluating care of a patient for crutches. Which finding indicates a successful outcome? a. The top of the crutch is three to four finger widths from the armpit. b. The elbows are slightly flexed at 30 to 35 degrees when the patient is standing. c. The tip of the crutch is 4 to 6 inches anterior to the front of the patient's shoes. d. The position of the handgrips allows the axilla to support the patient's body weight. - c. Keep the base of support narrow. d. Use the under-axilla technique. e. Use proper body mechanics. f. Use arms and legs. - ✔b. Face the direction of the movement. e. Use proper body mechanics. f. Use arms and legs. A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Pregnancy status d. Race e. Age - ✔a. Skeletal abnormalities b. Emotional factors c. Pregnancy status e. Age A nurse is working in a facility that uses no-lift policies. Which benefits will the nurse observe in the facility? (Select all that apply.) a. Reduced number of work-related injuries b. Increased musculoskeletal accidents c. Reduced safety of patients d. Improved health of nurses e. Increased indirect costs - ✔a. Reduced number of work-related injuries d. Improved health of nurses e. Increased indirect costs A nurse writes the following outcomes for a patient who has chronic obstructive pulmonary disease to improve activity level: Diastolic blood pressure will remain below 70 mm Hg with systolic below 130 mm Hg. Resting heart rate will range between 65 and 75. The last goal is that the patient will exercise 3 times a week. Which evaluative findings indicate successful goal achievement? (Select all that apply.) a. Resting heart rate 70 b. Blood pressure 126/64 c. Blood pressure 140/90 d. Reports doing stretching and flexibility exercises 2 times this week e. Reports doing resistive training 1 time and aerobics 2 times this week - ✔a. Resting heart rate 70 b. Blood pressure 126/64 e. Reports doing resistive training 1 time and aerobics 2 times this week A 55-year-old patient is preparing to start an exercise program. The health care provider wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add to the care plan as the target heart rate. Record answer as a whole number. _________ maximum heart rate - ✔99 A nurse is assessing body alignment. What is the nurse monitoring? a. The relationship of one body part to another while in different positions b. The coordinated efforts of the musculoskeletal and nervous systems c. The force that occurs in a direction to oppose movement d. The inability to move about freely - ✔a. The relationship of one body part to another while in different positions A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a. Moves patient's arm in a full circle. b. Moves patient's arm cross the body as far as possible. c. Moves patient's arm behind body, keeping elbow straight. d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed - ✔d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? a. Each movement is repeated 5 times by the patient. b. Each movement is performed until the patient reports pain. c. Each movement is completed quickly and smoothly by the nurse. d. Each movement is moved just to the point of resistance by the nurse - ✔d. Each movement is moved just to the point of resistance by the nurse A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action? a. Atelectasis b. Renal calculi c. Pressure ulcers d. Joint contractures - ✔d. Joint contractures A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation - ✔b. Changing the patient's position 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 - ✔c. Blood pressure cuff The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a. Maintain a narrow base of support. b. Dangle the patient at the bedside. c. Encourage isometric exercises. d. Suggest a high-calcium diet. - ✔b. Dangle the patient at the bedside. A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal stones c. Pressure ulcers d. Thrombus formation - ✔b. Renal stones A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Increased pulse rate - ✔d. Increased pulse rate A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for? a. Loss of bone mass b. Loss of strength c. Loss of weight d. Loss of hope - ✔d. Loss of hope The nurse is preparing to lift and reposition a patient. Which action will the nurse take first? a. Position a drawsheet under the patient. b. Assess weight to determine assistance needs. c. Delegate the task to a nursing assistive personnel. d. Attempt to manually lift the patient alone before asking for assistance. - ✔b. Assess weight to determine assistance needs. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan? a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Coordinate with occupational therapy for gait training. d. Place the patient on bed rest to prevent fatigue. - ✔a. Encourage the patient to perform as many self-care activities as possible. The nurse is observing the way a patient walks. Which aspect is the nurse assessing? a. Activity tolerance b. Body alignment c. Range of motion d. Gait - ✔d. Gait A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed "S" pattern. b. When observed posteriorly, the hips and shoulders form an "S" pattern. d. The patient will ambulate by the time of discharge. - ✔b. The patient will walk 100 feet using a walker by the time of discharge. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent? a. Arm b. Hip c. Back d. Ankle - ✔c. Back A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement? a. Encourage dairy products. b. Monitor intake of vitamin D. c. Increase intake of caffeinated drinks. d. Try to do as much as possible for the patient. - ✔b. Monitor intake of vitamin D. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea b. A bedridden patient who has a reddened area on the buttocks who needs to be turned c. A patient on bed rest who has renal calculi and needs to go to the bathroom d. A patient after knee surgery who needs range of motion exercises - ✔a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient? a. Thick, tenacious pulmonary secretions b. Low-molecular-weight heparin doses c. SCDs wrapped around the legs d. Elastic stockings (TED hose) - ✔b. Low-molecular-weight heparin doses The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient. 2. Move the patient and drawsheet to the desired position. 3. Position one nurse at each side of the bed. 4. Place the drawsheet under the patient from shoulder to thigh. 5. Place your feet apart with a forward-backward stance. 6. Flex knees and hips and on the count of three shift weight from the front to back leg. a. 1, 4, 5, 6, 3, 2 b. 4, 1, 3, 5, 6, 2 c. 3, 4, 1, 5, 6, 2 d. 5, 6, 3, 1, 4, 2 - ✔c. 3, 4, 1, 5, 6, 2 The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take? a. Place pillow under the patient's lower legs. b. Turn head toward one side with large, soft pillow. c. Position legs flat against bed. d. Raise head of bed to 45 degrees. - ✔a. Place pillow under the patient's lower legs. The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation? a. Hand rolls b. A trapeze bar c. A trochanter roll d. Hand-wrist splints - ✔c. A trochanter roll The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe? a. Place the pillow under the patient's head and shoulders. b. Do by self if the bed is in the flat position. c. Place the side rails in the up position. d. Use a friction-reducing device. - ✔d. Use a friction-reducing device. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use? a. Hand rolls b. A foot cradle c. A trapeze bar d. A trochanter roll - ✔b. A foot cradle A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome? a. Patient is lying on side. b. Patient is lying on back. c. Patient is lying semiprone. d. Patient is lying on abdomen - ✔a. Patient is lying on side. A nurse is evaluating care of an immobilized patient. Which action will the nurse take? a. Focus on whether the interdisciplinary team is satisfied with the care. b. Compare the patient's actual outcomes with the outcomes in the care plan. c. Involve primarily the patient's family and health care team to determine goal achievement. d. Use objective data solely in determining whether interventions have been successful. - ✔b. Compare the patient's actual outcomes with the outcomes in the care plan. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care? a. A patient with neck surgery b. A patient with hypostatic pneumonia c. A patient with a total knee replacement d. A patient with a stage IV pressure ulcer - ✔a. A patient with neck surgery The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend? a. High protein, high calorie b. High carbohydrate, low fat c. High vitamin A, high vitamin E d. Fluid restricted, bland - ✔a. High protein, high calorie the nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy? a. After the acute phase of the disease has passed. b. As soon as the ability to move is lost. c. Once the patient enters the rehab unit. d. When the patient requests it. - ✔b. As soon as the ability to move is lost. The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for "ROM as needed." What should the nurse do next? a. Restrict patient's mobility as much as possible. b. Realize the patient is unable to move extremities. c. Move all the patient's extremities. d. Further assess the patient - ✔d. Further assess the patient A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe? a. Chin, elbow, hips b. Ileum, clavicle, humerus c. Shoulder, anterior iliac spine, ankles d. Occipital region of the head, coccyx, heels - ✔b. Ileum, clavicle, humerus The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient? a. Obtain assistance and physically transfer the patient to the chair. b. Assist with ambulation and measure how far the patient walks. c. Give pain medication after ambulation so the patient will have a clear mind. d. Bring the patient to the cafeteria for group instruction on ambulation. - ✔b. Assist with ambulation and measure how far the patient walks d. Critical thinking will always be important. - ✔d. Critical thinking will always be important. When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse's action? a. Outer skin layer becomes more resilient. b. Less frequent bathing may be required. c. Skin becomes less subject to bruising. d. Sweat glands become more active. - ✔b. Less frequent bathing may be required. The nurse is bathing a patient and notices movement in the patient's hair. Which action will the nurse take? a. Use gloves to inspect the hair. b. Apply a lindane-based shampoo immediately. c. Shave the hair off of the patient's head. d. Ignore the movement and continue. - ✔a. Use gloves to inspect the hair. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? a. Stand to the side of the patient's eye and observe the cornea. b. Conclude that the glasses were lost during the accident. c. Notify the ambulance personnel for missing glasses. d. Ask the patient where the glasses are. - ✔a. Stand to the side of the patient's eye and observe the cornea. A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? a. A patient who is afebrile b. A patient who is diaphoretic c. A patient with strong pedal pulses d. A patient with adequate skin turgor - ✔b. A patient who is diaphoretic The nurse caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for the nurse's action? a. Inadequate blood flow leads to decreased tissue ischemia. b. Patients with limited caloric intake develop thicker skin. c. Pressure reduces circulation to affected tissue. d. Verbalization of skin care needs is decreased. - ✔c. Pressure reduces circulation to affected tissue. The nurse is caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, who is also experiencing peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? a. Decreased pain sensation and increased risk of skin impairment b. Decreased caloric intake and accelerated wound healing c. High risk for skin infection and low saliva pH level d. High risk for impaired venous return and dementia - ✔a. Decreased pain sensation and increased risk of skin impairment The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? a. Assess surfaces exposed to the edges of the cast for pressure areas. b. Keep the patient's blood pressure low to prevent overperfusion of tissue. c. Do not allow turning in bed because that may lead to re-dislocation of the leg. d. Restrict the patient's dietary intake to reduce the number of times on the bedpan. - ✔a. Assess surfaces exposed to the edges of the cast for pressure areas. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? a. Insert an indwelling urinary catheter. b. Limit caloric and protein intake. c. Turn the patient every 2 hours. d. Assess for pain during a bath. - ✔d. Assess for pain during a bath. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe? a. Corns b. A callus c. Plantar warts d. Athlete's foot - ✔c. Plantar warts The nurse is caring for a patient diagnosed with diabetes who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient? a. Corn pads are an adequate treatment and should be continued. b. The patient should avoid soaking the feet before using a pumice stone. c. The current self-treatment is likely impeding with circulation to the toes. d. Tighter shoes would help to compress the corns and make them smaller. - ✔c. The current self-treatment is likely impeding with circulation to the toes. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient? a. It is contagious with frequent recurrences. b. It is most helpful to air-dry feet after bathing. c. It is treated with salicylic acid. d. It is caused by lice. - ✔a. It is contagious with frequent recurrences. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition? a. Fungi b. Friction c. Nail polish d. Nail polish remover - ✔a. Fungi 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 - ✔d. Prevention of amputation The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift? a. Cheilitis b. Halitosis c. Glossitis d. Dental caries - ✔b. Halitosis The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel? a. Providing nail care b. Teaching foot care c. Making the patient's bed d. Determining aspiration risk - ✔c. Making the patient's bed The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority? a. Feet b. Nail beds c. Perineum d. Oral cavity - ✔d. Oral cavity The nurse is providing oral care to an unconscious patient. Which action should the nurse take to protect the patient from injury? a. Moisten the mouth using lemon-glycerin sponges. b. Hold the patient's mouth open with gloved fingers. c. Use foam swabs to help remove plaque. d. Suction the oral cavity - ✔d. Suction the oral cavity The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? a. Using waxed floss prevents bleeding b. Flossing removes plaque and tartar from the teeth c. Performing flossing at least 3 times a day is beneficial d. Applying toothpaste to the teeth before flossing is harmful - ✔b. Flossing removes plaque and tartar from the teeth The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? d. Cleansing upward from rectum to pubic area - ✔c. 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 - ✔c. Retract the foreskin and return it to its natural position when done. 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 - ✔c. Report sores on the patient's toes. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next? a. Insert an oral airway. b. Place the patient in a flat, supine position. c. Use undiluted hydrogen peroxide as a cleaner. d. Quickly proceed while not talking to the patient. - ✔a. Insert an oral airway. A nurse is providing oral care education to a patient with stomatitis. Which instructions will the nurse provide? a. Avoid commercial mouthwashes. b. Avoid normal saline rinses. c. Brush with a hard toothbrush. d. Brush with an alcohol-based toothpaste. - ✔a. Avoid commercial mouthwashes. The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session? a. Use tap water to clean soft lenses. b. Wash and rinse lens storage case daily. c. Reuse storage solution for no longer than a week. d. Keep the lenses is a cool dry place when not being used. - ✔b. Wash and rinse lens storage case daily. The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient's ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next? a. Teach the patient how to use cotton-tipped applicators. b. Tell the patient to use a bobby pin to extract earwax. c. Apply gentle, downward retraction of the ear canal. d. Instill hot water into the ear canal to melt the wax. - ✔c. Apply gentle, downward retraction of the ear canal. The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide? a. Change the battery every day or as needed. b. Adjust the volume for a talking distance of 1 yard. c. Wear the hearing aid 24 hours per day except when sleeping. d. Avoid the use of hairspray, but aerosol perfumes are allowed. - ✔b. Adjust the volume for a talking distance of 1 yard. The patient is reporting an inability to clear nasal passages. Which action will the nurse take? a. Use gentle suction to prevent tissue damage. b. Instruct patient to blow nose forcefully to clear the passage. c. Place a dry washcloth under the nose to absorb secretions. d. Insert a cotton-tipped applicator to the back of the nose. - ✔a. Use gentle suction to prevent tissue damage. A patient uses an in-the-canal hearing aid. Which assessment is a priority? a. Eyeglass usage b. Cerumen buildup c. Type of physical exercise d. Excessive moisture problems - ✔b. Cerumen buildup The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) a. Administer ordered analgesic 1 hour before bath time. b. Increase the frequency of skin assessment. c. Reduce triggers in the environment. d. Keep the room temperature cool. e. Be as quick as possible. - ✔b. Increase the frequency of skin assessment. c. Reduce triggers in the environment. The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.) a. Abnormal gait b. Foot deformities c. Absent or decreased pedal pulses d. Muscle wasting of lower extremities e. Decreased hair growth on legs and feet - ✔a. Abnormal gait b. Foot deformities d. Muscle wasting of lower extremities A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. d. Dry thoroughly between skin folds. e. Use two wipes for each area of the body - ✔a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. 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 - ✔a. A patient with rectal and genital surgical dressings b. A patient with urinary and fecal incontinence d. A patient who has an indwelling catheter e. A bariatric patient the patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) a. Apply sterile gloves. b. Keep soiled linen close to uniform. c. Advise patient will feel a lump when rolling over. d. Turn clean pillowcase inside out over the hand holding it. e. Make a modified mitered corner with sheet, blanket, and spread. - ✔c. Advise patient will feel a lump when rolling over. d. Turn clean pillowcase inside out over the hand holding it. e. Make a modified mitered corner with sheet, blanket, and A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure - ✔c. Temperature A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation - ✔c. Convection The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation - ✔b. Conduction A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? c. Obtain without the patient knowing. d. Estimate respirations. - ✔c. Obtain without the patient knowing. The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200 - ✔b. 80 The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium - ✔c. Hematocrit The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. Give CO2 via mask. - ✔b. Use oxygen cautiously in this patient. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg - ✔d. 50 mm Hg The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient's low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions. - ✔d. The patient has calcium channel blockers or digitalis medication prescriptions. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on - ✔b. Place a nonadhesive sensor on the patient's earlobe. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95% - ✔b. Hemoglobin level of 8.0 g/100 mL A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult - ✔c. 120/80 in a middle-aged adult The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African Americans d. Asian Americans - ✔c. African Americans A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement - ✔c. Smoking result in vasoconstriction, falsely elevating BP. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler. - ✔a. This is normal for an infant. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism. - ✔b. The patient has a normal temperature. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair. - ✔b. It has no risk of injury to patient or nurse. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to have confidence in the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site - ✔c. Brachial site The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15 - ✔a. 30 to 60 The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler's earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler's nose. d. Overlook variations between an oximeter pulse rate and the toddler's pulse rate - ✔b. Determine whether the toddler has a latex allergy. The nurse is preparing to assess the blood pressure of a 3 year old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b. Obtain the reading before the child has a chance to "settle down." c. Choose the cuff that says "Child" instead of "Infant." d. Explain the procedure to the child. - ✔d. Explain the procedure to the child. A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 - ✔c. A calm adolescent with P-95 and R-26 The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase d. Heavy alcohol intake The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers - ✔a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. e. Patients can provide information about patterns to health care providers . A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations - ✔a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia - ✔1. D 2. E 3. A 4. B 5. C A patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? a. Assess the patient's body language. b. Ask the patient to rate the level of pain. c. Observe the cardiac monitor for increased heart rate. d. Have the patient describe the effect of pain on the ability to cope - ✔b. Ask the patient to rate the level of pain. a nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any physical distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "OK, I will go get you some narcotic pain relievers immediately." c. "What would you like to try to alleviate your pain?" d. "You do not look like you are in pain. - ✔c. "What would you like to try to alleviate your pain?" A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate." c. "Meditation will help me sleep through the pain because it opens the gate." d. "Meditation stops the occurrence of pain stimuli." - ✔a. "Meditation controls pain by blocking pain impulses from coming through the gate." A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? a. "As adults age, their ability to perceive pain decreases." b. "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." c. "Patients who have dementia probably experience pain, and their pain is not always well controlled." d. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." - ✔a. "As adults age, their ability to perceive pain decreases." The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Meaning of pain b. Neurological factors c. Competency of the surgeon d. Postoperative support personnel - ✔a. Meaning of pain The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch? a. A 15-year-old adolescent with a fractured femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip - ✔c. A 50-year-old patient with prostate cancer A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient's safety? a. Restrict fluid intake. b. Label the tubing that leads to the epidural catheter. c. Apply a gauze dressing to the epidural catheter insertion site. d. Ask the nursing assistive personnel to check on the patient at least once every 2 hours - ✔b. Label the tubing that leads to the epidural catheter. A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Transcutaneous electrical nerve stimulation (TENS) b. Herbal supplements with analgesic effects c. Pudendal block (regional anesthesia) d. Relaxation and guided imagery - ✔d. Relaxation and guided imagery 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." - ✔b. "I feel less anxiety about the possibility of overdosing." A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management? a. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "We should work together to create a schedule to provide regular dosing of medication." d. "When you experience severe pain, you will need to take oral pain medications." - ✔c. "We should work together to create a schedule to provide regular dosing of medication." A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The primary health care provider did not prescribe the correct amount of medication. d. The nurse is allowing personal beliefs about pain to influence pain management at this time. - ✔b. The patient's culture is possibly influencing the patient's experience of pain. A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide? a. "You need to drink plenty of fluids and eat a diet high in fiber." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." 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. - ✔a. Use the FACES scale. A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs? a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg. b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin. c. A patient with severe pain who is nauseated and feels like he or she is about to vomit. d. A patient writhing and moaning from abdominal pain after abdominal surgery. - ✔a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg. 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." - ✔b. "I need to reassess the patient's pain 1 hour after administering oral pain medication." The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. "Have you considered working with a physical therapist?" b. "What activities, if any, has your pain prevented you from doing?" c. "Would you please rate your pain on a scale from 0 to 10 for me?" d. "When does your pain medication typically take effect on your pain? - ✔b. "What activities, if any, has your pain prevented you from doing?" The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching? a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "A patient's behavior is more reliable than the patient's report of pain." d. "Pain assessment scales determine the quality of a patient's pain." - ✔a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking. b. The patient who has a PCA running that needs the syringe replaced. c. The patient who needs to take a scheduled dose of maintenance pain medication. d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication - ✔d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. The patient needed a substantial dose of naloxone. b. The patient needs increasingly higher doses of opioid to control pain. c. The patient no longer experiences sedation from the usual dose of opioid. d. The patient asks for pain medication close to the time it is due around the clock. - ✔b. The patient needs increasingly higher doses of opioid to control pain. 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. - ✔a. Patient drinks 1 to 2 glasses of wine every night. The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Start an intravenous (IV) line. c. Administer pain-relief medications. d. Ask the patient to rate and describe the pain - ✔d. Ask the patient to rate and describe the pain 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. - ✔a. Administer a back massage to a patient with pain. 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. - ✔a. Give pain medications around the clock. A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record? a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain - ✔b. Somatic pain The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient? a. Infants cannot be assessed for pain. b. Infants respond behaviorally and physiologically to painful stimuli. c. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. d. Infants have a decreased sensitivity to pain when compared with older children. - ✔b. Infants respond behaviorally and physiologically to painful stimuli. The nurse is administering ibuprofen to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) a. Patient states allergy to aspirin. b. Patient states joint pain is 2/10 and intermittent. c. Patient reports past medical history of gastric ulcer. d. Patient reports last bowel movement was 4 days ago. e. Patient experiences respiratory depression after administration of an opioid medication. - ✔a. Patient states allergy to aspirin. c. Patient reports past medical history of gastric ulcer. The nurse is assessing the characteristics of a patient's pain. Match the characteristic to the question a nurse will ask to determine that specific characteristic. a. Could you rate your pain on a scale of 0 to 10? b. How often does it recur? c. Could you point to the area of pain? d. Do certain activities worsen the pain? e. What does the pain feel like? 1. Timing 2. Location 3. Severity 4. Quality 5. Aggravating factors - ✔1. B 2. C 3. A 4. E 5. D