Nursing Interventions and Evidence-Based Practice, Exams of Nursing

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NurseEdu. Fundamentals of Nursing - NCLEX-RN Exam Review: 349 Practice Questions with Detailed Rationales Explaining Correct & Incorrect Answer Choices. NEDU LLC. Kindle Edition The nurse encourages a patient with a history of heart failure to reduce energy expenditure by alternating activity and rest. Which nursing process phase is this? a. Diagnosis b. Planning c. Implementation d. Evaluation - ANSWER-C. Implementation Teaching a patient about alternating activity and rest is a component of patient education, which falls into the implementation phase. This is an example of putting an individualized plan into action. Other components of implementation include assisting with hygienic care, promoting physical comfort, supporting respiratory and elimination functions, facilitating ingestion of food/fluids, managing the patient's surroundings, promoting a therapeutic relationship, and carrying out other therapeutic nursing activities. The nurse on the medical-surgical unit is interested in implementing evidence-based practice. The nurse knows when evidence-based practice is utilized: a. National health agencies create clinical practice guidelines that must be used. b. Findings from randomized trials are used to plan care. c. Clinical decision-making and nursing judgment are used to find which evidence works for each specific situation in clinical practice.

d. Nursing interventions are statistically analyzed by a nurse in relation to patient outcomes to discover evidence for appropriate patient interventions. - ANSWER-c. Clinical decision-making and nursing judgment are used to find which evidence works for each specific situation in clinical practice. Evidence-based practice is based on evidence from nurses working with actual patients to find the best interventions for the best outcomes. It is through this evidence that nurses develop and improve their practice to achieve even greater patient outcomes. It is imperative that nurses continue to learn and improve their skills and use updated techniques as technology changes and patients have increasing acuity. New nurses in orientation are learning about completion of incident reports. Which of the following incidents would require an incident report be filed? a. Medication given 30 minutes before scheduled time b. Patient belongings lost when transferred to their hospital room c. Frayed electrical cord on an IV pump d. Medication order - ANSWER-b. Patient belongings lost when transferred to their hospital room Any time a patient's belongings are lost an incident report must be filed. This can help identify people and departments involved, ways to prevent the occurrence in the future, and even help in locating belongings. A nurse enters a patient's room to deliver medications that are due and discovers the patient is in the bathroom. Which of the following actions by the nurse is appropriate? a. Place the medication on the bedside table b. Place the medication on the bedside table and tell the patient not to forget to take them c. Ask the patient to call when out of the bathroom and give the medications at that time d. Ask the patient to call when out of the bathroom and leave the medications on the bedside table - ANSWER-c. Ask the patient to call when out of the bathroom and give the medications at that time The nurse should return when the patient is available to take the medications so the nurse can verify the medications have been taken. The nurse should never leave medications on the bedside table. A, B, C are incorrect because medications should never be left in the patient room.

The nurse is preparing to perform a focused assessment of the patient's abdomen. Which of the following choices is the correct order in which the focused assessment is performed? a. Palpation, Auscultation, Inspection, Percussion b. Inspection, Palpation, Percussion, Auscultation c. Percussion, Palpation, Inspection, Auscultation d. Inspection, Auscultation, Percussion, Palpation - ANSWER-d. Inspection, Auscultation, Percussion, Palpation When performing an abdominal assessment, inspection and auscultation should be performed prior to percussion and palpation because the last two techniques will alter bowel sounds. Inspection is looking at the appearance of the abdomen while the patient is lying supine, with their arms by their side, and head resting on a pillow. (If the neck is flexed, abdominal muscles may become flexed, and this can alter the appearance during assessment.). Auscultation is performed over all four quadrants. Consider, are bowel sounds present? What are the quality and quantity of the bowel sounds? Note any regional differences among the four quadrants. Percussion is performed by the fingers to test for dullness (solid mass) and tympany (air or gas). Palpation is performed to discover any pain or tenderness. When palpating, apply slow, steady pressure and avoid sharp movements that may cause discomfort. A patient is in the clinic with complaints of "not feeling well." The nurse knows the patient's primary defense against infection is: a. Fever b. Intact skin c. Inflammation d. Lethargy - ANSWER-b. Intact skin The primary defense from infection is intact skin. Breaks in the skin allow a route for infection to invade. A is incorrect because fever is a secondary defense against infection. Fever is significant when above 100.4℉ or 38℃. C is incorrect because inflammation is a secondary defense against infection. Inflammation produces redness, pain, swelling, and warmth as a result of infection, irritation, or injury. The body heals during the inflammatory process as leukocytes and proteins migrate to the area in order to fight infection and repair damage.

D is incorrect because lethargy is not a defense against infection. Lethargy can be a symptom of infection. The nurse on the medical unit is caring for a patient who does not speak English, and the nurse does not understand the patient's language. Which of the following is most appropriate for the nurse to do when speaking with the patient? a. Have the patient's wife translate b. Speak using medical terminology to avoid misunderstanding c. Keep in mind translation is more important than nonverbal communication d. Have a certified medical interpreter translate - ANSWER-d. Have a certified medical interpreter translate Medical interpreters are certified in translation for scenarios like this. Rigorous training and testing is performed before becoming a medical interpreter, so this is the best way to interpret for a patient and prevent mistakes and misunderstandings. The nurse is completing the preoperative checklist for a patient scheduled for surgery. In reviewing the chart, the nurse finds the consent has not been signed by the patient. When the patient starts asking questions regarding the surgery, what is the next action the nurse should take? a. Have the patient sign the consent b. Tell the patient all questions will be answered by the surgeon before the anesthesiologist administers anesthetic c. Contact the surgeon to inform them the patient has questions regarding the procedure d. Answer all the patient's questions - ANSWER-c. Contact the surgeon to inform them the patient has questions regarding the procedure Before any invasive procedure, the surgeon must inform the patient of what the procedure entails, the purpose for the procedure, and the potential risks associated with that procedure before the consent is signed by the patient. (Hence the term "informed consent.") If the consent has not been signed and the patient has questions, the healthcare provider has not reviewed the procedure and risks involved and needs to do so before the procedure. The nurse is caring for a patient who had an endoscopic total hysterectomy and is now experiencing urinary retention. The nurse is preparing to contact the healthcare provider using SBAR (situation

background assessment recommendation). Which of the following questions is a part of SBAR communication? a. "Could you tell me what I need to do?" b. "What do you need to know about the patient?" c. "I believe the patient needs a urinary catheter." d. "Why do you think the patient is unable to urinate?" - ANSWER-c. "I believe the patient needs a urinary catheter." Making a recommendation to the healthcare provider is part of SBAR. The following is an example of how the nurse could effectively use SBAR in this patient situation:

• Situation: "Mrs. Jones is experiencing urinary retention."
• Background: "She had an endoscopic total hysterectomy."
• Assessment: "Her vital signs have been stable today. She is taking PO fluids but has had no urine output in the last five hours. Her bladder is distended."
• Recommendation: "I recommend that you see her and we insert an indwelling urinary Foley catheter and measure urine output every two hours." A patient is recovering from a total abdominal hysterectomy. When assessed by the nurse eight hours after the procedure, which of the following would the nurse identify as an early sign of shock? a. Restlessness b. Warm, dry skin that is pale c. Heart rate of 115 bpm d. Urine output 50 mL/hr - ANSWER-a. Restlessness Early signs of shock include restlessness, anxiousness, nervousness, and irritability. This is due to the sympathetic nervous system release of epinephrine, which also decreases perfusion to the skin causing pallor, coolness, and clamminess. Other signs of shock include hypotension and confusion. A patient is admitted to the emergency room complaining of shortness of breath. The nurse knows the patient will be evaluated for hypoxia and anticipates the healthcare provider ordering which test? a. Complete blood cell count (CBC)

b. Sputum culture c. Hemoglobin (Hgb) d. Arterial blood gas (ABG) - ANSWER-d. Arterial blood gas (ABG) An ABG evaluates gas exchange in the lungs, which will provide the needed information regarding oxygenation status. An arterial blood gas reveals pH, carbon dioxide and oxygen partial pressures, bicarbonate level (HCO3-), and pH. Emergency medical services brings an unconscious adult in to the emergency room. When the nurse performs a rapid assessment, the location to check the pulse is: a. Radial b. Brachial c. Femoral d. Carotid - ANSWER-d. Carotid Rapid assessment of an unconscious adult patient begins with checking circulation, which is checked at the carotid artery. If a patient is hypotensive (decreased blood pressure), the most likely place to be able to feel a pulse is the carotid artery. A patient is admitted to the medical-surgical unit with methicillin-resistant staphylococcus aureus (MRSA) of a wound. The nurse initiates contact precautions, which includes use of which of the following? a. Clean gown and gloves b. N-95 respirator c. Biohazard bin placed in the room d. Negative airflow room - ANSWER-a. Clean gown and gloves Contact isolation requires all people entering the room to follow standard precautions in addition to wearing a clean (not sterile) gown and gloves. Other diseases that require contact precautions include the following: norovirus, rotavirus, and Clostridium difficile. Additionally, patients with draining wounds, uncontrolled secretions, pressure ulcers, generalized rash, and ostomy bags/tubes also warrant contact precautions. C is incorrect because linen and trash for this patient are not considered biohazardous.

A patient in the medical-surgical unit tells the nurse they haven't had a bowel movement in two days. What is the first intervention the nurse should implement? a. Review the patient's medical record to determine normal bowel pattern b. Offer prune juice with every meal c. Call the healthcare provider to request an order for stool softener d. Increase the patient's oral fluid intake - ANSWER-a. Review the patient's medical record to determine normal bowel pattern Bowel patterns can vary greatly in adults: three BMs weekly up to three BMs daily is considered within normal range. Several factors can influence normal bowel patterns, including surgery, stress, and opioid medications. The nurse should review the medical record to determine the patient's normal bowel patterns prior to hospitalization. A 40-year-old patient in the clinic tells the nurse they have frequent constipation. The patient has taken steps to remedy the constipation but would like to prevent it with a bowel-training program. Which of the following is of greatest concern to the nurse? a. The patient does not eat any fruits and vegetables b. The patient drinks 2 liters of water daily c. The patient exercises 3 to 4 days per week d. The patient's home recently tested positive for lead - ANSWER-d. The patient's home recently tested positive for lead Lead poisoning can cause constipation. This is the greatest concern for the nurse at this time. The patient will need their blood to be tested for lead, and other people living in the home will need to be assessed as well. A patient appears anxious about an upcoming procedure. Which of the following responses by the nurse will reduce this patient's anxiety? a. "Don't worry. It will be fine." b. "Read this pamphlet about the procedure and let me know if you have questions." c. "I will turn on some music for you."

d. "Would you like to talk about what's bothering you?" - ANSWER-d. "Would you like to talk about what's bothering you?" Anxiety is common before medical procedures. The patient may feel helpless, isolated, or insecure. Encouraging the patient to talk about their feelings can reduce anxiety and helps the nurse be supportive by developing goals with the patient for some sense of control. This is the response that displays therapeutic communication. A patient is admitted to the cardiac unit after myocardial infarction (MI). The patient tells the nurse they don't want their spouse to know what happened. What is the best response by the nurse? a. "I have to tell your spouse what happened." b. "I will need you to fill out paperwork preventing anyone from telling your spouse." c. "Why don't you want me to tell your spouse?" d. "Is there someone else you would like listed as an appropriate person with whom we can discuss your care?" - ANSWER-d. "Is there someone else you would like listed as an appropriate person with whom we can discuss your care?" Patients have the right to decide what information regarding their condition is shared with whom. It is the responsibility of the nurse to obtain this information from the patient and document it in the medical record so others following in care will know as well. Clarifying the patient statement and determining who the patient wants involved is the best response. The nurse is caring for a 72-year-old patient who has a history of a left-sided stroke. The patient uses a cane while walking. Which is the best way for the nurse to assess the strength of their lower extremities? a. Have the patient push with their feet against the nurse's hands b. Observe the patient walking in the hall c. Notify the physical therapy department and request an assessment d. Assist the patient to the bathroom - ANSWER-d. Assist the patient to the bathroom Patients who have experienced a stroke often have residual weakness on the affected side and use assistive devices to help with mobility. Using the cane and assisting the patient to the bathroom is the best way for the nurse to assess the patient's lower extremity strength. The nurse can assist the patient to the bathroom, and therefore, eliminate the risk for a fall.

A is incorrect because testing pedal strength only provides assessment data about the lower legs, not the full lower extremities. B is incorrect because observing the patient walking in the hall does not give an accurate assessment of lower extremity strength and could put the patient at risk for a fall. A patient has a urinary catheter ordered due to urinary retention. The patient should be placed in the dorsal recumbent position for the catheter insertion, but the patient states they have back pain and cannot assume that position. What is the most appropriate action the nurse should take? a. Place the patient in the dorsal recumbent position b. Place the patient on their side c. Place the patient in a prone position d. Notify the healthcare provider for an alternate order - ANSWER-b. Place the patient on their side Sterile procedure is critical when placing a urinary catheter. If the patient is unable to lie in the dorsal recumbent position for the procedure, another position such as side-lying should be used as long as the procedure can be completed in a sterile manner. Patient comfort is important as is maintaining sterile protocol during urinary catheter placement. C is incorrect because prone is lying face down which is not conducive to urinary catheter placement. D is incorrect because if the patient is experiencing urinary retention there is no alternative to the urinary catheter. The nurse is caring for the Jackson-Pratt (JP) wound drain of a patient who had abdominal surgery the prior day. When cleaning the site, which technique does the nurse use? a. Cleaning from directly around the tube outward using a circular motion b. Removing the drain before cleaning the site c. Use alcohol to briskly wipe the site d. Wearing sterile gloves and a mask - ANSWER-a. Cleaning from directly around the tube outward using a circular motion A wound drain should be cleaned from the drain site outward using a circular motion. This will prevent contamination from the skin and a wound infection. D is incorrect because a mask is not necessary.

A 64-year-old patient visits the clinic with an open wound on their foot. Which of the following strategies by the nurse is most appropriate to evaluate the patient's ability to change their dressing at home? a. Observe the patient changing their dressing b. Have the patient write down the steps of the dressing change for reference c. Write instructions for the patient for reference d. Observe the patient changing a dressing on a simulated wound model - ANSWER-a. Observe the patient changing their dressing Observing the patient changing the dressing will help the nurse evaluate the patient's ability. D is incorrect because performing the dressing change on a model may be helpful, but it does not evaluate ability of the patient to perform the dressing change on their own wound. The nurse in the long-term care facility is assessing patients. Which of the following does the nurse identify as being at highest risk for developing decubitus ulcers? a. 76-year-old malnourished patient on bed rest b. Obese patient who is wheelchair-bound and quit smoking one year ago c. Incontinent patient having frequent loose stools, on a high-protein diet d. 75-year-old patient with diabetes who is ambulatory - ANSWER-a. 76-year-old malnourished patient on bed rest Malnourished patients are more likely to have increased bony prominences, which are susceptible to decubitus ulcers and wounds from constant pressure. Malnourishment also contributes to decreased protein levels, which are paramount in maintaining fluid status and wound healing. B is incorrect because although obesity does contribute to risk for decubitus ulcers, this patient is not at the highest risk. Smoking is a risk factor for reduced blood flow and poor wound healing, but one year after quitting, this is not a current risk factor for decubitus ulcer. C is incorrect because although incontinence and diarrhea increase risk for decubitus ulcers, this patient is not at the highest risk. A high-protein diet does not contribute to the development of pressure ulcers. D is incorrect because although diabetes does contribute to the risk for decubitus ulcers, this patient is ambulatory and not at highest risk. The nurse is teaching a patient with newly diagnosed diabetes type 1 how to prepare an insulin syringe with 30 units of U-100 NPH insulin to self-administer. The first priority for the patient is to:

a. Select the appropriate injection site b. Assess the site chosen for injection c. Check the insulin syringe to verify correct dose has been drawn up d. Clean the site chosen for injection with an alcohol swab - ANSWER-c. Check the insulin syringe to verify correct dose has been drawn up When a nurse teaches a patient how to prepare insulin for injection, the first priority for the patient is validating accuracy of the dose. The proper steps in order are validate dosage, select site, assess site, clean site, and inject insulin. The nurse cares for a client with an ankle splint. Which of the following assessment findings is abnormal and requires adjustment of the splint? a. Palpable pedal pulses b. Capillary refill 2 seconds in the toes c. The client complains of pain after the splint is applied d. The padding does not extend beyond the elastic bandage - ANSWER-d. The padding does not extend beyond the elastic bandage This splint has been inappropriately placed. The padding should extend beyond the elastic bandage. The excess padding should be folded over the splint edges to form a smooth, soft border. If the elastic bandage is applied directly to the skin or if inadequate padding is used, skin breakdown can result. The nurse is developing the discharge education plan for a patient admitted for myocardial infarction (MI). Which of the following patient statements indicates the patient is ready to follow the care plan? a. "I don't believe I had a heart attack." b. "I go for walks 2 or 3 times a week, usually." c. "I will have to tell my spouse that we may not be able to have sex for a while." d. "My job requires me to travel, so it's difficult to eat right. - ANSWER-c. "I will have to tell my spouse that we may not be able to have sex for a while." C is a true statement. After a myocardial infarction, the heart is not healthy for vigorous exercise or sexual activity. Many doctors tell their patients not to resume sexual intercourse until the patient can

climb two flights of stairs without chest pain. Other doctors will request an exercise EKG before clearing the patient for sexual activity. This statement indicates an understanding of the discharge instructions. B is incorrect because it indicates the patient may believe that walking 2-3 times a week is sufficient exercise. This statement is not dangerous for the client but it does not indicate a willingness to make lifestyle changes. The nurse is preparing to teach a 42-year-old patient with new-onset diabetes type 2 about lifestyle modifications. Which of the following characteristics demonstrate patient's readiness to learn? a. Moderate anxiety about administering self-injections b. High self-efficacy regarding assessment of the injection site c. Contemplating change related to the need for frequent blood glucose self-monitoring d. Laughing about the diagnosis, the patient states, "It seems like our bodies fall apart as we get older!" - ANSWER-b. High self-efficacy regarding assessment of the injection site Self-efficacy is important when it comes to the teaching-learning process. If a patient has high self- efficacy, they are ready to take on the problem or new diagnosis and learn everything they can in order to manage/relieve it. A is incorrect because anxiety will only interfere with the teaching-learning process. C is incorrect because contemplation of change means the patient has not decided if they are willing to make changes, which will not enhance teaching-learning. The nurse is teaching a 68-year-old patient recently diagnosed with osteoporosis about how to prevent fractures. Which of the following statements indicates the patient understands the instructions? a. "I am so glad I can still attend my dance aerobics class, as usual." b. "Frequent exercise will help me lose weight." c. "I am excited to learn yoga and Pilates, with modifications for osteoporosis." d. "I understand I won't be able to use my elliptical machine anymore, but maybe I can start running outside when the weather is nice." - ANSWER-c. "I am excited to learn yoga and Pilates, with modifications for osteoporosis." Osteoporosis is a condition of bone loss through decreased calcium levels as adults age. This puts patients at an increased risk for fractures. Weight-bearing and stretching exercises, including yoga and Pilates, are beneficial in osteoporosis because they can strengthen muscles and joints, and help prevent further bone loss. Estrogen replacement and calcium can additionally prevent further bone loss.

The nurse is performing dietary teaching for a patient who experienced a myocardial infarction. Which meal choice by the patient indicates the patient understands the dietary teaching? (low-fat, low sodium) a. 3 oz. baked fish, baked potato with sour cream, ½ cup canned green beans, and milk b. 3 oz. fried salmon, steamed asparagus, garlic bread, and tea c. Ham sandwich, fruit salad, baked potato chips, and coffee d. 3 oz. roasted turkey, mashed sweet potato, ½ cup salad with light Italian dressing, and water - ANSWER-d. 3 oz. roasted turkey, mashed sweet potato, ½ cup salad with light Italian dressing, and water This dietary choice is low in fat and sodium and is the best choice, indicating the patient understood the dietary education. A heart-healthy diet should contain multiple servings of fruits, vegetables, and whole grains. Fat and sodium should be limited. The nurse supervises the nursing team caring for a patient receiving continuous enteral feeding via gastrostomy tube. The nurse will intervene when which of the following is observed? a. The nursing assistant completes the bed bath and then reconnects the enteral feeding with the head of the patient's bed elevated. b. The LPN/LVN cleans around the gastrostomy tube insertion site and then applies a clean dressing. c. The LPN verifies the patient's identity by checking the patient's hospital wristband and asking the patient to state their name. d. The nursing assistant flushes the gastrostomy tube with 20 mL sterile water after the LPN gives the medications. - ANSWER-d. The nursing assistant flushes the gastrostomy tube with 20 mL sterile water after the LPN gives the medications. Flushing a gastrostomy tube is not within the nursing assistant's scope of practice. Failure to delegate appropriately is negligent, and the nurse is responsible. A patient in the rehab facility reports pain to the nurse. Which of the following is the best response by the nurse? a. "What pain medications have been effective in the past?" b. "Please describe the location and intensity of the pain." c. "When did the pain begin?"

d. "Let me check when your next dose of medication is due." - ANSWER-b. "Please describe the location and intensity of the pain." This is the most open-ended answer choice and will give the nurse the most information. Determining the location and intensity of the pain is the priority now. This will lead to a discussion about the pain, including the pain-rating scale. (Other important assessments include: "Does the pain come and go, or is it continuous?" "What triggers the pain?") C is incorrect because it is a closed-ended question, which only gives the nurse one piece of information. Answer choice B will give more detail to help the nurse help the patient. The nurse is administering celecoxib to a patient diagnosed with arthritis. Which of the following medications on the patient's medication record could cause an interaction and adverse effects? a. Scopolamine b. Furosemide c. Acetaminophen d. Ibuprofen - ANSWER-d. Ibuprofen Celecoxib is an NSAID (nonsteroidal anti-inflammatory drug) belonging to the cyclooxygenase-2 (COX-2) inhibitor group. It is used to treat pain and inflammation associated with osteoarthritis, rheumatoid arthritis, and acute pain in adults. An adverse effect of the drug is bleeding, so it shouldn't be taken with other drugs that increase bleeding including other NSAIDs, such as ibuprofen. A patient diagnosed with chronic pain is prescribed therapy with a transcutaneous electrical nerve stimulation (TENS) unit. Which statement indicates the patient understands the benefit of this type of treatment is? a. "I'm glad this machine will reduce the pain in my hips when getting in and out of the bathtub." b. "Although this method of pain control will restrict my movement, it will decrease my pain." c. "I'm looking forward to having more control over my pain with this treatment." d. "I'm glad my family will be able to care for me at home now." - ANSWER-c. "I'm looking forward to having more control over my pain with this treatment." A TENS unit delivers cutaneous stimulation which can block the pain impulse from reaching the brain, thereby reducing the sensation of the pain. The patient can initiate the signal when feeling pain, thus

giving the patient control over their pain. This treatment can be performed anywhere, even in the comfort of the patient's own home. A patient in the cardiac unit calls the nurse to report pain shortly after an opioid was administered. The patient has been on bed rest as part of their recovery from a myocardial infarction (MI). The patient also has a duodenal ulcer and suffers from type 1 diabetes mellitus. The nurse offers therapeutic massage because it will: a. Decrease fluid retention in swollen legs b. Decrease the pain associated with duodenal ulcers c. Improve circulation and muscle tightness d. Improve healing in diabetic wounds - ANSWER-c. Improve circulation and muscle tightness Bed rest, despite the improvement of air mattresses, can cause muscle tension and pain over time. Therapeutic massage can improve circulation as well as decrease muscle tension. It is contraindicated in patients with deep vein thrombosis (DVT) or any condition that creates blood clots that can dislodge. The nurse has administered 2 mg morphine intravenously for a patient reporting pain after a Billroth's surgical procedure. Before leaving the patient's room, which of the following interventions is high priority for the nurse to perform? a. Leave the room light on b. Turn off the TV to provide a quiet atmosphere c. Raise the bed rails d. Document administration of the medication - ANSWER-c. Raise the bed rails Morphine is an opioid medication that can cause decreased level of consciousness, dizziness, drowsiness, and physical impairment. The nurse must ensure the bed rails are raised for patient safety before leaving the patient room. Safety is the greatest priority. (In a Billroth operation, the pylorus of the stomach is removed and the proximal stomach is connected directly to the duodenum.) D is incorrect because documentation of medication administration is required, but it does not provide patient safety. Direct patient care and patient safety are always prioritized ahead of documentation. A patient is complaining of pain following knee replacement surgery. When the nurse prepares to administer hydromorphone, which of the following assessments is highest priority to complete prior to administration of the medication?

a. Blood pressure b. Level of consciousness c. Respiratory rate d. Pain rating - ANSWER-c. Respiratory rate Hydromorphone is an opioid medication that can cause drowsiness, sedation, and respiratory depression. The medication should be withheld if the patient's respiratory rate is less than 12. The nurse administered 5 mg hydrocodone PO to a patient complaining of pain. Ten minutes later the patient experiences emesis. What is the first action the nurse should perform? a. Notify the healthcare provider b. Tell the patient, "We will wait until the nausea subsides before giving you any more pain medication." c. Assess the emesis for the medication d. Administer another dose of hydrocodone - ANSWER-c. Assess the emesis for the medication Any time a patient experiences emesis, the nurse needs to inspect it for color, consistency, and amount. In this situation, the recent dose of hydrocodone warrants assessing the emesis for the pill to determine whether the patient absorbed an effective dose. The next step is to contact the healthcare provider to determine if an additional dose will be given or an antiemetic prescribed. The nurse reassesses pain 30 minutes after a patient received hydrocodone. When the patient tells the nurse he is still experiencing pain, which of the following should the nurse implement? a. Notify the healthcare provider for additional pain medication b. Guided imagery c. Administer an additional dose of hydrocodone d. Ambulate the patient - ANSWER-b. Guided imagery Guided imagery is a method of distraction in which the patient envisions themselves in a different place experiencing something pleasant. This can be effective in decreasing pain without medication. A patient has a morphine sulfate patient-controlled analgesia (PCA) pump for pain post-thoracotomy. Which of the following interventions does the nurse perform to prevent adverse effects?

a. Teach the patient to perform deep breathing and use incentive spirometry four times daily b. Administer fiber supplements to prevent constipation c. Teach the family members that no one should press the button except the patient d. Tell the patient the button can only be pressed every 15 minutes - ANSWER-c. Teach the family members that no one should press the button except the patient Morphine is an opioid analgesic that is commonly used in PCA pumps to relieve pain. A thoracotomy is a surgery performed on the lung for several purposes including removal of infected tissue or removal of cancer. PCA pumps are frequently utilized with patients post-thoracic surgery such as thoracotomy. The patient and family should be taught that the patient is the only one who can push the button that delivers the pain medication. Others can seriously misjudge the patient's level of sedation resulting in over-sedation and respiratory depression. Opiates are one of four classes of medications that cause more than 60% of serious adverse events in the U.S. (others are insulin, anticoagulants, and antibiotics). D is incorrect because telling the patient the PCA button can only be pushed every 15 minutes will not prevent adverse effects of morphine. The PCA is designed for the patient to administer their own pain medication as often as they feel necessary. The nurse will set limits on the pump to prevent overdose. The nurse should assess the patient and the pump frequently to determine level of consciousness, pain rating, and frequency of demand. The nurse on the cardiac unit is caring for a patient who is experiencing a myocardial infarction (MI). When the patient complains of chest pain, the nurse administers sublingual nitroglycerin (NTG). The nurse instructs the patient to place the tablet: a. On top of the tongue b. On the roof of the mouth c. On the floor of the mouth under the tongue d. Between the cheek and gums - ANSWER-c. On the floor of the mouth under the tongue Sublingual nitroglycerin is given to patients experiencing myocardial infarction because it dilates the coronary arteries. It is given under the tongue on the floor of the mouth to dissolve directly into the bloodstream. This medication may cause vasodilation and thus, blood pressure should be monitored. Other forms of nitroglycerin include oral extended-release capsules, transdermal patch, and intravenous drip. The nurse cares for a patient admitted to the medical floor with a diagnosis of liver failure and a history of Raynaud's syndrome. While reviewing the medical record, which order should the nurse question?

a. CBC, CMP, and urinalysis upon admission b. Acetaminophen 325 mg PO every 4 hours as needed for pain c. Furosemide 40 mg IV every 12 hours d. EKG in AM - ANSWER-b. Acetaminophen 325 mg PO every 4 hours as needed for pain Tylenol is a non-opioid analgesic that is metabolized by the liver and is contraindicated in patients who are experiencing hepatic dysfunction. Acetaminophen can exacerbate the liver failure. The nurse should contact the healthcare provider to obtain an alternate order for pain medication. A patient is admitted to the medical-surgical unit with a closed head injury and confusion. Which of the following interventions does the nurse implement to keep the patient safe? a. Leave the bed in the low position with the side rails down so the patient can go to the bathroom b. Restrain the patient so they don't attempt to get out of bed c. Admit the patient to a room close to the nurses' station d. Call the healthcare provider to request a sedative medication - ANSWER-c. Admit the patient to a room close to the nurses' station Patients with closed head injuries such as concussions are commonly confused and require reorientation. Placing the patient in a room close to the nurses' station will make it possible for someone to visualize the patient at all times, decreasing the risk for falls and patient injury. A is incorrect because leaving the side rails down makes for easy exit from the bed, putting the patient at risk for a fall. B is incorrect because less restrictive measures to keep the patient safe should be used before placing restraints on the patient. D is incorrect because a sedative could potentially worsen the patient's confusion and put them at risk for falls. Sedatives and opioid medications are generally contraindicated in patients with a closed head injury because these medications can mask signs of increasing intracranial pressure. The nurse on the medical-surgical unit has just received a report on four patients. Which of the following patients should the nurse see first? a. Patient who is one day post-op hysterectomy awaiting discharge b. Patient who is scheduled for dialysis in two hours, reports chills c. Patient calling for pain medication

d. Patient who is two days post hip replacement surgery complaining of shortness of breath - ANSWER-d. Patient who is two days post hip replacement surgery complaining of shortness of breath Any patient who is complaining of shortness of breath takes priority. The patient who has just had hip replacement surgery is at risk for blood clots and could be experiencing a pulmonary embolus (PE). The nurse needs to see this patient first to determine what is happening. The nurse working on the surgical unit knows the National Patient Safety Goals as established by Joint Commission include (Select all that apply): a. Using side rails and bed alarms for fall prevention b. Using the read-back procedure for verification of verbal and phone orders c. Memorizing all rules set forth by Joint Commission d. Performing medication reconciliation for complete medication lists and ensuring appropriate use throughout a patient's care e. Keeping patients involved in care and encouraging them to question their care - ANSWER-a. Using side rails and bed alarms for fall prevention b. Using the read-back procedure for verification of verbal and phone orders d. Performing medication reconciliation for complete medication lists and ensuring appropriate use throughout a patient's care National Patient Safety Goals are set forth by Joint Commission and are modified yearly to correspond to healthcare needs. Some goals are consistent, including use of side rails and alarms to prevent falls, verification of verbal and phone orders, and performing medication reconciliation. Nurses need to be aware of these patient safety goals as they are modified and updated to keep patients safe and meet Joint Commission standards. A patient is admitted to the medical unit for COPD exacerbation. The nurse knows that chronic illnesses are characterized by (Select all that apply): a. Consistent and predictable course b. Permanent deviation from what is normal c. Stable and unstable phases d. Begin with acute illness but progress slowly e. Reversible pathologic changes - ANSWER-b. Permanent deviation from what is normal

c. Stable and unstable phases Chronic illnesses, like COPD, are characterized by permanent deviation from what is normal, irreversible pathologic changes, residual disability, need for rehabilitation, and need for long-term care. The nurse on the medical-surgical floor is caring for a patient who had open cardiac bypass surgery five days ago. The patient has a surgical incision and requires a dressing change. The nurse knows the way to prevent infection of the incision is (Select all that apply): a. Using hand sanitizer every time healthcare personnel enter or leave the room b. Administering antibiotics c. Wearing gloves and a mask when changing the surgical dressing d. Changing the surgical dressing regularly e. Preventing visitors from entering the room - ANSWER-c. Wearing gloves and a mask when changing the surgical dressing d. Changing the surgical dressing regularly Hand hygiene is the number one way to prevent infection in surgical incisions. However, the best way to prevent spread of microorganisms is to wash thoroughly with soap and water. Alcohol-based hand sanitizer is not an appropriate substitution every time. Wearing gloves and a mask when changing the surgical dressing is another way to prevent infection of the site. Regular dressing changes will also prevent infection. B is incorrect because routine use of antibiotics can lead to drug resistance in microorganisms. Prophylactic antibiotics are used carefully in surgical patients. The nurse is assisting a patient with ambulation when the patient reports feeling dizzy. Which of the following are appropriate actions by the nurse for patient safety? (Select all that apply): a. Stay with the patient and call for help b. Tell the patient to lean against the wall while the nurse gets a wheelchair c. Have the patient sit down on the floor d. Assist the patient to the floor if they start to fall e. Ambulate the patient back to their room and administer an antiemetic - ANSWER-a. Stay with the patient and call for help d. Assist the patient to the floor if they start to fall

Patient falls are common for causing patient injuries. Calling for help while staying with the patient and assisting a patient to the floor if they start to fall are both appropriate ways to prevent patient injury. C is incorrect because having the patient sit down on the floor is inappropriate and unsanitary. The nurse is caring for a 65-year-old patient admitted for peritonitis. The nurse knows that which of the following can influence this patient's health beliefs and health practices? (Select all that apply): a. Genetic background b. Emotional factors c. Family practices d. Financial status e. Developmental stage - ANSWER-b. Emotional factors c. Family practices d. Financial status e. Developmental stage Many factors influence a patient's health beliefs and health practices. These factors include emotional factors, family practices, financial status, and developmental stage. All of these factors have an impact on how the patient will deal with the current illness. A is incorrect because genetic background has no influence on health practices or health beliefs. A 44-year-old patient is admitted to the cardiac unit with chest pain. Which of the following are the external factors that influence this patient's illness behavior? (Select all that apply): a. Perception of illness b. Cultural background c. Social group d. Access to healthcare e. Chronic illness - ANSWER-b. Cultural background c. Social group d. Access to healthcare

Illness behavior is influenced by both internal and external factors. External factors include cultural background, social group, and access to healthcare. A and E are incorrect because both are internal factors influencing illness behavior. A new mother has expressed interest in breastfeeding her infant. Which of the following would be effective as provided by the nurse? (Select all that apply): a. Educate the new mother when she has visitors b. Teach at times when the infant is hungry c. Teach when the infant is crying d. Teach the patient and the spouse if approved by the patient e. Ask the new mother about how she feels as a new mom and about breastfeeding when teaching is completed - ANSWER-b. Teach at times when the infant is hungry d. Teach the patient and the spouse if approved by the patient Teaching is best performed when patients are ready and open to learning. Family members of adult patients can be taught as well, with the patient's approval. Breastfeeding instruction can be challenging, so the patient should be rested and the baby should be hungry but not crying. E is incorrect because asking about the patient's feelings and beliefs regarding breastfeeding is best done at the beginning of the session. The nurse is caring for four patients on the medical-surgical unit. Which of the following tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply): a. Start an IV in the patient complaining of pain b. Ambulate the patient who is two days post-op hysterectomy c. Help a patient ambulate initially after hip replacement d. Take vital signs on the patient receiving an IV antibiotic e. Provide a patient with discharge instruction - ANSWER-b. Ambulate the patient who is two days post- op hysterectomy d. Take vital signs on the patient receiving an IV antibiotic

Unlicensed assistive personnel (UAP) have limited training and education to assist with patient care. Their duties consist of tasks including taking vital signs, bathing, ambulating, turning, and assisting with activities of daily living for stable patients. The UAP can ambulate the two-day post-op patient and take vital signs on the patient receiving an IV antibiotic. C is incorrect because UAPs cannot ambulate a patient who has not been assessed for ability to ambulate after surgery. The nurse on the medical-surgical unit has just received a report on a new patient being admitted from the emergency room. The patient has an umbilical hernia with intestinal obstruction and is going to the OR in 4 hours for herniorrhaphy. The nurse knows the best time to prepare the room for the patient is: a. Once the patient arrives b. After the patient arrives c. Before the patient arrives d. The room is already prepared - ANSWER-c. Before the patient arrives The room should be prepared before the patient arrives. This allows the nurse to start the admission assessment upon arrival. Personalized care can begin immediately if the room is set up with all the needed equipment to care for the patient. If an emergency arises, a prepared room will prevent delay of intervention. Patient-centered care includes introducing yourself, delivering immediate care as needed, and providing education on the room, emergency procedures, and expected outcomes. D is incorrect because hospital rooms are not already prepared for specific needs of individual patients. Additional supplies and equipment needed to properly care for this patient include a truss-pad, which provides support for the herniated area until it can be surgically corrected. The nurse is preparing a patient for a scheduled procedure after the healthcare provider obtained written consent and has left the patient's room. The nurse knows if the patient understands the teaching, the patient will be able to: a. Tell the nurse why the procedure is going to be done b. Ambulate to the procedure room c. Use less pain medication after the procedure d. Be discharged as scheduled - ANSWER-a. Tell the nurse why the procedure is going to be done The nurse is responsible for reinforcing teaching about procedures and clarifying patient concerns. Each patient should be educated regarding the purpose of procedures and how they are performed. Helping

the patient understand the treatment plan gives them a better sense of control over their treatment and reduces anxiety. A patient about to be transferred to the medical-surgical unit from the intensive care unit (ICU) experiences deterioration in status. What is the first intervention the ICU nurse should implement? a. Initiate CPR and call for a code blue b. Notify the healthcare provider immediately c. Call the medical-surgical unit to inform them there will be a delay in the transfer d. Complete an incident report - ANSWER-b. Notify the healthcare provider immediately Deterioration in patient status is an unexpected outcome that can delay transfer to a lower level of care. Stabilizing the patient and calling the healthcare provider are the priorities. A is incorrect because CPR and code blue do not necessarily need to be initiated until further assessment information is obtained. "Deterioration" is vague and does not specifically indicate pulselessness, cardiac arrest, or asystole. The nurse is preparing to discharge a 53-year-old patient from the cardiac unit after myocardial infarction (MI). The patient has a history of type 1 diabetes and osteoporosis. The patient is ready for discharge and understands aftercare when: a. The patient is given the discharge packet b. The patient asks the nurse how they are supposed to prevent falls in the home c. The patient tells the nurse how they plan to increase their activity and make changes to their diet d. The patient lists the medications they will be taking - ANSWER-c. The patient tells the nurse how they plan to increase their activity and make changes to their diet The discharge process is multifaceted and can be very confusing to patients. It is essential to ensure the patient understands discharge instructions in order to prevent complications and unnecessary readmissions. The nurse must educate the patient regarding medications, activity level, dietary changes, and how to care for any procedural sites as applicable. B is incorrect because asking about fall prevention does not indicate an understanding of discharge instructions. This statement indicates a need for more teaching. D is incorrect because although the patient needs to know what medications they will be taking, they also need to be able to tell the nurse why the medications are needed, when to take them, and when to notify the healthcare provider.

A patient in the recovery room is experiencing pain despite administration of analgesia by the nurse. Which of the following statements by the nurse is an example of therapeutic communication? a. "I will notify the healthcare provider that you are still experiencing pain and see if we can get you some relief." b. "This pain is a problem. What do you want me to do?" c. "Your healthcare provider commonly under-medicates patients for pain." d. "The pain should subside once the medication has had a chance to take full effect." - ANSWER-a. "I will notify the healthcare provider that you are still experiencing pain and see if we can get you some relief." Therapeutic communication regarding pain should be goal-directed. In this example, the goal is better management of pain. D is incorrect because this is dismissive. There is not enough information in the question (what pain medication was administered, what route was used, how long ago was it given) for the nurse to make the assumption that the medication has not yet taken full effect. Unrelieved pain can be a sign of a complication and should be addressed by the nurse. The nurse is preparing to educate a patient regarding administration of enoxaparin injections. Which of the following questions would be most appropriate for the nurse to ask the patient? a. "Are you able to use a computer?" b. "Is your spouse here yet?" c. "Are you ready to give yourself an injection?" d. "What is your preferred way of learning?" - ANSWER-d. "What is your preferred way of learning?" Patient education is very important for patients to understand how injections are performed in order to prevent errors and complications. Everyone has different learning styles, so the nurse must identify how the patient learns best in order to provide appropriate patient education. C is incorrect because it is closed-ended and is inappropriate to ask until after the patient has been educated about enoxaparin and how to safely administer this drug. The nurse may administer the injection first and then assess readiness for self-injection at the next scheduled dose. The emergency room nurse is caring for a patient who has become belligerent and is yelling at the staff. Which of the following interventions by the nurse is the most appropriate for this patient?