Exam 1

What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.)

1. Prone position

2. Modified left lateral recumbent position

3. Semi-Fowler’s position with head to side

4. Trendelenburg position

5. Supine position

The student nurse is teaching a family member the importance of foot care for their mother, who has diabetes mellitus. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.)

1. Cut nails frequently.

2. Assess skin for redness, abrasions, and open areas daily.

3. Soak feet in water at least 10 minutes before nail care.

4. Apply lotion to feet daily.

5. Clean between toes after bathing

Which of the following factors directly impairs salivary gland secretion? (Select all that apply.)

1. Use of cough drops

2. Immunosuppression

3. Radiation therapy

4. Dehydration

5. Presence of oral airway

A nurse is assigned to care for the following patients. Which patient is most at risk for developing skin problems that will require thorough bathing and skin care?

1. A 44-year-old female patient who has had removal of a breast lesion and is in pain and unwilling to ambulate postoperatively.

2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration.

3. A 60-year-old female patient who experienced a stroke with right sided paralysis and has an orthopedic brace applied to the left leg

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and stool

When the nurse is assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should the nurse perform before the procedure? (Select all that apply.)

1. Oxygen saturation

2. Heart rate

3. Respirations

4. Gag reflex

5. Response to painful stimulus

The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.)

1. Use fluoride toothpaste.

2. Brush teeth 4 times a day

3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients.

4. Use a soft toothbrush for oral care.

5. Avoid cleaning the gums and tongue.

While planning morning care, which of the following patients would have the highest priority to receive a bath first?

1. A patient who just returned to the nursing unit from a diagnostic test

2. A patient with a fever who just finished a dose of intravenous antibiotics.

3. A patient who is experiencing frequent incontinent diarrheal stools and urine

4. A patient who has been awake all night because of pain 8/10

A patient with a malignant brain tumor requires oral care. The patient’s level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care.

1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.

2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees.

3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first.

4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity.

5. Remove partial plate or dentures if present.

6. Gently brush tongue but avoid stimulating gag reflex.

The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who had a stroke. Which intervention(s) would be appropriate for the assistive personnel to accomplish during the bath? (Select all that apply.)

1. Checking distal pulses

2. Providing range-of-motion (ROM) exercises to extremities

3. Determining type of treatment for Stage 1 pressure injury

4. Changing the dressing over an intravenous site

5. Providing special skin care as indicated by nurse

The nurse will delegate hygiene care for two patients of different cultures to the assistive personnel (AP). What cultural information does the nurse need to provide to the AP? (Select all that apply.)

1. Specific hygiene products

2. Timing of hygiene care

3. Socioeconomic status

4. The need for gender congruent caregiver

5. Religious practices

Which piece of clothing would the nurse remove when looking for excoriations?

Socks

Pants

Headband

Adult diaper

When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment?

Open wound over the sacrum

Red, scaly lesion on buttocks

Purplish discoloration under the cheek

An infected surgical wound

Which type of injury results in a puncture wound?

Paper cut

Dog bite

Popped blister

Black eye

A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider?

Presence of pediculosis

Halitosis related to poor oral hygiene

Oily, matted, and tangled hair

Warm, moist, and intact skin

Which assessment findings are indicative of poor hygiene?

Select all that apply.

• Body odors

• Chipped fingernail polish

• Tangled and matted hair

• Excessively long and dirty toenails

• Noticeably warm skin

The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)?

Select all that apply.

• “Do you know where you are?”

• “How many visitors did you have last week?”

• “Do you always make it to the bathroom on time?”

• “How often do you take a bath or shower?”

• “Can you bathe yourself without help?”

An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient’s skin for which signs of infection?

Select all that apply.

• Redness

• Freckles

• Scars

• Swelling

• Drainage

An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital?

Notify the health care provider.

Ask which family member will provide assistance.

Assist the patient with community referrals.

Tell the family to place the patient in a nursing home.

Which factors are potential causes of halitosis?

Select all that apply.

• Diabetes

• Pediculosis

• Medications

• Poor oral hygiene

• Infections of the oral cavity

At 1300 the registered nurse (RN) says to the assistive personnel (AP), “You did a good job transferring Mr. Harvey into his chair this morning at 0830. I saw that you recorded how long he stayed in his chair. I saw that Mr. Harvey did not have any shoes or nonslip slippers on, though. For safety, the next time you transfer a patient into a chair, you need to make sure that the patient wears slippers or shoes. Please get Mr. Harvey up in his chair again by 1500.” Which characteristics of positive feedback did the RN use when talking to the AP? (Select all that apply.)

1. Feedback is given immediately.

2. Feedback focuses on one issue.

3. Feedback offers concrete details.

4. Feedback identifies ways to improve.

5. Feedback focuses on changeable things.

6. Feedback is specific about what is done incorrectly only.

A nurse received change-of-shift reports on these four patients and starts rounding. Which patient does the nurse need to focus on as a priority?

1. A patient who had abdominal surgery 2 days ago and is requesting pain medication

2. A patient admitted yesterday with atrial fibrillation who now has a decreased level of consciousness

3. A patient with a wound drain who needs teaching before discharge in the early afternoon

4. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

A nurse asks an AP to help the patient in Room 418 walk to the bathroom right now. The nurse tells the AP that the patient needs the assistance of one person and the use of a walker. The nurse also tells the AP that the patient’s oxygen can be removed while he goes to the bathroom but to make sure that when it is put back on, the flowmeter is still at 2 L. The nurse also instructs the AP to make sure the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the “Five Rights of Delegation” were used by the nurse? (Select all that apply.)

1. Right task

2. Right circumstance

3. Right person

4. Right directions and communication

5. Right supervision and evaluation

While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient’s health care provider. Which of the following is the nurse exercising?

1. Authority

2. Responsibility

3. Accountability

4. Decision making

Which task is appropriate for a registered nurse (RN) to delegate to an AP?

1. Determining whether the patient understands the preoperative preparation required before the surgery in the morning

2. Administering the ordered antibiotic to the patient before surgery

3. Obtaining the patient’s signature on the surgical informed consent

4. Helping the patient to the bathroom before leaving for the operating room

A nurse performs the following four steps in delegating a task to an AP. Place the steps in the correct order of appropriate delegation.

1. Do you have any questions about walking with Mr. Malone?

2. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate.

3. In the next 30 minutes please assist Mr. Malone in Room 418 with his afternoon walk.

4. I will make sure that I check with you in about 40 minutes to see how the patient did.

Which example demonstrates a nurse performing the skill of evaluation?

1. The nurse explains the side effects of the new blood pressure medication ordered for the patient.

2. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering a pain medication.

3. After completing a teaching session, the nurse observes a patient drawing up and administering an insulin injection.

4. The nurse changes a patient’s leg ulcer dressing using aseptic technique

The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by the award winner? (Select all that apply.)

1. The nurse manager regularly rounds on staff to gather input on unit decisions.

2. The nurse manager sends thank-you notes to staff in recognition of a job well done.

3. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies.

4. The nurse manager has an “innovation idea box” to which staff are encouraged to submit ideas for unit improvements.

5. The nurse manager develops a philosophy of care for the staff.

A new nurse graduate is in orientation on a surgical unit and is being mentored by an experienced nurse. Which action completed by the new nurse graduate requires intervention by the experienced nurse? (Select all that apply.)

1. The new nurse stops documenting about a dressing change to take a patient some water.

2. The new nurse gathered the medications for two different patients at the same time.

3. The new nurse asked an AP to help transfer a patient from the bed to a wheelchair before discharge.

4. The new nurse educates a patient about pain management when administering a pain medication to a patient.

5. The new nurse gathers all equipment necessary to start a new IV site before entering a patient’s room.

JoAnn, a nurse, is calling a patient’s health care provider about a problem that her patient, Ms. Ducote, is having during a blood transfusion. The health care agency uses the SBAR system in reporting patient problems. Put the statements in the correct order according to the SBAR system.

1. I think she might need a diuretic ordered. Is it possible for you to come see her soon? Is there anything else you would like for me to do right now?

2. This is JoAnn. I am caring for Ms. Ducote. She is having labored breathing and her heart rate is higher now than it was an hour ago. She is receiving the second unit of her blood transfusion. She says she is having trouble catching her breath.

3. Ms. Ducote had surgery earlier yesterday to remove a tumor in the colon. Her hemoglobin was 9.6 grams/dL, and her hematocrit was 33.6% this morning. Her first ordered unit of packed red blood cells infused over 90 minutes, and she is 30 minutes into receiving her second unit of blood now. She states she takes furosemide 20 mg every morning at home. She does not currently have an order for furosemide.

4. The patient denies pain, and her vital signs are as follows: B/P 150/98 mm Hg; pulse 118; respiratory rate 28; temperature 98.8° F (37.1° C). I think she is showing signs of fluid volume overload.

A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the patient teaching? (Select all that apply.)

1. “The organism is usually transmitted through the fecal-oral route.”

2. “Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer.”

3. “Everyone coming into the room must wear a gown and gloves.”

4. “While I am in Contact Precautions, I cannot leave the room.”

5. “C. difficile dies quickly once outside the body.”

A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient?

1. Reverse isolation

2. Droplet Precautions

3. Standard Precautions

4. Contact Precautions

A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but the nurse recognizes that this is a normal response to isolation. Which is the nurse’s best intervention?

1. Provide a dark, quiet room to calm the patient.

2. Reduce the level of precautions to keep the patient from becoming angry.

3. Explain the reasons for isolation procedures and provide meaningful stimulation.

4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.)

1. Disposable gown

2. N95 respirator mask

3. Face shield or goggles

4. Disposable mask

5. Gloves

The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on the nurses’ part would contribute to reducing health care–acquired infections? (Select all that apply.)

1. Teaching correct handwashing to assigned patients

2. Using correct procedures in starting and caring for an intravenous infusion

3. Providing perineal care to a patient with an indwelling urinary catheter

4. Isolating a patient on antibiotics who has been having loose stool for 24 hours

5. Decreasing a patient’s environmental stimuli to decrease nausea

Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.)

1. The front and sides of the sterile gown are considered sterile from the waist up.

2. Keep the sterile field in view at all times.

3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated.

4. Only health care personnel within the sterile field must wear personal protective equipment.

5. After cleansing the hands with antiseptic rub, apply clean disposable gloves.

Put the following steps for removal of protective barriers after leaving an isolation room in order.

1. Remove and dispose of gloves.

2. Perform hand hygiene.

3. Remove eyewear or goggles.

4. Untie bottom and then top mask strings and remove from face.

5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse’s best response? (Select all that apply.)

1. There is more than one organism in the wound that is causing the infection.

2. The antibiotics the patient has received are not strong enough to kill the organism.

3. The patient will need more than one type of antibiotic to kill the organism.

4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively.

5. There are no longer any antibiotic options available to treat the patient’s infection.

Which of these statements are true regarding disinfection and cleaning? (Select all that apply.)

1. Proper cleaning requires mechanical removal of all soil from an object or area.

2. Routine environmental cleaning is an example of medical asepsis.

3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound.

4. Cleaning in a direction from the least to the most contaminated area helps reduce infections.

5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

The nurse assesses the following data from a patient with diabetes mellitus who is 4 days postoperative for repair of an abdominal aortic aneurysm. Which assessment finding is of greatest concern for the nurse?

1. Vesicular breath sounds in the lung bases

2. Temperature 38.5o C (101.4o F)

3. Incision pain rating of 6 out of 10

4. Blood glucose of 164 mg/dL

Which techniques can the nurse use for collecting patient assessment data?

Select all that apply.

• Performing a general assessment

• Speaking with the patient’s family

• Consulting the patient’s medical file

• Performing the physical assessment

• Obtaining a thorough history

• Speaking with the patient’s roommate

Which data collected during the nurse-patient interview is a subjective finding?

Bowel sounds active

Fatigue

Swollen left elbow

Blood pressure of 150/72 mm Hg

Which objective patient findings alert the nurse to the presence of infection or the risk for infection?

Select all that apply.

• Pressure injuries

• Enlarged lymph nodes

• Hyperactive bowel sounds

• Reports of pain

• Decreased breath sounds

Which blood test specifically assesses for the presence of an active inflammatory response?

White blood cell (WBC) count

Complete blood count (CBC)

Culture and sensitivity (C&S) test

Erythrocyte sedimentation rate (ESR)

Which laboratory finding is abnormal and must be reported to the health care provider?

White blood cell (WBC) count of 10,100 cells/mm³

Erythrocyte sedimentation rate (ESR) 20 mm/hr

Serum complement 140 hemolytic units

C-reactive protein of 0.9 mg/L

Which symptoms are consistent with a chronic inflammatory disorder?

Redness, swelling, and pain to the ankle while playing basketball

Pain and fever from a streptococcal sore throat

Pain and swelling of the knees from arthritis

Discomfort from a strained back muscle

Which patient has the most risk factors for developing an infection?

46-year-old recovering from elective noninvasive surgery

30-year-old with newly diagnosed early eating disorder

70-year-old with diabetes and an indwelling urinary catheter

50-year-old smoker who is receiving an intravenous antibiotic

Which finding would lead the nurse to conclude that a patient’s surgical incision that was inflamed is now infected?

Greenish drainage

Warm to the touch

Swelling at the edges

Slightly red color

Which manifestations indicate systemic infection and warrant further patient assessment?

Select all that apply.

• Blood pressure of 164/104 mm Hg

• Temperature 101.3°F (38.5°C) orally

• Heart rate 122 beats/min

• Respiratory rate 16 breaths/min

• Skin warm to touch and moist

A nurse is instructing a patient who has decreased leg strength on the left side on how to use a cane. Which actions indicate proper cane use by the patient? (Select all that apply.)

1. The patient keeps the cane on the left side of the body.

2. The patient slightly leans to one side while walking.

3. The patient keeps two points of support on the floor at all times.

4. After the patient places the cane forward, the patient then moves the right leg forward to the cane.

5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step.

A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a one-person assist in the hospital before transfer. The patient has a history of hypertension. His wife accompanies him at the time of transfer. Which of the following assessment data would you collect for this patient? (Select all that apply.)

1. Condition of surgical wound

2. Patient’s expectations of rehabilitation

3. Previous hospitalization experience

4. Vital signs

5. Ability to sit on side of bed unassisted

6. Gait and balance

7. History of recent weight changes

8. Social support from wife

A patient comes to an urgent care clinic with reports of pain in the right lower calf and ankle after participating in a 5K run. Which of the following assessment questions will determine the effects exercise has had on this patient?

1. Tell me specifically when your pain began.

2. Describe for me the pain you are having.

3. In what way has your daily activity changed since you noticed your pain?

4. How long have you been having the pain?

The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?

1. Increase the patient’s risk for falls and injuries

2. Result in less stress on the patient’s joints

3. Decrease the amount of work required for patient movement

4. Allow for mobility in spite of the aging effects on the patient’s joints

Place the following steps in the correct order to show how to transfer a patient with partial weight bearing and sufficient upper body strength to a chair.

1. Spread your feet apart. Flex hips and knees, aligning knees with patient’s knees.

2. Instruct patient to use armrests on chair for support and ease into chair.

3. Apply gait belt.

4. Flex hips and knees while lowering patient into chair.

5. Pivot on foot farthest from chair.

6. Hold the gait belt with both hands and fingers pointing up.

7. Maintain stability of patient’s weaker leg with your knee if needed.

8. Rock patient up to standing position on count of three while straightening hips and legs.

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

1. Patient’s weight

2. Patient’s activity tolerance

3. Patient’s level of mobility

4. Recent laboratory values

5. Nutritional intake

6. Safe mobility algorithm

Which of the following indicates that additional assistance is needed to transfer a patient from the bed to the stretcher? (Select all that apply.)

1. The patient is 167.6 cm (5 feet 6 inches) and weighs 54.5 kg (120 lb).

2. The patient speaks and understands English.

3. The patient is returning to the unit from the recovery room after a procedure requiring conscious sedation.

4. The patient has a history of being able to stand independently.

5. The patient received analgesia for pain 30 minutes ago.

Which of the following is the proper sequence for a four-point crutch gait?

A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? (Select all that apply.)

1. Move more and sit less throughout the day.

2. Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity.

3. Perform muscle-strengthening activities using light weights on 2 or more days a week.

4. Walk at a vigorous pace with wife at least 150 minutes over five days a week.

5. Focus on balance training.

Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)

1. A walker is useful for patients who have impaired balance.

2. The patient uses a walker by pushing the device forward.

3. Leaning over the walker improves the patient’s balance.

4. Walkers should not be used on stairs.

5. If the patient has difficulty advancing the walker, a walker with wheels is an option.

Which action by the nurse initiates the physical assessment of a patient’s mobility?

Inquiring about the patient’s health history

Asking the patient questions

Observing the patient

Palpating the patient’s joints

Which patient finding would alert the nurse to stop passive range-of-motion exercises?

Resistance to movement is felt.

The patient is unable to participate.

The patient’s joints move freely.

Atrophy occurs.

Which finding would be unexpected when the nurse is assessing for mobility issues?

Joint crepitus

Morse Fall Scale score of 18

Braden Scale score of 22

Straight posture

Patient reports of shortness of breath and fatigue while performing activities of daily living are indicative of which alteration?

Orthostatic hypotension

Deep vein thrombosis

Activity intolerance

Cerebellar problems

Which nutritional alteration is associated with immobility?

Enhanced appetite

Positive nitrogen balance

Decreased basal metabolic rate

Increased serum albumin levels

Which interpretation would the nurse make when observing a darkened or reddened area of skin in an immobile patient?

Tissue ischemia has occurred.

Blanching has developed.

Cyanosis has occurred.

Deep vein thrombosis has developed.

A patient with redness, warmth, and swelling in the right lower leg is at risk for which complication?

Joint damage

Pulmonary embolism

Orthostatic hypotension

Pathologic bone fractures

Which response would the nurse make to an immobile patient who says, “I am just not hungry. I don’t understand it. I am always hungry”?

“Don’t worry about it, every patient gets that way in the hospital.”

“Your loss of appetite is unusual; I will let your health care provider know.”

“You have been immobile for several days, which can decrease your metabolism and appetite.”

“Your lack of appetite is your body’s way of telling you that bed rest interferes with your body’s ability to digest food and not to eat too much.”

Which movement is the nurse assessing in the image?

Lateral flexion

Outward and inward rotation

Adduction and abduction

Flexion and extension

Which fall risk score would the nurse anticipate in a patient who is weak?

Hendrich II Fall Risk Model score of 8

Morse Fall Scale score of 10

Braden Scale score of 22

Johns Hopkins Fall Risk Assessment Tool score of 5

Which graphic record cue is associated with constipation?

Fever

Soft stools

90% of meals eaten

Infrequent stools

Which musculoskeletal alterations does immobility predispose a patient to developing?

Select all that apply.

• Weakness

• Decreased muscle tone

• Decreased muscle mass

• Increased bone mass

• Reduced bone density

Patients on bed rest are likely at risk for which physiologic effects and conditions?

Select all that apply.

• Increased venous return

• Decreased lung expansion

• Decreased cardiac workload

• Atelectasis

• Pneumonia

Which changes in vital signs are indicative of postural hypotension when a patient stands up?

Select all that apply.

• Heart rate increases from 60 to 70 beats/min

• Systolic blood pressure drops from 120 to 100 mm Hg

• Heart rate increases from 65 to 85 beats/min

• Systolic blood pressure drops from 110 to 100 mm Hg

• Diastolic blood pressure drops from 70 to 60 mm Hg

Which parameters would the nurse assess to determine if a urinary tract infection (UTI) has developed?

Select all that apply.

• Peripheral pulses

• Chills

• Urinary frequency

• Serum albumin levels

• Presence of dysuria

Which cues would likely occur with atelectasis?

Select all that apply.

• Cyanosis

• Dyspnea

• Chills

• Graphic record indicates a fever

• Diminished breath sounds noted in nurse’s notes

Match the alteration to its patient cues.

1. Unable to move joints because of foot drop

2. Decreased muscle size with weak handgrip

3. Inability to move, with a loss of sensation

4. Irregular patterns of behavior from inadequate coping

Paralysis

Muscle atrophy

Contracture

Fracture

Isolation

Altered self-concept

Match the pressure injury stage to its cues. (stages 1-4)

Blistering of epidermis or dermis

Intact skin with reddened area

Exposure of muscle and bone

Subcutaneous injury with possible tunneling

A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication?

1. Logging on to AMDS or unlocking medicine drawer or cart.

2. Before going to patient’s room, comparing patient’s name and name of medication on label of prepared drugs with MAR.

3. Selecting correct medication from ADMS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout.

4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient’s bedside.

The health care provider has written the following orders. Which order(s) does the nurse need to clarify before administering the medication? (Select all that apply.)

1. Timoptic .25% solution 1 drop OD BID

2. Metoprolol 12.50 mg QD

3. Insulin Glargine 6 u SC twice a day

4. Enalapril 2.5 mg. PO 3 times a day, hold for systolic blood pressure < 100

An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What actions should the nurse take to help the older adult patient? (Select all that apply.)

1. Provide a dispensing system for each day of the week.

2. Provide larger, easier-to-read labels.

3. Tell the patient what is in each container.

4. Have a family caregiver administer the medication.

5. Use teach-back to ensure that the patient knows what medication to take and when.

Which of the following guidelines must a nurse use for taking verbal or telephone orders? (Select all that apply).

1. Follow the health care agency guidelines regarding authorized staff who may receive and record verbal or telephone orders.

2. Clearly identify patient’s name, room number, and diagnosis.

3. Read back all orders to health care provider.

4. Use clarification questions to avoid misunderstandings.

5. Write “VO” (verbal order) or “TO” (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Which aspects of the patient’s care related to the administration of heparin can the nurse delegate to the nursing AP? (Select all that apply):

1. Notify the nurse if there are any signs of bleeding.

2. Assess the vital signs for possible symptoms of bleeding.

3. Assess bleeding sites and apply appropriate pressure to the sites.

4. Notify the nurse if there is blood noted in the patient’s urine.

5. Notify the nurse if there is oozing from any puncture sites.

The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through IV tubing. Place the following steps in the appropriate order.

1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration.

2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy.

3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate.

4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port.

5. Clean injection port with antiseptic swab. Allow to dry.

6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

A nurse is administering an MDI with a spacer to a patient with COPD. Place the steps of the procedure in the correct order.

1. Insert MDI into end of spacer.

2. Perform a respiratory assessment.

3. Remove mouthpiece from MDI and spacer device.

4. Place the spacer mouthpiece into patient’s mouth and instruct patient to close lips around the mouthpiece.

5. Depress medication canister, spraying 1 puff into spacer device.

6. Shake inhaler for 2 to 5 seconds.

7. Instruct patient to hold breath for 10 seconds.

8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.

A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.)

1. Verifying tube placement after medications are given

2. Mixing all medications together to give all at once

3. Using an enteral tube syringe to administer medications

4. Flushing tube with 30 to 60 mL of water after the last dose of medication

5. Checking for gastric residual before giving the medications

6. Keeping the head of the bed elevated for 30 to 60 minutes after the medications are given

Place the steps of administering an intradermal injection in the correct order.

1. Inject medication slowly.

2. Note the presence of a bleb.

3. Advance needle through epidermis to 3 mm.

4. Using non-dominant hand, stretch skin over site with forefinger.

5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt.

6. Cleanse site with antiseptic swab.

After receiving an IM injection in the deltoid, a patient states, “My arm really hurts. It’s burning and tingling where I got my injection.” What should the nurse do next? (Select all that apply.)

1. Assess the injection site.

2. Administer an oral medication for pain.

3. Notify the patient’s health care provider of assessment findings.

4. Document assessment findings and related interventions in the patient’s medical record.

5. This is a normal finding, so nothing needs to be done.

6. Apply ice to the site for relief of burning pain.

A patient has been hospitalized with a serious flulike infection and is on bed rest. He is receiving multiple medications through two different IV infusions and is on high-flow oxygen therapy by oxygen mask. Currently the patient’s head of bed is elevated to semi-Fowler position. The patient initiates little movement and responds only to being shaken. Vitals signs are temperature, 38.6°C (101.6°F); heart rate, 88 beats/min; blood pressure 140/84 mm Hg; and respirations, 20. Which of the following assessment findings suggest that the patient has a risk for an immobility complication? (Select all that apply.)

1. High-flow oxygen therapy by mask

2. Positioned semi-Fowler

3. Temperature 38.6°C (101.6°F)

4. Receiving multiple medications

5. Initiates little movement

6. Reduced conscious response

7. Bed rest

A nurse is caring for a patient who was in an auto accident and has entered rehab after a 6-day hospitalization. The patient had multiple internal injuries and has nursing diagnoses of Hopelessness and Impaired Mobility at time of discharge. The nurse’s assessment revealed the patient asking nurses to let him stay in bed and the patient having limited involvement in hygiene and a loss of appetite. The patient has a cast on his non-dominant left hand and has reduced movement in the right lower leg, which is splinted. The health care provider has ordered the patient to ambulate 3 times a day. Which of the following is a priority for the rehab nurse?

1. Providing assistance with meals

2. Teaching patient exercises to strengthen right leg

3. Making preferred hygiene products available to the patient to use

4. Setting times to discuss relationship of hopelessness to injuries

A patient has been on bed rest for over 5 days. Which of these findings during the nurse’s assessment may indicate a complication of immobility?

1. Decreased peristalsis

2. Decreased heart rate

3. Increased blood pressure

4. Increased urinary output

Place the following steps in the correct order for repositioning a patient in the 30-degree lateral side-lying position using two nurses.

1. Using knee and hip for leverage, nurse rolls patient onto side.

2. Nurse facing patient’s back places hands under patient’s dependent shoulder and brings shoulder blade forward.

3. Place pillows under semiflexed upper leg level at hip from groin to foot.

4. Flex patient’s knee that will not be next to mattress, after being turned. Keep foot on mattress. Nurse places one hand on patient’s upper bent leg.

5. Place hands under dependent hip and bring hip slightly forward so angle from hip to mattress is approximately 30 degrees.

6. Position patient on side of bed in opposite direction toward which patient is to be turned, then move upper and lower trunk.

7. Lower head of bed completely or as low as patient can tolerate. One nurse on each side of bed.

The effects of immobility on the cardiac system include which of the following? (Select all that apply.)

1. Thrombus formation

2. Increased cardiac workload

3. Weak peripheral pulses

4. Irregular heartbeat

5. Orthostatic hypotension

A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and placed in an immobilization device to limit further injury until the fracture can safely be repaired. Which measures are appropriate for this patient to prevent complications of bed rest? (Select all that apply.)

1. Administer IV analgesic as ordered.

2. Have patient perform incentive spirometry.

3. Support patient in active assisted ROM exercises of upper extremities.

4. Provide patient a low-calorie diet.

5. Apply SCDs to legs

A patient has an order for application of compression stockings. Place the following steps for application of the compression stockings in the correct order:

1. Place patient’s toes into foot of stocking up to the heel; keep smooth.

2. Use tape measure to measure patient’s leg for proper stocking size.

3. Slide stocking up over patient’s calf until sock is completely extended.

4. Turn elastic stocking inside out, keeping hand inside holding heel. Take other hand and pull stocking inside out until reaching the heel.

5. Slide remaining portion of stocking over patient’s foot, covering toes. Be sure foot fits into toe and heel of stocking.

An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply.)

1. Patient’s usual exercise pattern at home

2. Time and date of the patient’s last bowel movement

3. Preadmission activity tolerance

4. Baseline heart rate and blood pressure

5. Patient’s home living situation

A nurse is helping a patient perform active assisted ROM in the right elbow. Which statement describes the correct technique?

1. Support elbow by holding distal part of extremity.

2. Grasp joint with fingers to provide support.

3. Have patient move joint independently.

4. Move the joint past the point of resistance.

5. Perform the exercise three times during the session, and gradually build up to more.

A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply.)

1. Oxygen saturation of 89%

2. Irregular radial pulse

3. Diminished breath sounds in bilateral bases of lungs

4. Blood pressure 132/84 mm Hg

5. Pain reported at 3 on scale of 0 to 10 following medication

6. Respiratory rate of 26

The nurse is caring for a 72-year-old patient who is on bed rest after hip surgery for an injury sustained from a fall at home. The patient has a history of diabetes and ongoing dementia. Upon assessment, the nurse notes an intravenous (IV) infusion, a nasogastric tube, and a urinary drainage catheter. According to the Morse Fall Scale, what is the patient’s total score?

The nurse is asking the patient a series of questions about the patient’s activities of daily living. The patient asks the nurse why that information is important. Which nursing response is appropriate?

“The answers to these questions will help us determine if you need any assistance at home.”

“This information will help your health care provider determine if you need to be placed in a skilled nursing facility.”

“The questions are designed to get you to think about going home from the hospital.”

“This is part of our regular patient assessment form that we must complete.”

A patient is on a large number of medications, and the nurse is concerned about the patient’s personal ability to manage taking all the medications at home. Which questions would the nurse ask to assess the patient’s potential safety risk?

Select all that apply.

• “Do you take your medications consistently?”

• “Do any young children live in the home who know about your medications?”

• “Do you know how to take these prescriptions?”

• “Do you know when to take your drugs?”

• “Do you know why the health care provider has prescribed these medications?”

A patient with paraplegia is being prepared for discharge from a spinal cord rehabilitation unit. Which question is most important for the nurse to ask when performing a home safety assessment?

“Do you have a carbon monoxide detector?”

“Do you have a plan to exit the home in case of an emergency?”

“Where are your medications stored?”

“Do you have a fire extinguisher?”