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Fscj Nursing Term I Pharma Ch 1 – Flashcards

Patricia Harrah

7 July 2022

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question

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colon-rectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A) The family comes to visit the patient. B) The patient expresses concern about pain control. C) The patient's vital signs change, showing a drop in blood pressure. D) The charge nurse approaches the nurse and requests a report at end of shift.

answer

B) The patient expresses concern about pain control. C) The patient's vital signs change, showing a drop in blood pressure. Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.

question

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? A) Reconnect the drainage tubing B) Inspect the condition of the IV dressing C) Improve the patient's comfort and turn onto her side. D) Obtain the next IV fluid bag from the medication room

answer

A) Reconnect the drainage tubing The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.

question

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) A) Patient will be turned every 2 hours within 24 hours. B) Patient will have normal bowel function within 72 hours. C) Patient's skin will remain intact through discharge. D) Patient's skin condition will improve by discharge.

answer

B) Patient will have normal bowel function within 72 hours. C) Patient's skin will remain intact through discharge. The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.

question

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? A) Patient will explain relationship of insulin to blood glucose control. B) Patient will self-administer insulin. C) Patient will achieve glucose control. D) Patient will describe steps for preparing insulin in a syringe.

answer

C) Patient will achieve glucose control. It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.

question

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) A) Goal within reach of the patient B) The nurse's own competency in teaching about insulin C) The patient's cognitive function D) Availability of family members to assist

answer

A) Goal within reach of the patient C) The patient's cognitive function D) Availability of family members to assist A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.

question

The nurse writes an expected-outcome statement in measurable terms. An example is: A) Patient will be pain free. B) Patient will have less pain. C) Patient will take pain medication every 4 hours. D) Patient will report pain acuity less than 4 on a scale of 0 to 10

answer

D) Patient will report pain acuity less than 4 on a scale of 0 to 10. Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal; the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.

question

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? A) Provide frequent mouth care. B) Maintain intravenous (IV) infusion at 100 mL/hr. C) Administer prochlorperazine (Compazine) via rectal suppository. D) Consult with dietitian on initial foods to offer patient. E) Control aversive odors or unpleasant visual stimulation that triggers nausea.

answer

D) Consult with dietitian on initial foods to offer patient. Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.

question

A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient: Nursing Diagnoses 1. Impaired gas exchange _____ 2. Risk for activity intolerance _____ 3. Ineffective self-health management _____ Priority Level a. Long term b. Short term c. Intermediate

answer

1b, 2c, 3a. The patient's oxygenation status is the priority in this situation. The patient's condition creates the risk for activity intolerance, making this an intermediate priority for which the nurse must monitor. Ineffective self-help management is a long-term goal that might be applicable if the patient has physical limitations at the time of discharge.

question

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals 1. Patient will ambulate independently in 3 days. _____ 2. Patient will be injury free for 1 month. _____ 3. Patient will be less agitated. _____ 4. Patient will achieve pain relief. _____ Outcomes a. Patient will express fewer nonverbal signs of discomfort. b. Patient will follow a set care routine. c. Patient will walk correctly using a walker. d. Patient will exit a low bed without falling.

answer

1c, 2d, 3b, 4a

question

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? A) This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening. B) The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care. C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. D) The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.

answer

C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. Creating a culture of blame does not support questioning, which is needed for good handoff communication. Talking about the patient's anxiety during handoff is patient centered and thus appropriate, referring to the EHR to review interventions ensures that essential information is included, and administering a pain medication before the report allows the nurse to be organized and uninterrupted during rounds.

question

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) A) Patient will eat at least three fourths of each meal by 1 week. B) Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C) Patient will eat foods with high-calorie content by 1 week. D) Give patient liquid supplements 3 times a day

answer

B) Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. D) Give patient liquid supplements 3 times a day. The statement "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" is not singular. The statement "Give patient liquid supplements 3 times a day" is an intervention.

question

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? A) The goals of care will always be more long term. B) The patient and family need to be able to independently provide most of the health care. C) The patient's goals need to be mutually set with family members who will care for him or her. D) The expected outcomes need to address what can be influenced by interventions.

answer

B) The patient and family need to be able to independently provide most of the health care. A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term; goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect; the outcomes allow you to direct your evaluation of care.

question

Which outcome allows you to measure a patient's response to care more precisely? A) The patient's wound will appear normal within 3 days. B) The patient's wound will have less drainage within 72 hours. C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. D) The patient's wound will heal without redness or drainage by day 4.

answer

C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.

question

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) A) Turn the patient regularly from side to back to side. B) Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. C) Apply a pressure-relief device to bed. D) Apply transparent dressing to sacral pressure ulcer.

answer

A) Turn the patient regularly from side to back to side. C) Apply a pressure-relief device to bed. The statements "Turn the patient regularly from side to back to side" and "Apply a pressure-relief device to bed" do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.

question

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply.) A) The application of the skin barrier is a dependent care measure. B) The call to the ostomy and wound care specialist is an indirect care measure. C) The cleansing of the skin is a direct care measure. D) The application of the skin barrier is a direct care measure.

answer

B) The call to the ostomy and wound care specialist is an indirect care measure. C) The cleansing of the skin is a direct care measure. D) The application of the skin barrier is a direct care measure. The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.

question

During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in the correct order: A) Review the care plan. B) Decide if the nursing interventions remain appropriate. C) Reassess the patient. D) Compare assessment findings to validate existing nursing diagnoses.

answer

C, A, D, B After reassessing a patient, the nurse reviews the care plan and compares assessment data to validate the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, the nurse modifies the nursing care plan.

question

A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: A) Have the nurse colleague check the dose with her before giving the medication. B) Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. C) Ask the nurse colleague to administer the medication to her patient. D) Administer the medication as prescribed and on time.

answer

B) Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. When a nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse's best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.

question

When does implementation begin as the fourth step of the nursing process? A) During the assessment phase B) Immediately in some critical situations C) After the care plan has been developed D) After there is mutual goal setting between nurse and patient

answer

C) After the care plan has been developed Implementation begins after the nurse has developed the plan of care. Even in emergent situations a nurse assesses a situation quickly, considers options, and then implements nursing measures. Goal setting is part of planning.

question

Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A) Cognitive B) Interpersonal C) Psychomotor D) Consultative

answer

A) Cognitive Thinking and anticipating how to approach implementation involve a cognitive implementation skill. The nurse considers the rationale for an intervention and evidence in nursing science that supports that intervention or alternatives.

question

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? A) Meeting the patient's expressed wishes B) Indirect care measure C) Protecting a patient from injury D) Staying organized when implementing a procedure

answer

C) Protecting a patient from injury A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse's action. Although meeting patient needs is important, it is not a physical care technique.

question

In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) A) Following the procedural guideline for IV insertion B) Seeking necessary knowledge about the steps of the procedure from a more experienced nurse C) Showing confidence in performing the correct IV insertion technique D) Being sure that the IV dressing covers the IV site completely

answer

B) Seeking necessary knowledge about the steps of the procedure from a more experienced nurse C) Showing confidence in performing the correct IV insertion technique Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.

question

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) A) Seeks necessary knowledge B) Reassesses the patient's condition C) Collects all necessary equipment D) Delegates the procedure to a more experienced staff member E) Considers all possible consequences of the procedure

answer

A) Seeks necessary knowledge C) Collects all necessary equipment E) Considers all possible consequences of the procedure You require additional knowledge and skills in situations in which you are less experienced. When you are asked to administer a new procedure with which you are unfamiliar, follow the three choices: seek necessary knowledge, collect necessary equipment, and consider all possible consequences of the procedure. Collecting necessary equipment and considering potential consequences is needed for any procedure.

question

For each of the following interventions, note which are direct and which are indirect nursing interventions. Place a D for direct or I for indirect in the space provided. 1. A nurse checks the monthly performance improvement report on fall occurrences on a unit. _______________ 2. A nurse discusses with the patient exercise restrictions to follow on return home. _______________ 3. A nurse consults with a dietitian about a patient's therapeutic diet food choices. _______________ 4. A nurse administers a tube feeding. _______________ 5. A nurse assists a colleague in applying a complex dressing to a patient's wound. _______________

answer

1 (I), 2 (D), 3 (I), 4 (D), 5 (D). Direct activities are those that nurses perform through patient interactions. Indirect care measures include nurse actions aimed at management of the patient care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions.

question

A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? A) Tertiary B) Direct care C) Primary D) Secondary

answer

C) Primary An immunization is an example of a primary prevention aimed at health promotion.

question

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? A) Standing orders are used to meet our physician's preferences. B) Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. C) Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. D) Standing orders minimize the documentation we have to provide.

answer

C) Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. Standing orders are preprinted documents containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. They are common in critical care settings and other specialized practice settings in which patients' needs change rapidly and require immediate attention.

question

A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the following steps in their proper order: A) The nurse revises approaches in the plan for controlling environmental factors that worsen nausea. B) The nurse enters data in the assessment column showing new information about the patient's nausea. C) The nurse adds the current date to show that the diagnosis of nausea is still relevant. D) The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures.

answer

B) The nurse enters data in the assessment column showing new information about the patient's nausea. C) The nurse adds the current date to show that the diagnosis of nausea is still relevant. D) The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures.

question

When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? A) Interpersonal B) Cognitive C) Collaborative D) Psychomotor

answer

D) Psychomotor Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.

question

The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? A) Preventive B) Controlling for an adverse reaction C) Consulting D) Counseling

answer

B) Controlling for an adverse reaction Anticipating the need to start the feeding at a slower rate is an example of controlling for an adverse reaction, which in this case would be a harmful or unintended effect (diarrhea) of therapeutic intervention.

question

A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.) A) Review the set of all possible nursing interventions for the patient's problem B) Review all possible consequences associated with each possible nursing action C) Consider own level of competency D) Determine the probability of all possible consequences

answer

A) Review the set of all possible nursing interventions for the patient's problem B) Review all possible consequences associated with each possible nursing action D) Determine the probability of all possible consequences When making decisions about implementation, reviewing all possible interventions and consequences and determining the probability of consequences are necessary steps. The nurse is responsible for having the necessary knowledge and clinical competency to perform an intervention, but this is not part of the decision making involved.

question

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? A) Suctioning the airway B) Sitting patient up in bed C) Auscultating lung sounds D) Patient describing type of discomfort

answer

C) Auscultating lung sounds Auscultation was the measure used to determine if the suctioning of the airway was effective. Suctioning and sitting the patient up are interventions. The nurse did not ask the patient or evaluate the nature of the pain.

question

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.) A) Patient drinks contents of water glass. B) Patient's lungs are clear to auscultation in bases. C) Patient reports abdominal pain on scale of 0 to 10. D) Patient's rate and depth of breathing are normal with head of bed elevated.

answer

B) Patient's lungs are clear to auscultation in bases. D) Patient's rate and depth of breathing are normal with head of bed elevated. The criteria of clear lung sounds and rate and depth of breathing are evaluative criteria for determining if the patient's airway is clear. Drinking the contents of the water glass is a completed intervention. The patient's report of pain is assessment data.

question

The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? A) Evaluating the patient's response to selected nursing interventions B) Selecting an observable or measurable state or behavior that reflects goal achievement C) Reviewing the patient's nursing diagnoses and establishing goals and outcome statements D) Matching the results of evaluative measures with expected outcomes to determine patient's status

answer

D) Matching the results of evaluative measures with expected outcomes to determine patient's status When interpreting findings, you compare the patient's behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.

question

A goal specifies the expected behavior or response that indicates: A) The specific nursing action was completed. B) The validation of the nurse's physical assessment. C) The nurse has made the correct nursing diagnoses. D) Resolution of a nursing diagnosis or maintenance of a healthy state.

answer

D) Resolution of a nursing diagnosis or maintenance of a healthy state. The success in meeting a goal is reflected in achieving expected outcomes—the physiological responses or behaviors that indicate that a nursing diagnosis has been resolved and the patient's health is improving.

question

A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? A) Patient will remain afebrile to discharge. B) Patient's wound will remain free of infection by discharge. C) Patient will receive ordered antibiotic on time over next 3 days. D) Patient's abdominal incision will be covered with a sterile dressing for 2 days.

answer

B) Patient's wound will remain free of infection by discharge. When selecting an at-risk diagnosis, the goal is to avoid or prevent the condition at risk, in this case infection. The statement "Patient will remain afebrile to discharge" is a potential outcome measure for the goal. The patient receiving an ordered antibiotic and having the abdominal incision covered are both interventions.

question

Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) A) Redefine priorities B) Continue intervention C) Discontinue care plan D) Gather assessment data on a different nursing diagnosis E) Compare the patient's response with that of another patient

answer

A) Redefine priorities B) Continue intervention When you determine that a goal has not been met or has been met only partially, intervention must continue; and the fact that the health problem still exists suggests that priorities may need to be redefined. You do not discontinue a plan unless a goal has been achieved. Evaluation never involves comparing a patient's data with that of another patient. A patient may develop new diagnoses at any time, but assessment of a new diagnosis does not address goals for an existing diagnosis.

question

A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply.) A) The patient eats 2000 calories a day. B) The patient is weighed during each clinic visit. C) The patient discusses factors that increase the risk of an asthma attack. D) The patient's food diary that tracks intake of daily meals is reviewed.

answer

B) The patient is weighed during each clinic visit. D) The patient's food diary that tracks intake of daily meals is reviewed. Weighing the patient during each clinic visit and reviewing a food diary indicate whether weight loss is occurring and if the patient is eating the proper foods designed to reduce his or her weight.

question

The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. 1. The nurse judges the extent to which the condition of the skin matches the outcome criteria. 2. The nurse tries to determine why the outcome criteria and actual condition of skin do not agree. 3. The nurse inspects the condition of the skin. 4. The nurse reviews the outcome criteria to identify the desired skin condition. 5. The nurse compares the degree of agreement between desired and actual condition of the skin.

answer

4, 3, 5, 1, 2

question

The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply.) A) Checked the IV infusion location in left arm B) Checked the type of IV solution C) Confirmed from nurses' notes the time of dressing change and checked label D) Inspected the condition of the IV dressing

answer

C) Confirmed from nurses' notes the time of dressing change and checked label D) Inspected the condition of the IV dressing The evaluation of interventions examines two factors: the appropriateness of the interventions selected (whether the IV dressing was changed as the standard of care requires) and the correct application of the intervention (whether the dressing was in place and secure). Checking the IV infusion location in the left arm is an evaluation measure, and checking the type of IV solution is an assessment step to ensure that correct fluid is infusing.

question

Which of the following statements correctly describe the evaluation process? (Select all that apply.) A) Evaluation is an ongoing process. B) Evaluation usually reveals obvious changes in patients. C) Evaluation involves making clinical decisions. D) Evaluation requires the use of assessment skills.

answer

A) Evaluation is an ongoing process. C) Evaluation involves making clinical decisions. D) Evaluation requires the use of assessment skills. Evaluation often reveals changes that are not obvious. Changes are often subtle and occur over a period of time.

question

A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of imbalanced nutrition: less than body requirements related to reduced intake of food. For the goal of, "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply.) A) Patient will discuss source of depression by next clinic visit. B) Patient will achieve a calorie intake of 2400 daily in 2 weeks. C) Patient will report improvement in appetite in 1 week. D) Patient will identify food protein sources.

answer

B) Patient will achieve a calorie intake of 2400 daily in 2 weeks. C) Patient will report improvement in appetite in 1 week. With the related factor of reduced intake of food, the outcomes should focus on behaviors that reflect an increase in intake. Thus achieving an increase in calories and an improved appetite for food would be appropriate. The patient's depression probably contributes to the loss of appetite, but being able to discuss the source of depression is not an outcome for improving her baseline weight. Being able to identify protein sources would improve any knowledge deficit the patient might have but would not help her gain weight.

question

A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of: A) Evaluative measure. B) Expected outcome. C) Reassessment. D) Standard of care.

answer

B) Expected outcome. An expected outcome is an end result that is measureable, desirable, observable, and translates into observable patient behaviors. It is a measure that tells you if the educational interventions led to successful goal achievement, the patient's self-care of the wound. An evaluative measure would be the process of observing the patient. Reassessment is a behavior performed by the nurse. The type of wound cleanser and dressings would be a standard of care.

question

A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? A) Uses walker during ambulation B) Presence of altered balance C) Limited mobility in lower extremities D) Observation of distance patient is able to walk

answer

D) Observation of distance patient is able to walk An evaluative measure determines a patient's response to therapy, in this case how well the patient is able to ambulate (distance walked).

question

A patient is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? A) Patient expresses acceptance of health status by day of discharge. B) Patient's surgical wound will remain free of infection. C) Patient's IV site will remain free of phlebitis. D) Patient understands when to call physician to report possible complications.

answer

C) Patient's IV site will remain free of phlebitis. To achieve the goal of preventing phlebitis the nurse evaluates for signs of phlebitis, which include redness or inflammation. The outcome for this goal would be stated as, "IV site will show no signs of inflammation to discharge."

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A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. A nursing-sensitive outcome suitable for this diagnosis would be: A) Patient will achieve pain relief by discharge. B) Patient will be free of a surgical wound infection by discharge. C) Patient will report reduced pain severity in 2 days. D) Patient will describe purpose of pain medicine by discharge.

answer

C) Patient will report reduced pain severity in 2 days. An example of a nursing-sensitive outcome is one that is influenced and sensitive to nursing interventions. Such is the case with "reduction in pain severity." The patient achieving pain relief by discharge is a goal. The patient being free of a surgical wound infection by discharge is a medical outcome. The patient describing the purpose of pain medication by discharge is an outcome for a knowledge problem but not for the diagnosis of acute pain.

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The nurse is having difficulty reading a physician's order for a medication. He or she knows that the physician is very busy and does not like to be called. What is the most appropriate next step for the nurse to take? A) Call a pharmacist to interpret the order B) Call the physician to have the order clarified C) Consult the unit manager to help interpret the order D) Ask the unit secretary to interpret the physician's handwriting

answer

B) Call the physician to have the order clarified You must have the right documentation and clarify all orders with the prescriber before administering medications.

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The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her? A) 2 mL B) 5 mL C) 16 mL D) 30 mL

answer

D) 30 mL 1 tablespoon = 15 mL; 2 tablespoons = 30 mL.

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A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient's ear when administering the medication? A) Outward B) Back C) Upward and back D) Upward and outward

answer

D) Upward and outward Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.

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A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 250-mg tablets. How many tablets does the nurse administer? A) ½ tablet B) 1 tablet C) 1 ½ tablets D) 2 tablets

answer

D) 2 tablets Using dimensional analysis: Tablets = 1tablet/250 mg× 500 mg = 500/250 = 2 tablets.

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A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, "I don't remember my child having that medication before." What is the nurse's next action? A) Give the medications B) Identify the patient using two patient identifiers C) Withhold the medications and verify the medication orders D) Provide medication education to the mother to help her better understand her child's medications

answer

C) Withhold the medications and verify the medication orders Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.

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A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse? A) Set up the follow-up appointments with the physician for the patient. B) Ensure that someone will provide housekeeping for the patient at home. C) Ensure that the home care agency is aware of medication and health teaching needs. D) Make sure that the patient's family knows how to safely bathe him or her and provide mouth care.

answer

C) Ensure that the home care agency is aware of medication and health teaching needs. A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.

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A basic concept of pharmacology that the nurse must understand is how the drug influences cell physiology. What is the term for this concept? A) a. Pharmacokinetics B) b. Pharmacotherapeutics C) c. Pharmacodynamics D) d. Pharmacology

answer

C) c. Pharmacodynamics Pharmacodynamics refers to what the drug does to the body; that is, how it influences cellular physiology. Pharmacokinetics is the study of what the body does to the drug. Pharmacotherapeutics refers to the study of the therapeutic use of drugs. Pharmacology is the study of drugs.

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Which statement best indicates that the nurse understands the meaning of pharmacokinetics? A) a. "It involves the study of physiologic interactions of drugs." B) b. "It explains the distribution of the drug between various body compartments." C) c. "It explains interactions between various drugs." D) d. "It explains the adverse reactions to drugs."

answer

B) b. "It explains the distribution of the drug between various body compartments." Pharmacokinetics involves the study of how the drug moves through the body, including absorption, distribution, metabolism, and excretion.

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The pharmacist states that the client's biotransformation of a drug was altered. What does the nurse realize has affected the drug? A) a. Absorption B) b. Dilution C) c. Excretion D) d. Metabolism

answer

D) d. Metabolism Metabolism connotes a breakdown of a product. Biotransformation is actually a more accurate term because some drugs are actually changed into an active form in the liver in contrast to being broken down for excretion. a. Biotransformation of a drug does not occur during absorption. b. Biotransformation of a drug does not occur with dilution. c. Biotransformation of a drug does not occur during excretion.

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The nurse realizes that a drug administered by this route will require the most immediate evaluation of therapeutic effect. A) a. Intravenous B) b. Oral C) c. Subcutaneous D) d. Topical

answer

A) a. Intravenous Intravenous medications are not altered by first pass effect and enter the system quickly. Oral medications are absorbed in the stomach and small intestine, travel through the portal system, and are metabolized by the liver before they reach general circulation. Subcutaneous medications need to be absorbed into the bloodstream before entering the circulation to exert effect. Topical medications need to be absorbed through the skin before entering the blood stream and exerting an effect.

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The nurse reads that the half-life of the medication being administered is 12 hours. What assumption will guide the nurse's care of this client? A) a. This medication will be 50% eliminated in 12 hours, so the dosing will be spread apart. B) b. The medication will be administered every 6 hours to maintain consistent blood levels. C) c. The medication will not work for the first 12 hours. D) d. The client will require two doses of the medication before there is an effect.

answer

A) a. This medication will be 50% eliminated in 12 hours, so the dosing will be spread apart. Half-life refers to the time it takes to excrete a drug from the body. Administering the medication every 6 hours would not be appropriate; it would be too soon. Half-life does not refer to onset of action or to the number of doses in 24 hours.

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Which nursing intervention will best enhance the absorption of an intramuscular injection? A) a. Apply cold packs to the injection site. B) b. Administer in the leg, below the level of the heart. C) c. Administer the medication via the Z-track method. D) d. Massage the site after injection.

answer

D) d. Massage the site after injection. Massaging the site increases circulation to the area and thus increases absorption. Cold will cause vasoconstriction and will not enhance absorption. Administration in the leg and the Z-track method will not enhance absorption.

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A nurse is administering two highly protein-bound drugs. Which is the safest course of action for the nurse to take? A) a. Assess the client frequently for the risk of drug-drug interactions. B) b. Administer the drugs with food. C) c. Administer the drugs with 8 ounces of water. D) d. Assess baseline liver function tests.

answer

A) a. Assess the client frequently for the risk of drug-drug interactions. When administering two drugs that are protein-bound, one of the drugs will have fewer sites to which to bind and thus more drug available for activity, thereby increasing the risk of toxicity. Food or water will not change the outcome of administration. Hepatic function is a concern at this time.

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A client is complaining of pain rated "10" on a scale of 1 to 10. The nurse has several choices of pain medication to administer. Which order is the best for the nurse to administer at this time? A) a. Morphine sulfate 1 mg IV (intravenous) B) b. MS Contin 2 tablets PO (by mouth) C) c. Transdermal patch D) d. Tylenol suppository

answer

A) a. Morphine sulfate 1 mg IV (intravenous) When a drug is administered intravenously, it does not need to be absorbed because it is placed directly into general circulation. The other medications will not have an immediate effect.

question

The nurse is administering medications to a client with chronic renal failure. What is a priority action of the nurse? A) a. Administer all medications via IV route. B) b. Assess drug levels daily. C) c. Assess the client for toxicity to the medications. D) d. Hold medications for low urinary output.

answer

C) c. Assess the client for toxicity to the medications. The kidneys are responsible for the majority of drug excretion. With excretion impaired, the medication can remain in the system longer and there is more chance for toxicity to develop.

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answer

A) a. Evaluation of therapeutic effect Therapeutic effect occurs after the administration of the medication, and the nurse should assess for expected outcomes. Tolerance cannot be assessed by taking postadministration blood pressure. Toxicity cannot be assessed by taking blood pressure after administration. Need is determined before the administration of the drug.

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The nurse understands that there are several mechanisms by which drugs can exert their action on the body, including which mechanisms? (Select all that apply.) A) a. Interacting with specific receptors B) b. Making the cell perform a new function C) c. Inhibiting the action of a specific enzyme D) d. Altering metabolic chemical processes E) e. Nonspecific binding to a macromolecular receptor F) f. Binding with external cells

answer

A) a. Interacting with specific receptors C) c. Inhibiting the action of a specific enzyme D) d. Altering metabolic chemical processes E) e. Nonspecific binding to a macromolecular receptor Drugs cannot make a cell perform a new function, only alter the way it performs its current function. Nonspecific binding to a macromolecular receptor (e.g., general anesthetics) can alter the function of membrane proteins. Drugs do not bind with external cells. The majority of drugs bind to specific receptors on the surface or interior of cells. Drugs may also inhibit the action of a specific enzyme.

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The nurse has administered several oral medications to the client. What factors will influence the absorption of these medications? (Select all that apply.) A) a. Presence of food in the stomach B) b. pH of the stomach C) c. Client position upon intake of medication D) d. Form of drug preparation E) e. Pain F) f. Amount of saliva

answer

A) a. Presence of food in the stomach B) b. pH of the stomach D) d. Form of drug preparation E) e. Pain The presence of food in the stomach usually decreases absorption of drugs but may increase absorption for a few specific medications. The pH of the stomach affects absorption of drugs dependent on the pH of the drug. Alkaline drugs are absorbed more readily in an alkaline environment, and acidic drugs are absorbed more readily in an acidic environment. The form of the drug also affects absorption, with liquid drugs being absorbed the fastest and enteric-coated tablets the slowest. Pain can affect absorption by slowing gastric emptying time. Position will not influence absorption. Amount of saliva will not influence absorption.

question

The client questions a nurse about herbal treatments for arthritic pain. What is the nurse's best response? A) a. "Ginkgo biloba has shown tremendous benefit as an anti-inflammatory agent." B) b. "High doses of vitamins have been used for many years to help maintain joint health." C) c. "There are no safe herbal treatments for pain. Your best action would be to take your prescription medications." D) d. "Glucosamine sulfate with chondroitin has demonstrated promising results in the treatment of joint stiffness and pain. Consult your health care provider."

answer

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While performing an admission interview, which question would be the most appropriate for the nurse to ask in regard to the use of herbal supplements? A) a. "Are you aware that you must stop all herbal supplements before admission to the hospital?" B) b. "Is your physician aware of the herbal supplements you take?" C) c. "What is your opinion about herbal supplements?" D) d. "What supplements do you take, and how often?"

answer

D) d. "What supplements do you take, and how often?" The nurse needs to assess what herbs the client takes, as this may affect the client's treatment or interfere with medications.

question

Which client will the nurse assess first? A) a. The client with a history of cardiac disease who has been taking garlic daily B) b. The client with a history of dementia who is taking gingko biloba C) c. The client scheduled for surgery who is taking dong quai D) d. The client who is nauseous and is taking ginger

answer

C) c. The client scheduled for surgery who is taking dong quai Dong quai increases the risk of bleeding. Garlic will reportedly decrease high cholesterol and may help a client with a cardiac history. Gingko is purported to help clients diagnosed with dementia. Ginger is purported to help decrease the risk of vomiting in nausea.

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A client admitted with angina states "I take dong quai every day, and I don't want to stop." What is the nurse's best response? A) a. "What medications do you currently take?" B) b. "You will not be able to take this medication anymore." C) c. "You will have to discuss this with your health care provider." D) d. "You do not have to stop this supplement; it will help you."

answer

A) a. "What medications do you currently take?" The nurse must first assess to determine if the client's medications may interact with the herbal supplement.

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A nursing student takes a patient's antibiotic to his room. The patient asks the nursing student what it is and why he should take it. Which information does the nursing student include when replying to the patient? A) Only the patient's physician can give this information. B) The student provides the name of the medication and a description of its desired effect. C) Information about medications is confidential and cannot be shared. D) He has to speak with his assigned nurse about this.

answer

B) The student provides the name of the medication and a description of its desired effect. Patients need to know information about their medications so they can take them correctly and safely.

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The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse's next best course of action? A) Ask the prescriber to change the order B) Crush the pill with a mortar and pestle C) Hide the capsule in a piece of solid food D) Open the capsule and sprinkle it over pudding

answer

A) Ask the prescriber to change the order Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.

question

The nurse takes a medication to a patient, and the patient tells him or her to take it away because she is not going to take it. What is the nurse's next action? A) Ask the patient's reason for refusal B) Explain that she must take the medication C) Take the medication away and chart the patient's refusal D) Tell the patient that her physician knows what is best for her

answer

A) Ask the patient's reason for refusal When patients refuse a medication, first ask why they are refusing it.

question

The nurse receives an order to start giving a loop diuretic to a patient to help lower his or her blood pressure. The nurse determines the appropriate route for administering the diuretic according to: A) Hospital policy. B) The prescriber's orders. C) The type of medication ordered. D) The patient's size and muscle mass.

answer

B) The prescriber's orders. The order from the prescriber needs to indicate the route of administration.

question

A patient is receiving an intravenous (IV) push medication. If the drug infiltrates into the outer tissues, the nurse: A) Continues to let the IV run. B) Applies a warm compress to the infiltrated site. C) Stops the administration of the medication and follows agency policy. D) Should not worry about this because vesicant filtration is not a problem.

answer

C) Stops the administration of the medication and follows agency policy. When an IV medication infiltrates, stop giving the medication and follow agency policy.

question

If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects: A) Sepsis. B) Phlebitis. C) Infiltration. D) Fluid overload.

answer

B) Phlebitis. Redness, warmth, and tenderness at the IV site are signs of phlebitis.

question

After seeing a patient, the physician gives a nursing student a verbal order for a new medication. The nursing student first needs to: A) Follow ISMP guidelines for safe medication abbreviations. B) Explain to the physician that the order needs to be given to a registered nurse. C) Write down the order on the patient's order sheet and read it back to the physician. D) Ensure that the six rights of medication administration are followed when giving the medication.

answer

B) Explain to the physician that the order needs to be given to a registered nurse. Nursing students cannot take orders.

question

A nurse accidently gives a patient a medication at the wrong time. The nurse's first priority is to: A) Complete an occurrence report. B) Notify the health care provider. C) Inform the charge nurse of the error. D) Assess the patient for adverse effects.

answer

D) Assess the patient for adverse effects. Patient safety and assessing the patient are priorities when a medication error occurs.

question

A patient is taking albuterol through a pressurized metered dose inhaler (pMDI) that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. How many days will the pMDI last? __________ days

answer

16; Two puffs × 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will not last a total of 17 days,

question

When planning patient education, it is important to remember that patients with which of the following often find relief in complementary therapies? A) Lupus and diabetes B) Ulcers and hepatitis C) Heart disease and pancreatitis D) Chronic back pain and arthritis

answer

D) Chronic back pain and arthritis Evidence supports the use of many complementary therapies for chronic pain syndromes, particularly pain that is unremitting and unresponsive to conventional allopathic therapies.

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Which complementary therapies are most easily learned and applied by the nurse? (Select all that apply.) A) Massage therapy B) Traditional Chinese medicine C) Progressive relaxation D) Breath work and imagery E) Therapeutic touch

answer

C) Progressive relaxation D) Breath work and imagery These were identified as nurse-accessible complementary therapies. Massage therapists are licensed by local governmental agencies, and additional educational preparation is required to practice. Traditional Chinese medicine practitioners also attend training/educational programs, typically accredited by the Accreditation Commission for Acupuncture and Oriental Medicine.

question

Which statement best describes the evidence associated with complementary therapies as a whole? A) Many clinical trials in complementary therapies support their effectiveness in a wide range of clinical problems. B) It is difficult to find funding for studies about complementary therapies. Therefore we should not expect to find evidence supporting its use. C) The science supporting the effectiveness of complementary therapies is early in its development. Systematic reviews of the evidence often indicate beginning support for therapies, but there is a lack of strong evidence supporting their widespread use. D) Most of the research examining complementary and alternative therapies has found little evidence, suggesting that although people like them, they are not effective.

answer

C) The science supporting the effectiveness of complementary therapies is early in its development. Systematic reviews of the evidence often indicate beginning support for therapies, but there is a lack of strong evidence supporting their widespread use. Science in the field is just beginning. Before the 1990s there was little attention in the United States at the National Institutes of Health to support funding for studies about complementary therapies. Most of the evidence cited in systematic reviews throughout this chapter indicates preliminary support for the effectiveness of a variety of complementary therapies. Conditions that appear to be particularly responsive include chronic pain, chronic autoimmune disorders, anxiety, depression, impaired well-being and quality of life that accompany cancer and other chronic conditions, and some time-limited acute illnesses and the symptoms that accompany them (e.g., gastrointestinal disturbances, colds/flus).

question

The nurse understands that providing holistic care includes treating which of the following? A) Disease, spirit, and family interactions B) Desires and emotions of the patient C) Mind-body-spirit of the patient and their families D) Muscles, nerves, and spine disorders

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question

In addition to an adequate patient assessment, when the nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? A) The family has provided permission. B) The patient has provided permission and consent. C) The health care provider has given approval or provided orders for the therapy. D) He or she has documented that the patient has a complete understanding of complementary and alternative medicine.

answer

B) The patient has provided permission and consent. Nurse-accessible therapies are independent nursing interventions. As long as the Scope of Practice identified by the nurse's State Board of Nursing permits this activity, you do not need to obtain permission from the patient's primary provider or their family members unless the patient is underage. An adult can provide consent. Complete understanding of any procedure or intervention is impossible to ensure.

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Which role do patients have in complementary and alternative medicine therapy? A) Submissive to the practitioner B) Actively involved in the treatment C) An educator for other health care professionals D) A total believer in what is being taught

answer

B) Actively involved in the treatment One of the characteristics of complementary therapy users is that they want to be more involved in their care and decision making about the types of treatments that are used. Complementary therapies are one way to provide the patient with increased control of the health care.

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The nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? A) Always fail and cause illness and disease B) Cause structural damage to the body C) React the same way for all individuals D) Protect an individual from harm in the short term but cause negative responses over time

answer

D) Protect an individual from harm in the short term but cause negative responses over time In the beginning stress responses serve as a warning and physiological "alarm" of sorts, preparing the person to respond to harm. In this way it can be a protective mechanism. However, stress that continues unmitigated for long periods of time creates states of "exhaustion" that translate ultimately into negative physiological and psychological events.

question

When meditation therapy is used, nurses need to monitor patients' medications carefully because meditation may augment the effects of certain drugs such as: A) Prednisone and antibiotics. B) Insulin and vitamins. C) Cough syrups and aspirin. D) Antihypertensive and thyroid-regulating medications.

answer

D) Antihypertensive and thyroid-regulating medications. Mind-body techniques, including meditation, create physiological responses in the cardiovascular and respiratory systems. These responses may include decreased blood pressure, reduced heart rate, and slowed respirations. They decrease the need for antihypertensive and other cardiac regulators and thyroid-regulating medications.

question

The nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for imagery? A) Pregnant patient B) Hypertensive patient C) Patient with posttraumatic stress disorder (PTSD) D) A pediatric patient

answer

C) Patient with posttraumatic stress disorder (PTSD) Imagery can often recreate the traumatic experience, intensifying the sensations and emotions that accompany the memory of it and bringing the PTSD to a crisis level.

question

A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome related to using this additional modality? A) To eat less food B) To control diabetes C) To live longer with acquired immune deficiency syndrome (AIDS) D) To learn how to control some autonomic nervous system responses

answer

D) To learn how to control some autonomic nervous system responses Biofeedback is a mind-body technique that teaches self-regulation and voluntary control over specific physiological responses, including autonomic nervous system response.

question

A patient asks a nurse about therapeutic touch (TT). Which of the following does the nurse include when providing patient education about TT? Therapeutic touch: A) Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield B) Intentionally heals specific diseases or corrects certain symptoms C) Is overwhelmingly effective in many conditions D) Is completely safe and does not warrant any special precautions

answer

A) Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield TT is focused on healing the whole person and providing energy to the body that supports innate healing responses. The research literature is questionable; systematic analyses claim that the research designs are too weak for any conclusive evidence to be identified with confidence. Although TT is relatively safe and there have been very few negative events associated with its use, all therapies (complementary or conventional) should be used with caution in certain populations.

question

The nurse is caring for a patient who uses several herbal preparations in addition to prescribed medications. What does the nurse need to understand about herbal preparations? A) They are regulated by the Food and Drug Administration (FDA); therefore patients and providers should feel confident that they are completely safe. B) They are natural products and therefore are safe as long as you use them cautiously and prudently for the conditions that are indicated. C) They are covered by insurance, including Medicare, Medicaid, and private payers. D) They should be treated as though they were "drugs" of sorts because many have active ingredients that can interact with other medications and change physiological responses.

answer

D) They should be treated as though they were "drugs" of sorts because many have active ingredients that can interact with other medications and change physiological responses. Herbal therapies are derived from plant materials and often contain the same active components as medications. Yet, they are viewed as dietary supplements and are not regulated by the FDA. You should always explicitly ask patients whether they are taking supplements or other herbal remedies or vitamins when you ask them about the medications that are currently being used during a health history. Many patients do not tell you about these products voluntarily because they do not view them as medications, they fear that conventional providers will not approve of these substances and they want to continue taking them, or they do not think that you are interested in a substance that was not prescribed.

question

A nurse provides care for a diverse group of patients, including many immigrants. To better understand various types of health care, the nurse learns the traditional Chinese medicine system: A) Uses acupuncture as its primary intervention modality B) Uses many modalities that are based on the individual and include herbal therapies, moxibustion, and acupuncture C) Uses primarily herbal remedies (that are known to have high levels of lead products) and exercise D) Is the equivalent of medical acupuncture

answer

B) Uses many modalities that are based on the individual and include herbal therapies, moxibustion, and acupuncture TCM practitioners use a variety of interventions that are based on individual patient assessment findings and needs. Modalities include herbal therapies, acupuncture, moxibustion, cupping, prescribed exercise such as tai chi or qi gong, and lifestyle changes. Although acupuncture is often confused with TCM, when used alone acupuncture is not a whole system of medicine. Rather NIH/NCCAM considers it to be a mind-body technique that is often referred to as medical acupuncture. Although herbal therapies and exercise are considered to be part of the treatment repertoire of the TCM provider, these modalities are not considered to be primary interventions.

question

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention? (Select all that apply.) A) Improved health among the staff B) Increased patient safety C) Improved staff satisfaction D) Increased staff retention E) Fewer overtime assignments

answer

C) Improved staff satisfaction D) Increased staff retention urrent research has been able to determine that reducing stress by using relaxation strategies in the workplace leads to improved staff relationships, communication, satisfaction, and retention (decreased turnover).

question

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) A) Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. B) Nurses are often asked for recommendations and strategies that promote well-being and quality of life. C) Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. D) Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. E) Nurses play an essential role in the safe use of complementary therapies. F) Nurses learn how to provide all of the complementary modalities during their basic education.

answer

A) Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. B) Nurses are often asked for recommendations and strategies that promote well-being and quality of life. C) Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. D) Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. E) Nurses play an essential role in the safe use of complementary therapies. All of the statements are true except "nurses learn how to provide all of the complementary modalities during their basic education." Nurses play an essential role in the safe use of complementary therapies in our emerging health care system. They have an appreciation for many types of interventions and can understand the patient's need to become more involved in their health care decisions and choices. They also understand patients' desire to take a more active role in their healing and health promotion processes. Culturally relevant care that uses a full complement of intervention strategies that are supported with evidence is a central tenet of contemporary nursing practice.

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The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A) Referent B) Channel C) Environment D) Feedback

answer

D) Feedback Feedback is the message the receiver returns that indicates understanding. By summarizing what the patient has said, the nurse can determine if the message was received accurately.

question

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? A) Provide her the opportunity to practice drawing up insulin B) Coach her to give herself positive messages about her ability to do this C) Bring her written material that clearly describes the steps of insulin administration D) Use therapeutic communication to help her express her feeling about giving herself an injection

answer

B) Coach her to give herself positive messages about her ability to do this Intrapersonal communication is self-talk. The other options may help her better understand insulin administration or deal with her anxiety, but they do not involve intrapersonal communication.

question

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? A) The respiratory rate is 28. B) The patient has a history of lung cancer. C) The patient is short of breath. D) He or she requests an order for a breathing treatment.

answer

C) The patient is short of breath. Using the acronym SBAR, the nurse should begin with "S," which is Situation. The situation is that the patient is short of breath. The history of lung cancer is Background, the respiratory rate is Assessment, and the request for an order is a Recommendation.

question

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? A) Summarize what you have talked about in the previous sessions B) Review his medical record and talk to other nurses about how he is reacting C) Explore his feelings about losing his leg D) Talk with him about his favorite hobbies

answer

D) Talk with him about his favorite hobbies Socializing is used during the orientation phase of a relationship to get acquainted and help establish trust.

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The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A) Providing information B) Clarifying C) Focusing D) Paraphrasing

answer

B) Clarifying The nurse is not sure what the patient means by living up to expectations and is clarifying the patient's concern.

question

Which of the following statements would be most likely to block communication? A) "You look kind of tired today." B) "Why do you always put so much salt on your food?" C) "It sounds like this has been a hard time for you." D) "If you use your oxygen when you walk, you may be able to walk farther."

answer

B) "Why do you always put so much salt on your food?" Avoid asking "why" questions. They tend to imply an accusation and can build resentment.

question

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A) Leave the room quietly since she evidently does not want to be bothered right now B) Repeat the question in a loud voice, speaking very slowly C) Move to her bedside, get her attention, and repeat the question while facing her D) Bring her a communication board so she can express her needs

answer

C) Move to her bedside, get her attention, and repeat the question while facing her You do not want to assume that she is hard of hearing because she is 80, but it is more likely. She may have not responded because you were across the room and water was running. Don't jump to conclusions, but instead try again to communicate with her as you would with someone who is hard of hearing.

question

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A) Say nothing and walk away. Find a different nurse to help you. B) "When you brush me off like that, it takes me even longer to do my job." C) "Why do you always put me down like that?" D) "I guess I just enjoy having you make fun of me."

answer

B) "When you brush me off like that, it takes me even longer to do my job." Lateral violence can be dealt with by using assertive communication. Simple assertive statements include referencing the person you are addressing, the behavior that is a problem, and its effect. Avoiding the situation, becoming defensive, or making sarcastic remarks does not help to resolve the problem.

question

When the nurse takes the patient's nursing history, he or she sits: A) Next to the patient. B) 4 to 12 feet from the patient. C) 18 inches to 4 feet from the patient. D) 12 inches to 3 feet from the patient.

answer

C) 18 inches to 4 feet from the patient. The personal zone is 18 inches to 4 feet. This distance allows for easy communication without invading the person's personal space.

question

When working with an older adult, the nurse remembers to avoid: A) Touching the patient. B) Allowing the patient to reminisce. C) Shifting quickly from subject to subject. D) Asking the patient how he or she feels.

answer

C) Shifting quickly from subject to subject. Shifting quickly from subject to subject may be difficult for an older person to follow, especially if the person is hard of hearing. Focusing on the patient's feelings and encouraging reminiscence help the person process changes or loss.

question

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A) The professional nurse consults the health care provider for direction in establishing goals for patients. B) The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C) The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D) The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

answer

D) The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care. Collaboration involves everyone working together to best meet the needs of the patient. A care plan that incorporates the expertise of professionals from varied disciplines best addresses patient needs.

question

Identify behaviors that foster the development of trust. (Select all that apply.) A) Answer the call light promptly. B) Call the patient by first name unless requested otherwise. C) Do all the care as quickly as possible and leave the room so the patient can rest. D) Answer questions honestly. E) Demonstrate competence when doing treatments.

answer

A) Answer the call light promptly. D) Answer questions honestly. E) Demonstrate competence when doing treatments. Consistency, courtesy, competency, and honesty build trust. Rushing and avoiding spending time with the patient may decrease or slow the development of trust.

question

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A) Turning on the television to her favorite show B) Pulling the curtain to provide privacy C) Offering to discuss information about her condition D) Asking her why she is crying E) Sitting quietly by her bed and hold her hand

answer

C) Obtains an interpreter to facilitate communication of medication information It is essential that patients understand discharge instructions to safely care for themselves at home. If a patient has limited ability to speak or understand English, he or she has a legal right to an interpreter to ensure understanding of essential information.

question

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A) Uses a dictionary to give directions for medication administration B) Explains the directions to the patient's 14-year-old daughter C) Obtains an interpreter to facilitate communication of medication information D) Uses a picture board and visual aids to communicate medication administration information

answer

B) Pulling the curtain to provide privacy C) Offering to discuss information about her condition E) Sitting quietly by her bed and hold her hand Privacy and lack of distraction create an environment conducive to therapeutic communication. Nursing presence and touch convey caring and compassion and allow the patient to collect her thoughts. Providing information tells people what they need or want to know. "Why" questions may seem intrusive and block communication.

question

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A) Use therapeutic communication to assess for increased anxiety B) Sit down and position yourself closer so you are at eye level C) Deflect your eyes downward to show respect D) Continue to maintain eye contact

answer

C) Deflect your eyes downward to show respect Many cultures, especially the eastern cultures, view direct eye contact as rude. Deflecting your eyes downward indicates respect.

question

A patient needs to learn to use a walker. Which domain is required for learning this skill? A) Affective domain B) Cognitive domain C) Attentional domain D) Psychomotor domain

answer

D) Psychomotor domain Using a walker requires the integration of mental and muscular activity.

question

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur? (Select all that apply.) A) When there are visitors in the room B) When the patient's pain medications are working C) Just before lunch, when the patient is most awake and alert D) When the patient is talking about current stressors in his or her life

answer

B) When the patient's pain medications are working C) Just before lunch, when the patient is most awake and alert Plan teaching when the patient is most attentive, receptive, alert, and comfortable.

question

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient? A) Teach the patient's spouse B) Focus on knowledge the patient will need in a few weeks C) Provide only the information that the patient needs to go home D) Convince the patient that learning about her health is necessary

answer

C) Provide only the information that the patient needs to go home This patient is in denial; thus it is appropriate to only give her information that is needed immediately.

question

The school nurse is about to teach a freshman-level high school health class about nutrition. What is the best instructional approach to ensure that the students meet the learning outcomes? A) Provide information using a lecture B) Use simple words to promote understanding C) Develop topics for discussion that require problem solving D) Complete an extensive literature search focusing on eating disorders

answer

C) Develop topics for discussion that require problem solving Adolescents learn best when they are able to use problem solving to help them make choices.

question

A nurse is going to teach a patient how to perform breast self-examination. Which behavioral objective does the nurse set to best measure the patient's ability to perform the examination? A) The patient will verbalize the steps involved in breast self-examination within 1 week. B) The nurse will explain the importance of performing breast self-examination once a month. C) The patient will perform breast self-examination correctly on herself before the end of the teaching session. D) The nurse will demonstrate breast self-examination on a breast model provided by the American Cancer Society.

answer

C) The patient will perform breast self-examination correctly on herself before the end of the teaching session. Return demonstration provides an excellent source of feedback and reinforcement to evaluate learning.

question

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation? A) Telling approach B) Selling approach C) Entrusting approach D) Participating approach

answer

A) Telling approach The telling approach is most appropriate when preparing a patient for an emergency procedure.

question

The nurse is teaching a parenting class to a group of pregnant adolescents. The nurse pretends to be the baby's father, and the adolescent mother is asked to show how she would respond to the father if he gave her a can of beer. Which teaching approach did the nurse use? A) Role play B) Discovery C) An analogy D) A demonstration

answer

A) Role play In role play people are asked to play themselves or someone else in a situation to enhance their confidence in handling that situation in the future.

question

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse: A) Speaks loudly. B) Presents the information once. C) Expects the patient to understand the information quickly. D) Allows the patient time to express himself or herself and ask questions.

answer

D) Allows the patient time to express himself or herself and ask questions. When teaching older adults, it is important to establish rapport, involve them in their care, and allow them to progress at their own pace.

question

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn? A) Describing difficulties a family member has had in taking insulin B) Expressing the importance of learning the skill correctly C) Being able to see and understand the markings on the syringe D) Having the dexterity needed to prepare and inject the medication

answer

B) Expressing the importance of learning the skill correctly Patients are ready to learn when they understand the importance of learning and are motivated to learn.

question

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use? A) Simulation B) Demonstration C) Group instruction D) One-on-one discussion

answer

B) Demonstration Demonstration is used to help patients learn psychomotor skills.

question

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, he or she tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use? A) Telling B) Analogy C) Demonstration D) Simulation

answer

B) Analogy Analogies use familiar images when teaching to help explain complex information.

question

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first? A) How to use an inhaler during an asthma attack B) The need to avoid people who smoke to prevent asthma attacks C) Where to purchase a medical alert bracelet that says she has asthma D) The importance of maintaining a healthy diet and exercising regularly

answer

A) How to use an inhaler during an asthma attack It is important to start with essential life-saving information when teaching people because they usually remember what you tell them first.

question

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. What type of content is the nurse providing? A) Simulation B) Restoring health C) Coping with impaired function D) Health promotion and illness prevention

answer

D) Health promotion and illness prevention Health promotion and illness prevention are the focus when nurses provide information to help patients improve their health and avoid illness.

question

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of: A) A teaching plan. B) A learning objective. C) Reinforcement of content. D) Enhancing the children's self-efficacy.

answer

B) A learning objective. A learning objective describes what the learner will do after the teaching session.

question

A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages based on his blood sugar results. What type of learning is this? A) Cognitive B) Affective C) Adaptation D) Psychomotor

answer

A) Cognitive Cognitive learning requires thinking; learning how to adjust insulin requires analysis, synthesis, and evaluation, which are all types of cognitive learning.

question

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.

answer

D) Enter only objective and factual information about the patient. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

question

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.

answer

C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.

question

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.

answer

D) The patient stated that he felt frustrated by the lack of information he received regarding his tests. This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern.

question

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

answer

C) HIPAA provides you with greater control over your personal health care information. HIPAA provides patients with control over who receives and accesses their medical records. It does not allow uncontrolled access to the medical records. HIPAA also does not dictate what must be documented in the patient's medical record.

question

A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.

answer

B) Indicate that she has the right to read her record. Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.

question

Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

answer

D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise. The statement "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise" provides the most accurate, objective information for the chart.

question

Match the correct entry with the appropriate SOAP (Subjective—Objective—Assessment—Plan) category. A. Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. B. "The pain increases every time I try to turn on my left side." C. Acute pain related to tissue injury from surgical incision. D. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.

answer

"The pain increases every time I try to turn on my left side.":S, Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation.:O, Acute pain related to tissue injury from surgical incision.:A, Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device.:P

question

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.

answer

B) Electronic health record. This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting. In this question you are able to access information about the patient from the current hospitalization and from four previous times when the patient accessed care.

question

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

answer

A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include response to treatments such as response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.

question

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.

answer

A) Documented medication given by another nursing student. Nurses only document the care they provide; entries in the chart need to be dated, timed, and signed.

question

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."

answer

A) "CPOE reduces transcription errors." CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly.

question

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

answer

B) You need to use words the patients can understand when writing the directions. Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patients' reading ability.

question

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry

answer

C) Clinical decision support system A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.

question

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.

answer

B) The nurses were charting by exception. Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.

question

What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents

answer

C) Place in a secure canister marked for shredding Confidential patient information should be shredded. It is generally collected in large secure containers and shredded at scheduled times.

question

5. A client is admitted with multiple bruises over the arms and legs. What is the nurse's first action? A) a. To ask the client for a list of medications and herbal supplements B) b. To call the health care provider C) c. To notify the police about possible abuse D) d. To draw blood for coagulation studies

answer

A) a. To ask the client for a list of medications and herbal supplements The nurse should first assess before acting. Medications as well as supplements can cause a client to be susceptible to bruising.

question

A client is admitted for elective surgery. The client declares a belief in herbs and natural remedies. What is the nurse's priority action? A) a. To determine what herbs the client takes on a regular basis B) b. To determine when the last time was the client took herbs C) c. To teach the client why natural remedies are not safe D) d. To have the client cancel the surgery

answer

A) a. To determine what herbs the client takes on a regular basis The nurse should first determine what herbs the client takes on a regular basis. It could be that the herbs will not interfere with the client's surgery and medications. Once the nurse determines what herbs the client takes, then the nurse should ask about the last time the client took the herbs.

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