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68C Practice Test 11
Practice Test 11
| Question | Answer |
|---|---|
| ming responsibility for a patient’s care forms a legally binding situation described as? | nurse-patient relationship |
| Universal guidelines that define appropriate measures for all nursing interventions that should be observed during the performance of those interventions are known as? | standard of care |
| The laws that formally define and limit the scope of nursing practice in that state are the? | nurse practice act |
| A nurse who failed to irrigate a feeding tube as ordered resulting in harm to the patient could be found guilty of: | malpractice |
| Patients have expectations regarding the health care services they receive. To protect these expectations, which has become law? | American Hospital Association’s Patient’s Bill of Rights |
| The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? | Informed consent |
| By protecting the information in a patient’s record, the nurse fulfills the ethical responsibility of: | confidentiality. |
| An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. The best nursing action is to: | report the bruises to the charge nurse. |
| The nurse concludes that the best way to avoid a lawsuit is to: | provide compassionate, competent care. |
| When seeking advice involving the patient’s right to refuse medication, the nurse should most appropriately consult: | the hospital ethics committee. |
| Although the nurse may disagree with a do-not-resuscitate (DNR) order, legally he or she: | must follow the order. |
| The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, the nurse has the right to: | ask for another assignment. |
| The new LPN/LVN is concerned regarding what should or should not be done for patients. Select the resource that will best provide this information. | Standards of care define what should or should not be done for patients. |
| The nurse who diligently works for the protection of patients’ interests is functioning in the role of: | advocate. |
| When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? | The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. |
| The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. The nurse recognizes it is necessary to: | The nurse can assist the patient in values clarification without giving an opinion. |
| When confronted with an ethical decision, the nurse must observe the first fundamental principle of: | The first fundamental principle is respect for people. |
| Since a nurse’s first duty is to the patient’s health, safety, and well-being, it is necessary to report: | A member of the nursing profession must report behavior that does not meet established standards. |
| Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? | Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. |
| A nurse could be cited for malpractice in the event of: | Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. |
| A lumbar puncture was performed on a patient without a signed informed consent form. This may be a situation in which a patient could sue for: | Civil assault charges can be brought against someone performing an invasive procedure without the patient’s informed consent legally documented. |
| A physician instructs the nurse to bladder train a patient. The nurse clamps the patient’s indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. The nurse’s actions are an example of: | A nurse is liable for acts of commission and omission performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. |
| What is true about nurse practice acts? | The nurse must know the nurse practice act within his or her state. |
| During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? | The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel. |
| Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person’s behavior in a given situation are referred to as | values |
| A newly licensed LPN/LVN may practice: | An LPN/LVN practices under the supervision of a physician, dentist, OD, or RN. |
| The document in which the role and responsibilities of the LPN/LVN are identified is the: | The LPN/LVN functions under the Nurse Practice Act. |
| A cost-effective delivery of care being used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients is: | Case management is a cost-effective method of care. |
| The American Hospital Association's 1972 document that outlines the patient’s expectations to be treated with dignity and compassion is: | Patient expectations are outlined by the Patient’s Bill of Rights. |
| Maslow’s hierarchy of needs is based on the premise that: | basic needs must be met before the next level of needs can be met. |
| The role and responsibilities of the LPN/LVN as a responsible caregiver require that the LPN/LVN: | The LPN/LVN is required to gain continuing education units. Membership with the ANA is for RNs; there is no requirement for the LPN/LVN to continue education to the RN level. The LPN/LVN works under the supervision of an RN. |
| A system of comprehensive patient care that considers the physical, emotional, and social environment and spiritual needs of a person is: | Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. |
| The official agency that exists exclusively for LPN/LVN membership and promotes standards for the LPN/LVN is the: | The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. |
| The part of the body that maintains a balance between heat production and heat loss, regulating body temperature, is the: | Body temperature is regulated by the hypothalamus. |
| The type of body temperature that remains relatively constant is the: | The core body temperature remains relatively constant. |
| The nurse uses cooling techniques to keep the body temperature below 105° F because such elevated temperature can: | If temperature exceeds 105° F, normal body cells may be damaged. |
| The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. The nurse is aware that death can occur if the temperature falls below: | Death can occur if temperature falls below 93.2° F. |
| A fever that rises and falls but does not return to normal until the patient is well is classified as: | A remittent fever does not return to normal until the patient becomes well. |
| Using the tympanic thermometer for a child, the nurse should pull the ear pinna: | Using the tympanic thermometer for a child, the nurse will tug the ear pinna down and back. |
| To ensure optimum reception from a stethoscope, the nurse should place the earpieces pointing | To ensure the best reception of sound, place earpieces pointing toward the face. |
| The nurse uses the diaphragm of the stethoscope to best assess: | Lung sounds are auscultated by using the diaphragm of the stethoscope. |
| The nurse explains that the pulse—the expansion and contraction of an artery—is produced by contraction of the: | Expansion and contraction of an artery is caused by the ejection of blood from the left ventricle. |
| When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120. This pulse is: | If the pulse is faster than 100 beats per minute on an adult patient, it is considered to be tachycardia. |
| The patient’s pulse is below 60. Because the nurse is aware that the patient is not receiving digoxin, the nurse believes that the bradycardia might be caused by: | Bradycardia can result from unrelieved severe pain. |
| If a peripheral pulse needs to be assessed quickly, the nurse should select the: | The carotid site is the best for finding a pulse quickly. |
| The exchange of carbon dioxide and oxygen that takes place at the alveolar level is termed: | Internal respiration is the exchange of gas at the alveolar level. |
| Because a cardiac arrhythmia is suspected, the nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. The difference between the two rates is termed: | The difference between radial and apical pulses is called a pulse deficit. |
| The nurse is alarmed when a patient with a severe head injury of the occipital lobe has a respiratory rate of 10 breaths per minute because this may indicate an injury to the: | Rate of respiration is controlled by the medulla oblongata. |
| The respirations of a patient who is demonstrating pursed-lip breathing, flared nostrils, and retractions are described as: | The patient who is using ancillary muscles to breathe is exhibiting dyspnea. |
| A nurse assesses a neonate’s temperature by using a temporal artery scanner. If the neonate’s temperature is 96 F, the nurse should: | record the findings. The neonate’s temperature normally ranges from 96 to 99.5 F (35.5 to 37.5 C). |
| A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is difficult to feel and not palpable when only slight pressure is applied, the nurse should document this finding as a: | A thready pulse is difficult to feel and is not palpable when only slight pressure is applied |
| A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is not palpable when light pressure is applied, the nurse should document this finding as | A weak pulse is somewhat stronger than a thready pulse but not palpable when light pressure is applied. |
| A nurse assesses a patient’s dorsalis pedis pulse. If the pulse is easily felt but not palpable when moderate pressure is applied, the nurse should document this finding as a: | A normal pulse is easily felt but not palpable when moderate pressure is applied |
| A nurse assesses a patient’s dorsalis pedis pulse. If the pulse feels full and springlike even under moderate pressure, the nurse should document this finding as a: | A bounding pulse feels full and springlike even under moderate pressure. |
| When instructing a primary caregiver about keeping a daily log of blood pressure readings, the nurse should include what instruction(s | Readings, taken at the same time daily, same arm. The cuff applied 2” above antecubital fossa, secured snugly. The pulse is assessed with the diaphragm of stethoscope |
| The nurse assesses for the fifth vital sign, which is | PAIN |
| If a patient has an axillary temperature of 96.2° F, the nurse understands that the true temperature is | 97.2° F, Axillary temperatures are considered to be 1° F below core temperature. |
| The nurse assesses the blood pressure as 192/86, noting that the patient has a pulse pressure of | 106, The pulse pressure is the difference between the diastolic and systolic readings. |
| When assessing factors that may influence the patient’s pulse rate, what should the nurse take into consideration? | Age, Sex, Emotion, Temperature, Physical activity |
| The nurse is collecting data during an initial assessment. The data that can be seen, heard, measured, or felt and is objective is called a(n): | A sign can be seen, heard, measured, or felt. |
| As part of an assessment, the nurse asks the patient for subjective information related to the present illness. Subjective findings that are perceived by the patient are known as: | Symptoms are subjective indications of illness that are perceived by the patient. |
| Any disturbance of a structure or function of the body is a pathological condition. This condition is termed a(n): | A disease is any disturbance of a structure or function of the body. |
| The nurse is assessing a patient to collect subjective and objective data. These data will provide the basis for making a: | Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis. |
| The nurse is discussing the origin of diabetes with a diabetic patient. The most appropriate explanation is that this disease is caused by a dysfunction of the: | Diabetes mellitus results from dysfunction of the pancreas. |
| There are four categories of factors that increase an individual’s vulnerability to developing a disease: genetic, physiological, age, and lifestyle. These are called: | Risk factors are placed into four categories. |
| When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration? | Diabetes mellitus is an example of a chronic disease. |
| The term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease is: | Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. |
| When a disease results in a structural change in an organ that interferes with its functioning, this is a(n): | An organic disease results in a structural change in an organ. |
| Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation: | Inflammation is a protective response. |
| The purpose of criminal law is to punish or deter crimes against society, Involves public offenses such as? | Murder, Robbery, Assault |
| Basic Categories of law | Criminal, Civil |
| Criminal and civil laws have one of two sources | Statutory law, Civil or Common law |
| A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the basis for? | The information contained in the database is the basis for an individualized plan of care. |
| The nurse is meeting a patient for the first time. The initial step when initiating a nurse-patient relationship is for the nurse to | The first step in a nurse-patient relationship is for the nurse to introduce her/himself. |
| A patient interview being conducted by the nurse should convey to the patient that the nurse has: | The nurse must convey feelings of concern. |
| While conducting an assessment of a patient, the nurse recognizes that the initial step is: | The nursing health history is the initial step in the assessment process. |
| When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data to assist in establishing: | The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions. |
| During the nursing interview, several histories are taken. The history that involves data concerning habits and lifestyle patterns is called: | The nurse identifies habits and lifestyle patterns under past health history. |
| The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. This method is a: | A review of systems is a systematic method. |
| The nurse is developing a nursing care plan for a newly admitted patient. The first step in developing this care plan is a: | The nursing assessment is the critical step in forming the nursing care plan. |
| The patient should be assessed as soon as possible after admission. This initial assessment is done by the: | The initial assessment is done by the registered nurse. |
| A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. This change in condition requires an assessment called: | When the nurse observes a change in the patient’s condition, the assessment is focused. |
| When performing a nursing physical assessment, the nurse uses a head-to-toe approach. When using this method, the nurse begins with a: | When performing a head-to-toe assessment, the nurse begins with a neurological assessment. |
| An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. The nurse recognizes this could be caused by: | Dehydration results in decreased skin turgor. |
| During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse and are most often heard: | Crackles are usually heard during inspiration. |
| Auscultating the heart sounds should result in a “lubb-dupp” sound when using the bell and the diaphragm of the stethoscope. The “lubb” sound is caused by the: | The “lubb-dupp” sound of the heart is caused by the closing of the AV and semilunar valves, respectively. |
| The nurse assesses a patient for capillary refill. After the fingernail is compressed for 5 seconds, the refill time should be fewer than: | Capillary refill should take fewer than 3 seconds. |
| Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is: | The normal rate of bowel sounds per minute is 4-32. |
| A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema because the edema disappears in: | The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds. |
| Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. Percussion is used to determine: | The sounds indicate the density of the underlying tissue. |
| The nurse is obtaining a history of a patient’s present illness. The PQRST system is used for the interview. In this system, the R stands for: | In the PQRST system, the R stands for region. |
| When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. This technique is: | Deep palpation is used to detect tenderness or masses of the abdomen. |
| The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. These are identified as: | Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways. |
| When auscultating the thorax, the suggested sequence for a systematic approach is to begin with the: | The suggested sequence for a systematic auscultation of the thorax is to begin with the apices. |
| A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective? The patient: | Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety an objective assessment finding. |
| Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is an objective assessment finding. | A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data? |
| A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? | Complains of Chest pain, Symptoms are subjective indications of illness that are perceived by the patient |
| complains of pruritus, Symptoms are subjective indications of illness that are perceived by the patient | A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data |
| When performing a head-to-toe assessment, the nurse should begin by assessing the patient’s | performing a head-to-toe assessment, the nurse begins with a neurological assessment, then assesses the skin, hair, head, neck, eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in order. |
| During a head-to-toe assessment, the nurse assesses the patient’s abdomen. Which area should the nurse assess next? | Perineal area |
| During a head-to-toe assessment, the nurse assesses the patient’s perineal area. Which area should the nurse assess next? | Legs and feet |
| During a neurological assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve? | III. A traumatic brain injury can result in increased intracranial pressure, edema to the brain stem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil. |
| A physician needs to insert a vaginal speculum into a patient for a vaginal examination. The nurse should place the patient in what position? | Lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum |
| A physician needs to assess extension of a patient’s hip joint. The nurse should place the patient in what position? | Prone position is used to assess extension of a patient’s hip joint. |
| A physician needs to assess a patient for a heart murmur. The nurse should place the patient in what position? | Lateral recumbent position aids in detecting heart murmurs. |
| A physician needs to assess a patient’s rectal area. The nurse should place the patient in what position? | Knee-chest position provides maximum exposure of the rectal area. |
| A nurse needs to auscultate a patient’s lung sounds. The nurse should place the patient in what position? | Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. |
| During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. The nurse should document that the patient is experiencing: | Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. |
| During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. The nurse should document that the patient is experiencing: | Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions. |
| During a physical assessment, the nurse notes a patient has a loss of strength and energy. The nurse should document that the patient is experiencing: | Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. |
| During a physical assessment, the nurse notes that a patient’s heart rate is 56 beats per minute. The nurse should document that the patient is experiencing: | Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. |
| During a physical assessment, the patient complains of difficulty in passing stools. The nurse should document that the patient is experiencing: | Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional. |
| During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. The nurse should document that the patient is experiencing: | Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs. |
| During a physical assessment, the nurse notes a patient has profuse secretions of sweat. The nurse should document that the patient is experiencing: | Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress. |
| During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. The nurse should document that the patient is experiencing: | Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source |
| During a physical assessment, the nurse notes that a patient has bright red blood in the feces. The nurse recognizes that the bleeding is most likely caused by: | Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. |
| A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. The nurse should document that the patient is experiencing: | Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety. |
| A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. The nurse should document that the patient has: | Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise). |
| When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. The nurse should document this finding as: | Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn. |
| When assessing a patient with hepatitis, the nurse notes a yellow tingle to the patient’s skin. The nurse understands that jaundice most likely results from an obstruction in the flow of bile from the: | Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. |
| When assessing a patient, the nurse notes a yellow tinge to the patient’s skin. The nurse should document that the patient has: | Jaundice is a yellow tinge to the skin |
| When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient to a sitting position, the patient is able to breathe more easily. The nurse should document that the patient is experiencing: | Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems. |
| When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. The nurse should document this finding as: | Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes. |
| When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratching frequently. The nurse should document that the patient is experiencing | Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation. |
| A physician documents that a patient is having purulent drainage from a wound. The nurse understands that this is most likely caused by | Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause.. |
| A physician documents that a patient has a sallow complexion. The nurse understands that this means the patient has a: | Sallow is an unhealthy, yellow color; usually said of a complexion or skin. |
| A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient’s sclera is: | Scleral icterus means the color of the sclera is yellow. |
| A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient’s sclera is yellow and is caused by infiltration of: | The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. |
| When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include | With the exception of information relative to pregnancies, all options would be informative about risk for heart disease. Family history of illness, diet, smoking, exercise |
| Arrange these assessment techniques in correct order of a standard physical examination. | Inspection > Palpation > Auscultation > Percussion |
| Nursing process is best defined as a: | The nursing process is a framework by which to organize individualized nursing care. |
| A systematic method by which nurses plan and provide care for patients is known as the _________ ____________. | nursing process, serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients. |
| Which are considered phases of the nursing process | The nursing process consists of six dynamic and interrelated phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. |
| When admitting a patient to the hospital, the nurse observes that the patient is distracted and tense. This behavior suggests a common reaction to hospitalization, which is: | Fear of the unknown may be the most common reaction to hospitalization. |
| During the admission procedure, the nursing intervention would best help reduce patient anxiety? | Greeting the patient by name is one of the most important aspects of admission. |
| An essential part of the admission procedure performed by the RN is to | obtain a health history. Admission assessment is performed by the RN. |
| Discharge planning should begin: | Discharge planning begins shortly after admission. |
| To help the family of a patient find a source of financial aid to meet medical expenses, the nurse can make a referral to: | Often a patient will require services of various disciplines within the hospital. Social services can assist with meeting medical financial obligations. |
| When a patient demands to be discharged without a physician’s order and is leaving the unit with his belongings, the nurse should ask the patient to sign a(n): | If a doctor cannot convince the patient to stay, the patient should sign an against medical advice form. |
| The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. A child will usually cry, whereas an older adult will often demonstrate: | The older adult may demonstrate depression as a result of separation anxiety entering the hospital |
| Upon admission, the nurse notes that a patient has a billfold filled with cash. Because there is no family member present, the nurse suggests that the money be: | Valuables should be locked in the hospital safe. |
| If a patient has an order for an interagency transfer, the nurse explains that the patient will be moved from: | The interagency transfer moves a patient from one health care agency to another. |
| Before the actual discharge, the nurse must ensure that the patient: | It is essential that the patient be fully aware of the discharge instructions before being discharged. |
| A patient who is alert and oriented is threatening to leave the hospital against medical advice (AMA). The nurse should: | When a patient threatens to leave AMA, the physician should be notified immediately. If the physician fails to convince the patient to remain in the facility, the physician will ask the patient to sign an AMA form |
| How can the nurse help reduce the stress of a hospital admission? | demonstrating how bedside equipment works, explaining hospital policies, and involving the patient in the plan of care from the start all help to reduce the stress of a hospital admission. family interventions are frequently helpful in reducing stress. |
| The nurse adheres to the discharge standards set by The Joint Commission (TJC), which include that patients will receive instruction regarding which aspect(s) of care? | The Joint Commission (TJC) standards require info about medication, rehabilitation instructions, referral to community agencies, instruction in using any medical equipment, family care responsibility, diet, and how to obtain further treatment. |
| Before giving the patient a bath, the nurse must ensure that the temperature of the room should be no cooler than | The recommended room temperature is 68° to 74° F. |
| The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area and should last at least: | The sitz bath should last 20 to 30 minutes. |
| If a patient recovering from a hemorrhoidectomy experiences dizziness within 5 minutes when taking a sitz bath, the nurse should: | The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal |
| When the nurse is preparing a tepid bath for a patient, the water temperature should be: | The tepid bath is taken in water that is 98.6° F. |
| The nurse assessing a patient’s skin for signs of impaired skin integrity knowing that a major manifestation is a(n): | A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels. |
| When there is sustained skin pressure, especially over bony prominences, pressure ulcers may form as a result of: | A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels. |
| To meet the needs of an unconscious patient with a risk for skin impairment, the nurse will plan to have the patient’s position changed every: | The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time |
| The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently and moving to which favorable position? | It is preferable to use the 30-degree lateral incline position. |
| Proper hair care is important for the patient’s self-image. When shampooing a patient’s hair, the proper water temperature is: | Water at 110° F should be used to shampoo a patient’s hair. |
| When shaving a patient, the nurse must remember to use an electric razor when: | A patient with a bleeding disorder should use an electric razor. |
| Perineal care for the female patient requires draping the patient. The best method for using a bath blanket to drape the patient is to place it in a: | Drape the patient with a bath blanket in the diamond position. |
| The nurse should clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula at least every: | When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours. |
| The nurse must follow the principles of medical asepsis while making a patient’s bed, including procedures for handling linens. Soiled linens should be | held away from the uniform. Soiled linen should not come into contact with a uniform. |
| If a physician orders a patient to be placed in Trendelenburg’s position, the nurse should position the bed | The entire bed is tilted downward with the head of the bed down when placing a patient in Trendelenburg’s position. |
| If a physician orders a patient to be placed in reverse Trendelenburg’s position, the nurse should place the bed: | The entire bed is tilted downward with the foot of the bed down when placing a patient in reverse Trendelenburg’s position. |
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68C14006
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