FUNDA NCLEX Flashcards
The most important nursing intervention to correct skin dryness is:
A. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection.
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear.
C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
D. Avoid bathing the patient until the condition is remedied, and notify the physician.
Correct Answer: C. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas.
Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use non irritating soaps or no soap when bathing the patient, and lubricate the patient’s skin with lotion. In most cases, dry skin responds well to lifestyle measures, such as using moisturizers and avoiding long, hot showers and baths. Moisturizers provide a seal over the skin to keep water from escaping. Apply moisturizer several times a day and after bathing.
Option B: The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary. Natural fibers, such as cotton and silk, allow the skin to breathe. But wool, although natural, can irritate even normal skin. Wash clothes with detergents without dyes or perfumes, both of which can irritate the skin.
Option C: Increasing fat intake is unnecessary. Hot, dry, indoor air can parch sensitive skin and worsen itching and flaking. A portable home humidifier or one attached to the furnace adds moisture to the air inside the home. Be sure to keep the humidifier clean. It’s best to use cleansing creams or gentle skin cleansers and bath or shower gels with added moisturizers. Choose mild soaps that have added oils and fats. Avoid deodorant and antibacterial detergents, fragrance, and alcohol.
Option D: Bathing may be limited but need not be avoided entirely. Long showers or baths and hot water remove oils from your skin. Limit your bath or shower to five to 10 minutes and use warm, not hot, water.
When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:
A. Provides an opportunity for skin assessment.
B. Avoids undue strain on the nurse.
C. Increases venous blood return.
D. Causes vasoconstriction and increases circulation.
Correct Answer: C. Increases venous blood return.
Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Good personal hygiene is essential for skin health but it also has an important role in maintaining self-esteem and quality of life. Supporting patients to maintain personal hygiene is a fundamental aspect of nursing care.
Option A: The nurse can assess the patient’s condition throughout the bath. Helping patients to wash and dress is frequently delegated to junior staff, but time spent attending to a patient’s hygiene needs is a valuable opportunity for nurses to carry out a holistic assessment (Dougherty and Lister, 2015; Burns and Day, 2012). It also allows time to address any concerns patients have and provides a valuable opportunity to assess the condition of their skin.
Option B: The nurse should feel no strain while bathing the patient. Nurses should also discuss with patients any religious and cultural issues relating to personal care (Dougherty and Lister, 2015). For example, ideally, Muslim patients should be cared for by a nurse of the same gender (Rassool, 2015), and Hindus may wish to wash before prayer (Dougherty and Lister, 2015).
Option D: It improves circulation but does not result in vasoconstriction. Bed bathing is not as effective as showering or bathing and should only be undertaken when there is no alternative (Dougherty and Lister, 2015). If a bed bath is required, it is important to offer patients the opportunity to participate in their own care, which helps to maintain their independence, self-esteem and dignity.
Vivid dreaming occurs in which stage of sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
Correct Answer: B. Rapid eye movement (REM) stage
Other characteristics of rapid eye movement (REM) sleep are deep sleep (the patient cannot be awakened easily), depressed muscle tone, and possibly irregular heart and respiratory rates. This is the stage associated with dreaming. Interestingly, the EEG is similar to an awake individual, but the skeletal muscles are atonic and without movement. The exception is the eye and diaphragmatic breathing muscles, which remain active. The breathing rate is altered though, being more erratic and irregular. This stage usually starts 90 minutes after you fall asleep, and each of your REM cycles gets longer throughout the night. The first period typically lasts 10 minutes, and the final one can last up to an hour.
Option A: Non-REM sleep is a deep, restful sleep without dreaming. This is the lightest stage of sleep and starts when more than 50% of the alpha waves are replaced with low-amplitude mixed-frequency (LAMF) activity. There is muscle tone present in the skeletal muscle and breathing tends to occur at a regular rate. This stage tends to last 1 to 5 minutes, consisting of around 5% of the total cycle.
Option C: This stage represents deeper sleep as your heart rate and body temperature drop. It is characterized by the presence of sleep spindles, K-complexes, or both. These sleep spindles will activate the superior temporal gyri, anterior cingulate, insular cortices, and the thalamus. The K-complexes show a transition into a deeper sleep. Stage 2 sleep lasts around 25 minutes in the initial cycle and lengthens with each successive cycle, eventually consisting of about 50% of total sleep.
Option D: Delta stage, or slow-wave sleep, occurs during non-REM Stages III and IV and is often equated with quiet sleep. This is considered the deepest stage of sleep and is characterized by a much slower frequency with high amplitude signals known as delta waves. This stage is the most difficult to awaken from, and for some people, even loud noises (over 100 decibels) will not awaken them. As people get older, they tend to spend less time in this slow, delta wave sleep and more time stage N2 sleep. This is the stage when the body repairs and regrows its tissues, builds bone and muscle, and strengthens the immune system.
The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
A. Flurazepam
B. Temazepam
C. Methotrimeprazine
D. Tryptophan
Correct Answer: D. Tryptophan
Tryptophan is a natural sedative; flurazepam (Dalmane), temazepam (Restoril), and methotrimeprazine (Levoprome) are hypnotic sedatives. Protein foods such as milk and milk products contain the sleep-inducing amino acid tryptophan. Having warm milk at bedtime is a good way to work towards reaching the recommended number of servings of Milk and Alternatives each day, and can be a comforting way to unwind. Tryptophan is an amino acid that promotes sleep and is found in small amounts in all protein foods. It is a precursor to the sleep-inducing compounds serotonin (a neurotransmitter), and melatonin (a hormone which also acts as a neurotransmitter).
Option A: Flurazepam (marketed under the brand names Dalmane and Dalmadorm) is a drug which is a benzodiazepine derivative. It possesses anxiolytic, anticonvulsant, hypnotic, sedative and skeletal muscle relaxant properties. It produces a metabolite with a long half-life, which may stay in the bloodstream for days. Option B: Temazepam is used on a short-term basis to treat insomnia (difficulty falling asleep or staying asleep). Temazepam is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow sleep. Option C: Levomepromazine (also known as methotrimeprazine) is used to treat severe mental/mood disorders (such as schizophrenia, bipolar disorder). It works by helping to restore certain natural substances in the brain. Levomepromazine belongs to a class of drugs known as phenothiazines. It can help the client to think clearly and take part in everyday life. It is also used to treat anxiety disorders, a certain sleep problem (insomnia), nausea/vomiting, and pain. This medication has calming, relaxing, and pain-relieving effects.
Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:
A. Have the patient take a 30- to 60-minute nap in the afternoon.
B. Turn on the television in the patient’s room.
C. Provide quiet music and interesting reading material.
D. Massage the patient’s back with long strokes.
Correct Answer: A. Have the patient take a 30- to 60-minute nap in the afternoon.
Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep.
Option B: For patients in the hospital, factors that can prevent sound sleep include staff noise during a shift, telephones and call lights, doors, paging systems, and even carts wheeled through corridors. Safety and comfort can be promoted by raising side rails, placing the bed in a low position, and using night-lights.
Option C: For individuals who are unable to sleep, they must get out of bed and spend some time in another room. There, they can start some relaxing activities like reading and listening to soft music. They should continue the activity till they feel drowsy.
Option D: Rituals can be supported in institutionalized patients by assisting them with a hand and face wash, massage, pillow plumping, and even talking about today’s accomplishments and enjoyable events. These can promote relaxation and peace of mind.
Restraints can be used for all of the following purposes except to:
A. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters.
B. Prevent a patient from falling out of bed or a chair.
C. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety.
D. Prevent a patient from becoming confused or disoriented.
Correct Answer: D. Prevent a patient from becoming confused or disoriented.
By restricting a patient’s movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient’s movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. The other choices are valid reasons for using restraints.
Option A: Sometimes hospital patients who are confused need restraints so that they do not remove catheters and tubes that give them medicine and fluids. A nurse who has special training in using restraints can begin to use them. A doctor or another provider must also be told restraints are being used. The doctor or other provider must then sign a form to allow the continued use of restraints.
Option B: Restraints may be used to keep a person in proper position and prevent movement or falling during surgery or while on a stretcher. Patients who are restrained also need to have their blood flow checked to make sure the restraints are not cutting off their blood flow. They also need to be watched carefully so that the restraints can be removed as soon as the situation is safe.
Option C: Restraints can also be used to control or prevent harmful behavior or get out of bed, fall, and hurt themselves. Restraints should not cause harm or be used as punishment. Health care providers should first try other methods to control a patient and ensure safety. Restraints should be used only as a last choice.
Which of the following is the nurse’s legal responsibility when applying restraints?
A. Document the patient’s behavior.
B. Document the type of restraint used.
C. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others.
D. All of the above.
Correct Answer: D. All of the above
When applying restraints, the nurse must document the type of behavior that prompted her to use them, document the type of restraints used, and obtain a physician’s written order for the restraints. Nurses are accountable for providing, facilitating, advocating and promoting the best possible patient care and to take action when patient safety and well-being are compromised, including when deciding to apply restraints.
Option A: Restraint use should be continually assessed by the health care team and reduced or discontinued as soon as possible. After the discontinuing restraints, interprofessional teams should debrief with the patient, patient’s family, or substitute decision maker to discuss intervention, previous interventions and alternatives to restraints.
Option B: There are three types of restraints: physical, chemical and environmental. Physical restraints limit a patient’s movement. Chemical restraints are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behaviour or movement. Environmental restraints control a patient’s mobility.
Option C: With any intervention, such as restraint use, nurses need to ensure they actively involve the patient, patient’s family, substitute decision-makers and the broader health care team. Nurses are also accountable for documenting nursing care provided, including assessment, planning, intervention and evaluation. In emergency situations, nurses may apply restraints without consent when a serious threat of harm to the patient or others exists and only after all alternative interventions were unsuccessful.
Kubler-Ross’s five successive stages of death and dying are:
A. Anger, bargaining, denial, depression, acceptance
B. Denial, anger, depression, bargaining, acceptance
C. Denial, anger, bargaining, depression acceptance
D. Bargaining, denial, anger, depression, acceptance
Correct Answer: C. Denial, anger, bargaining, depression acceptance
Kubler-Ross’s five successive stages of death and dying are denial, anger, bargaining, depression, and acceptance. The patient may move back and forth through the different stages as he and his family members react to the process of dying, but he usually goes through all of these stages to reach acceptance.
Option A: Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. Patients may directly deny the diagnosis, attribute it to faulty tests or an unqualified physician, or simply avoid the topic in conversation.
Option B: Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice.
Option D: Bargaining typically manifests as patients seek some measure of control over their illness. The negotiation could be verbalized or internal and could be medical, social, or religious. The patients’ proffered bargains could be rational, such as a commitment to adhere to treatment recommendations or accept help from their caregivers, or could represent more magical thinking, such as with efforts to appease misattributed guilt they may feel is responsible for their diagnosis. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Acceptance describes recognizing the reality of a difficult diagnosis while no longer protesting or struggling against it. Patients may choose to focus on enjoying the time they have left and reflecting on their memories.
A terminally ill patient usually experiences all of the following feelings during the anger stage except:
A. Rage
B. Envy
C. Numbness
D. Resentment
Correct Answer: C. Numbness
Numbness is typical of the depression stage, when the patient feels a great sense of loss. Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia. Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages.
Option A: The anger stage includes such feelings as rage, envy, resentment, and the patient’s questioning “Why me?” Anger, as Kubler-Ross pointed out, is commonly experienced and expressed by patients as they concede the reality of a terminal illness. It may be directed, as with blame of medical providers for inadequately preventing the illness, of family members for contributing to risks of not being sufficiently supportive, or of spiritual providers or higher powers for the diagnosis’ injustice.
Option B: Patients may feel sadness, anger, or confusion. They are experiencing the pain of loss. The task is completed as the patient begins to feel “normal” again.
Option D: The anger may also be generalized and undirected, manifesting as a shorter temper or a loss of patience. Recognizing anger as a natural response can help health care providers and loved-ones to tolerate what might otherwise feel like hurtful accusations, though they must take care not to disregard criticism that may be warranted by attributing them solely to an emotional stage.
Nurses and other healthcare providers often have difficulty helping a terminally ill patient through the necessary stages leading to acceptance of death. Which of the following strategies is most helpful to the nurse in achieving this goal?
A. Taking psychology courses related to gerontology.
B. Reading books and other literature on the subject of thanatology.
C. Reflecting on the significance of death.
D. Reviewing varying cultural beliefs and practices related to death
Correct Answer: C. Reflecting on the significance of death
According to thanatologists, reflecting on the significance of death helps to reduce the fear of death and enables the health care provider to better understand the terminally ill patient’s feelings. It also helps to overcome the belief that medical and nursing measures have failed, when a patient cannot be cured. Thanatology is the science and study of death and dying from multiple perspectives—medical, physical, psychological, spiritual, ethical, and more.
Option A: Professionals in a wide range of disciplines use thanatology to inform their work, from doctors and coroners to hospice workers and grief counselors. There also are thanatology specialists who focus on a specific aspect of the dying process or work directly with people facing their own death or that of loved ones.
Option B: A wide variety of professionals incorporate thanatology into their work. How they do so depends on what they need to know about the dying process. For example, a medical examiner, coroner, doctor, nurse, or other medical practitioners might study thanatology to better understand the physical process of death—what happens to the body during death as well as immediately after.
Option D: Thanatology also examines attitudes toward death, the meaning and behaviors of bereavement and grief, and the moral and ethical questions of euthanasia, organ transplants, and life support.
Which of the following symptoms is the best indicator of imminent death?
A. A weak, slow pulse
B. Increased muscle tone
C. Fixed, dilated pupils
D. Slow, shallow respirations
Correct Answer: C. Fixed, dilated pupils
Fixed, dilated pupils are a sign of imminent death. Death is a part of natural life; however, society is notorious for being uncomfortable with death and dying as a topic on the whole. Many caregivers experience a level of burden from their duties during end-of-life care. This burden is multi-faceted and may include performing medical tasks, communicating with providers, decision-making and possibly anticipating the grief of impending loss.
Option A: Pulse becomes weak but rapid. It is important to identify how to know death has occurred and to educate the family of a patient who may be actively dying. This is especially important if the patient is choosing to die at home.
Option B: Muscles become weak and atonic. It is imperative that patients and families have access to the care and support they require when entering a terminal phase of life. This phase is different for each patient, and the needs may differ for each patient and family, but it is vital for healthcare providers to provide care and support in a way that respects the patient’s dignity and autonomous wishes.
Option D: In the late stages, an altered respiratory pattern which can be periods of apnea alternated with hyperpnea or irregular breathing can be noticed.
A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the:
A. National League for Nursing (NLN)
B. Centers for Disease Control (CDC)
C. American Medical Association (AMA)
D. American Nurses Association (ANA)
Correct Answer: B. Centers for Disease Control (CDC)
The Center of Disease Control (CDC) publishes and frequently updates guidelines on caring for patients who require isolation. CDC is responsible for controlling the introduction and spread of infectious diseases, and provides consultation and assistance to other nations and international agencies to assist in improving their disease prevention and control, environmental health, and health promotion activities.
Option A: The National League of Nursing’s (NLN’s) major function is accrediting nursing education programs in the United States. The NLN, the premier organization for nurse educators, offers professional development, teaching resources, research grants, testing services, and public policy initiatives to its 40,000 individual and 1,200 institutional members, comprising nursing education programs across higher education and health care.
Option C: The American Medical Association (AMA) is a national organization of physicians. American Medical Association (AMA), organization of American physicians, the objective of which is “to promote the science and art of medicine and the betterment of public health.” It was founded in Philadelphia in 1847 by 250 delegates representing more than 40 medical societies and 28 colleges.
Option D: The American Nurses’ Association (ANA) is a national organization of registered nurses. ANA guides the profession on issues of nursing practice, health policy, and social concerns that impact patient wellbeing. Through their position statements, ANA amplifies the voice of nurses and educates both consumers and policymakers.
To institute appropriate isolation precautions, the nurse must first know the:
A. Organism’s mode of transmission
B. Organism’s Gram-staining characteristics
C. Organism’s susceptibility to antibiotics
D. Patient’s susceptibility to the organism
Correct Answer: A. Organism’s mode of transmission
Before instituting isolation precaution, the nurse must first determine the organism’s mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a gown, and gloves when coming in direct contact with the patient.
Option B: The organism’s Gram-staining characteristics reveal whether the organism is gram-negative or gram-positive, an important criterion in the physician’s choice for drug therapy and the nurse’s development of an effective plan of care.
Option C: The nurse also needs to know whether the organism is susceptible to antibiotics, but this could take several days to determine; if she waits for the results before instituting isolation precautions, the organism could be transmitted in the meantime.
Option D: The patient’s susceptibility to the organism has already been established. The nurse would not be instituting isolation precautions for a non-infected patient.
Which is the correct procedure for collecting a sputum specimen for culture and sensitivity testing?
A. Have the patient place the specimen in a container and enclose the container in a plastic bag.
B. Have the patient expectorate the sputum while the nurse holds the container.
C. Have the patient expectorate the sputum into a sterile container.
D. Offer the patient an antiseptic mouthwash just before he expectorate the sputum.
Correct Answer: C. Have the patient expectorate the sputum into a sterile container
Placing the specimen in a sterile container ensures that it will not become contaminated. A sputum specimen is obtained for culture to identify the microorganism responsible for lung infections; identify cancer cells shed by lung tumors; or aid in the diagnosis and management of occupational lung diseases. The other answers are incorrect because they do not mention sterility and because antiseptic mouthwash could destroy the organism to be cultured (before sputum collection, the patient may use only tap water for nursing the mouth).
Option A: Using the sterile collection container provided, instruct the patient to take three deep breaths, then force a deep cough and expectorate into a sterile screw-top container. To prevent contamination by particles in the air, keep the container closed until the patient is ready to spit into it.
Option B: Ten to 15 ml of sputum is typically needed for laboratory analysis. A specimen will be rejected by the laboratory if it contains excessive numbers of epithelial cells from the mouth or throat or if it fails to show adequate numbers of neutrophils on gram staining. If the patient cannot cough up a specimen, the respiratory therapist can use sputum induction techniques such as heated aerosol (nebulization), followed in some instances by postural drainage and percussion.
Option D: Don’t allow the patient to brush his teeth or use mouthwash. Doing so could kill bacteria in the sputum, rendering it useless. For best results, obtain the sample first thing in the morning. If it can’t be obtained before the patient has breakfast, though, wait at least an hour after he’s eaten before trying. Before beginning, describe the procedure to him.
An autoclave is used to sterilize hospital supplies because:
A. More articles can be sterilized at a time.
B. Steam causes less damage to the materials.
C. A lower temperature can be obtained.
D. Pressurized steam penetrates the supplies better
Correct Answer: D. Pressurized steam penetrates the supplies better.
An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressurized steam, is used because it can destroy all forms of microorganisms, including spores. Autoclaves operate at high temperature and pressure in order to kill microorganisms and spores. They are used to decontaminate certain biological waste and sterilize media, instruments, and labware.
Option A: Autoclaves provide a physical method for disinfection and sterilization. They work with a combination of steam, pressure, and time. Autoclaves operate at high temperature and pressure in order to kill microorganisms and spores. They are used to decontaminate certain biological waste and sterilize media, instruments and lab ware. Regulated medical waste that might contain bacteria, viruses and other biological material are recommended to be inactivated by autoclaving before disposal.
Option B: The rate of exhaust will depend upon the nature of the load. Dry material can be treated in a fast exhaust cycle, while liquids and biological waste require slow exhaust to prevent boiling over of superheated liquids.
Option C: To be effective, the autoclave must reach and maintain a temperature of 121° C for at least 30 minutes by using saturated steam under at least 15 psi of pressure. Increased cycle time may be necessary depending upon the make-up and volume of the load.
The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to:
A. Wash the gloves before removing them.
B. Gently pull on the fingers of the gloves when removing them.
C. Gently pull just below the cuff and invert the gloves when removing them.
D. Remove the gloves and then turn them inside out.
Correct Answer: C. Gently pull just below the cuff and invert the gloves when removing them
Turning the gloves inside out while removing them keeps all contaminants inside the gloves. They should then be placed in a plastic bag with soiled dressings and discarded in a soiled utility room garbage pail (double bagged). The other choices can spread pathogens within the environment.
Option A: They should also only be worn once, being changed between patients or between treatment areas on the same patient. For situations where there is a high risk of contamination or infection, NHS Professionals advise wearing two sets of gloves, known as ‘double gloving’.
Option B: Grasp the outside of one glove at the wrist. Do not touch the bare skin. Peel the glove away from the body, pulling it inside out. Hold the glove that was just removed in a gloved hand.
Option D: Peel off the second glove by putting the fingers inside the glove at the top of the wrist. Turn the second glove inside out while pulling it away from the body, leaving the first glove inside the second.
After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
A. Infection
B. Infiltration
C. Phlebitis
D. Bleeding
Correct Answer: C. Phlebitis
Tenderness, warmth, swelling, and, in some instances, a burning sensation are signs and symptoms of phlebitis. Superficial phlebitis affects veins on the skin surface. The condition is rarely serious and, with proper care, usually resolves rapidly. Sometimes people with superficial phlebitis also get deep vein thrombophlebitis, so a medical evaluation is necessary.
Option A: Infection is less likely because no drainage or fever is present. Call a health care provider if there are signs and symptoms of swelling, pain, and inflamed superficial veins on the arms or legs. If the client is not better in a week or two or if it gets any worse, he or she should get reevaluated to make sure they don’t have a more serious condition.
Option B: Infiltration would result in swelling and pallor, not erythema, near the insertion site. In phlebitis, there is usually a slow onset of a tender red area along the superficial veins on the skin. A long, thin red area may be seen as the inflammation follows a superficial vein. This area may feel hard, warm, and tender. The skin around the vein may be itchy and swollen. The area may begin to throb or burn.
Option D: The patient has no evidence of bleeding. Injury to a vein increases the risk of forming a blood clot. Sometimes clots occur without an injury.
To ensure homogenization when diluting powdered medication in a vial, the nurse should:
A. Shake the vial vigorously.
B. Roll the vial gently between the palms.
C. Invert the vial and let it stand for 1 minute.
D. Do nothing after adding the solution to the vial.
Correct Answer: B. Roll the vial gently between the palms.
Gently rolling a sealed vial between the palms produces sufficient heat to enhance dissolution of a powdered medication.
Option A: Shaking the vial vigorously can break down the medication and alter its pharmacologic action.
Option C: Inverting the vial or leaving it alone does not ensure thorough homogenization of the powder and the solvent.
Option D: Use aseptic technique to draw up the specified amount of diluent and inject it into the medication vial. Roll the vial in the hands to dissolve all the powder (emphasize not to shake the vial).
The nurse is teaching a patient to prepare a syringe with 40 units of U-100 NPH insulin for self-injection. The patient’s first priority concerning self-injection in this situation is to:
A. Assess the injection site.
B. Select the appropriate injection site.
C. Check the syringe to verify that the nurse has removed the prescribed insulin dose.
D. Clean the injection site in a circular manner with an alcohol sponge.
Correct Answer: C. Check the syringe to verify that the nurse has removed the prescribed insulin dose
When the nurse teaches the patient to prepare an insulin injection, the patient’s first priority is to validate the dose accuracy. The next steps are to select the site, assess the site, and clean the site with alcohol before injecting the insulin.
Option A: The site the client chooses for the injection should be clean and dry. If the skin is visibly dirty, clean it with soap and water. DO NOT use an alcohol wipe on the injection site. Choose where to give the injection. Keep a chart of places that have been used, so the client does not inject the insulin in the same place all the time. Ask the doctor for a chart.
Option B: The insulin needs to go into the fat layer under the skin. If the skin tissues are thicker, the client may be able to inject straight up and down (90º angle). Check with the provider before doing this.
Option D: To give an insulin injection, the client needs to fill the right syringe with the right amount of medicine, decide where to give the injection, and know how to give the injection.
The physician’s order reads “Administer 1 g cefazolin sodium (Ancef) in 150 ml of normal saline solution in 60 minutes.” What is the flow rate if the drop factor is 10 gtt = 1 ml?
A. 25 gtt/minute
B. 37 gtt/minute
C. 50 gtt/minute
D. 60 gtt/minute
Correct Answer: A. 25 gtt/minute
When you have an order for an IV infusion, it is the nurse’s responsibility to make sure the fluid will infuse at the prescribed rate. IV fluids may be infused by gravity using a manual roller clamp or dial-a-flow, or infused using an infusion pump. Regardless of the method, it is important to know how to calculate the correct IV flow rate.
Option B: When calculating the flow rate, determine which IV tubing you will be using, microdrip or macrodrip, so you can use the proper drop factor in your calculations. The drop factor is the number of drops in one mL of solution, and is printed on the IV tubing package.
Option C: Macrodrip and microdrip refers to the diameter of the needle where the drop enters the drip chamber. Macrodrip tubing delivers 10 to 20 gtts/mL and is used to infuse large volumes or to infuse fluids quickly. Microdrip tubing delivers 60 gtts/mL and is used for small or very precise amounts of fluid, as with neonates or pediatric patients.
Option D: If you simply need to figure out the mL per hour to infuse, take the total volume in mL, divided by the total time in hours, to equal the mL per hour.
A patient must receive 50 units of Humulin regular insulin. The label reads 100 units = 1 ml. How many milliliters should the nurse administer?
A. 0.5 ml
B. 0.75 ml
C. 1 ml
D. 2 ml
Correct Answer: A. 0.5 ml
There are 3 primary methods for calculation of medication dosages; Dimensional Analysis, Ratio Proportion, and Formula or Desired Over Have Method. Desired Over Have or Formula Method uses a formula or equation to solve for an unknown quantity (x) much like ratio proportion.
Option B: Drug calculations require the use of conversion factors, for example, when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows clinicians to work with various units of measurement, converting factors to find the answer. These methods are useful in checking the accuracy of the other methods of calculation, thus acting as a double or triple check.
Option C: The Ratio and Proportion Method has been around for years and is one of the oldest methods utilized in drug calculations (as cited in Boyer, 2002)[Lindow, 2004]. Addition principals is a problem-solving technique that has no bearing on this relationship, only multiplication, and division are used to navigate through a ratio and proportion problem, not adding.
Option D: High-risk medications such as heparin and insulin often require a second check on dosage amounts by more than one provider before the administration of the drug. Follow institutional policies and recommendations on the double-checking of dose calculations by another licensed provider.
How should the nurse prepare an injection for a patient who takes both regular and NPH insulin?
A. Draw up the NPH insulin, then the regular insulin, in the same syringe.
B. Draw up the regular insulin, then the NPH insulin, in the same syringe.
C. Use two separate syringes.
D. Check with the physician.
Correct Answer: B. Draw up the regular insulin, then the NPH insulin, in the same syringe.
Drugs that are compatible may be mixed together in one syringe. In the case of insulin, the shorter-acting, clear insulin (regular) should be drawn up before the longer-acting, cloudy insulin (NPH) to ensure accurate measurements.
Option A: Insulin, regular when administered subcutaneously, it should be injected 30 to 40 minutes before each meal. Avoid cold injections. The injection is in the buttocks, thighs, arms, or abdomen; it is necessary to rotate injection sites to avoid lipodystrophy. Do not inject if the solution is viscous or cloudy; use only if clear and colorless.
Option C: When administered intravenously, U-100 administration should be with close monitoring of serum potassium and blood glucose. Do not use if the solution is viscous or cloudy; administration should only take place if it is colorless and clear.
Option D: For intravenous infusions, to minimize insulin adsorption to plastic IV tubing, flush the intravenous tube with priming infusion of 20 mL from a 100 mL-polyvinyl chloride bag insulin, every time a new intravenous tubing is added to the insulin infusion container.
A patient has just received 30 mg of codeine by mouth for pain. Five minutes later he vomits. What should the nurse do first?
A. Call the physician
B. Remedicate the patient
C. Observe the emesis
D. Explain to the patient that she can do nothing to help him.
Correct Answer: C. Observe the emesis.
After a patient has vomited, the nurse must inspect the emesis to document color, consistency, and amount. Nausea or vomiting is another commonly seen adverse effect that is expected to diminish the following days to weeks of continued codeine exposure. Antiemetic therapies, in oral and rectal formulations, are available for the treatment of nausea or vomiting.
Option A: The nurse must then notify the physician, who will decide whether to repeat the dose or prescribe an antiemetic. Monitoring should include subjective as well as objective assessment via laboratory testing. There must be documentation of pain intensity, level of functioning, progress toward therapeutic goals, the presence of adverse effects, and adherence to the therapy.
Option B: In this situation, the patient recently ingested medication, so the nurse needs to check for remnants of the medication to help determine whether the patient retained enough of it to be effective.
Option D: Codeine has a half-life of 3 hours. Initial dosing and titration can be individualized depending on the patient’s health status, previous opioid exposure, attainment of therapeutic outcomes, and predicted or observed adverse events.
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:
A. Trauma has occurred.
B. His 24-hour output is adequate.
C. He has a urinary tract infection.
D. Residual urine remains in the bladder after voiding.
Correct Answer: B. His 24-hour output is adequate.
A 24-hour urine output of less than 500 ml in an adult is considered inadequate and may indicate kidney failure. This must be corrected while the patient is in the acute state so that appropriate fluids, electrolytes, and medications can be administered and excreted. Indwelling catheterization is not needed to diagnose trauma, urinary tract infection, or residual urine.
Option A: Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes. Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling (long-term).
Option C: Cystitis, urethritis, prostatitis (common infectious etiology in men), and vulvovaginitis in the woman can cause urinary retention.
Option D: Brain or spinal cord injury, cerebrovascular accident, multiple sclerosis, Parkinson disease, and dementia can lead to urinary retention.
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
A. Writing down all assignments.
B. Making changes after evaluating the situation and having discussions with the staff.
C. Telling the staff nurses that she is making changes to benefit their performance.
D. Evaluating the clinical performance of each staff nurse in a private conference.
Correct Answer: B. Making changes after evaluating the situation and having discussions with the staff.
A new assistant nurse manager should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change.
Option A: Written assignments allow all staff members to know their own and others’ responsibilities and serve as a checklist for the manager, enabling her to gauge whether the unit is being run effectively and whether patients are receiving appropriate care.
Option C: Telling the staff nurses that she is making changes to benefit their performance should occur only after the nurse has made a thorough evaluation.
Option D: Evaluations are usually done on a yearly basis or as needed.
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
A. Decreased plasma drug levels
B. Sensory deficits
C. Lack of family support
D. History of Tourette syndrome
Correct Answer: B. Sensory deficits
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Age-related decline of the five classical senses (vision, smell, hearing, touch, and taste) poses significant burdens on older adults. The co-occurrence of multiple sensory deficits in older adults is not well characterized and may reflect a common mechanism resulting in global sensory impairment.
Option A: Decreased plasma drug levels do not alter the patient’s knowledge about the drug. Aging has long been associated with decline in sensory function, a critical component of the health and quality of life of older people
Option C: A lack of family support may affect compliance, not knowledge retention. Vision impairment is correlated with depression, poor quality of life, cognitive decline, and mortality. Hearing loss is associated with slower gait speed (a marker of physical decline), poor cognition, and mortality. Like smell, taste has been associated with nutritional compromise and in-patient mortality, suggesting that chemosensory function is critical. Tactile discrimination declines with age due to the cumulative effects of decreased nerve conduction velocity, decreased density of Meissner’s and Pacinian corpuscles, and gray matter changes within the central nervous system, and is also associated with cognitive decline
Option D: Tourette syndrome is unrelated to knowledge retention. Tourette syndrome referred to as Tourette disorder in the recently updated Diagnostic and Statistical Manual of Mental Disorders (DSM–5), is a common neurodevelopmental disorder affecting up to 1% of the population. It is characterized by multiple motor and vocal tics and starts in childhood.
When examining a patient with abdominal pain the nurse in charge should assess:
A. Any quadrant first
B. The symptomatic quadrant first
C. The symptomatic quadrant last
D. The symptomatic quadrant either second or third
Correct Answer: C. The symptomatic quadrant last
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Option A: When possible, the history should be obtained from a non sedated patient. The initial differential diagnosis can be determined by a delineation of the pain’s location, radiation, and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the right lower quadrant of the abdomen).
Option B: After the location is identified, the physician should obtain general information about onset, duration, severity, and quality of pain and about exacerbating and remitting factors.
Option D: There are several specialized maneuvers that evaluate for signs associated with causes of abdominal pain. When present, some signs are highly predictive of certain diseases.
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
A. Vital signs
B. Laboratory test result
C. Patient’s description of pain
D. Electrocardiographic (ECG) waveforms
Correct Answer: C. Patient’s description of pain
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Subjective data provide clues to possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that may reveal a client’s risk for a problem as well as areas of strengths for the client. The information is obtained through interviewing. Vital signs, laboratory test results, and ECG waveforms are examples of objective data.
Option A: Vital sign monitoring is a fundamental component of nursing care. A patient’s pulse, respirations, blood pressure, and body temperature are essential in identifying clinical deterioration and that these parameters must be measured consistently and recorded accurately.
Option B: Many other tests are reported as numbers or values. Laboratory test results reported as numbers are not meaningful by themselves. Their meaning comes from comparison to reference values. Reference values are the values expected for a healthy person. They are sometimes called “normal” values.
Option D: The standard 12-lead electrocardiogram (ECG) is one of the most commonly used medical studies in the assessment of cardiovascular disease. It is the most important test for interpretation of the cardiac rhythm, detection of myocardial ischemia and infarction, conduction system abnormalities, preexcitation, long QT syndromes, atrial abnormalities, ventricular hypertrophy, pericarditis, and other conditions.
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
A. A palpable radial pulse
B. A palpable ulnar pulse
C. Cool, pale fingers
D. Pink nail beds
Correct Answer: C. Cool, pale fingers
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
Option A: To palpate a radial pulse, place the tips of the first two or three fingers over the groove along the radial (or thumb) side of the patient’s inner wrist. Slightly extended or flexed the patient’s wrist with the palm down until the pulse was strongest. Lightly compressed the artery against the radius, obliterating the pulse initially.
Option B: The pulse is felt just above a large, raised bony area called the zygomatic arch. Like the radial pulse, the ulnar pulse is taken at the wrist.
Option D: These old cells flatten and harden, thanks to keratin, a protein made by these cells. The newly formed nail then slides along the nail bed, the flat surface under the nails. The nail bed sits on top of tiny blood vessels that feed it and give the nails their pink color.
Which of the following planes divides the body longitudinally into anterior and posterior regions?
A. Frontal plane
B. Sagittal plane
C. Midsagittal plane
D. Transverse plane
Correct Answer: A. Frontal plane
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. The coronal plane or frontal plane (vertical) divides the body into dorsal and ventral (back and front, or posterior and anterior) portions. An anatomical plane is a hypothetical plane used to transect the body, in order to describe the location of structures or the direction of movements.
Option B: A sagittal plane runs longitudinally dividing the body into right and left regions. The sagittal plane or lateral plane (longitudinal, anteroposterior) is a plane parallel to the sagittal suture. It divides the body into left and right.
Option C: If exactly midline, it is called a midsagittal plane. The midsagittal or median plane is in the midline; i.e. it would pass through midline structures such as the navel or spine, and all other sagittal planes (also referred to as parasagittal planes) are parallel to it. Median can also refer to the midsagittal plane of other structures, such as a digit.
Option D: A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions. The transverse plane or axial plane (horizontal) divides the body into cranial and caudal (head and tail) portions.
A female patient with a terminal illness is in denial. Indicators of denial include:
A. Shock dismay
B. Numbness
C. Stoicism
D. Preparatory grief
Correct Answer: A. Shock dismay
Shock and dismay are early signs of denial-the first stage of grief. Denial is a common defense mechanism used to protect oneself from the hardship of considering an upsetting reality. Kubler-Ross noted that after the initial shock of receiving a terminal diagnosis, patients would often reject the reality of the new information. The other options are associated with depression—a later stage of grief.
Option B: Depression is perhaps the most immediately understandable of Kubler-Ross’s stages and patients experience it with unsurprising symptoms such as sadness, fatigue, and anhedonia.
Option C: Spending time in the first three stages is potentially an unconscious effort to protect oneself from this emotional pain, and, while the patient’s actions may potentially be easier to understand, they may be more jarring in juxtaposition to behaviors arising from the first three stages.
Option D: Consequently, caregivers may need to make a conscious effort to restore compassion that may have waned while caring for patients progressing through the first three stages.
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
A. Position the head of the bed flat.
B. Helps the patient dangle the legs.
C. Stands behind the patient.
D. Place the chair facing away from the bed.
Correct Answer: B. Helps the patient dangle the legs
After placing the patient in High Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
Option A: Allow the patient to sit for a few moments, in case the patient feels dizzy when first sitting up. To get the patient into a seated position, roll the patient onto the same side as the wheelchair.
Option C: The nurse should put one arm under the patient’s shoulders and one behind the knees. Bend the knees. Swing the patient’s feet off the edge of the bed and use the momentum to help the patient into a sitting position.
Option D: Move the patient to the edge of the bed and lower the bed so the patient’s feet are touching the ground. Make sure any loose rugs are out of the way to prevent slipping. You may want to put non-skid socks or shoes on the patient’s feet if the patient needs to step onto a slippery surface.
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
A. Asking frequently if the patient understands the instruction.
B. Asking an interpreter to replay the instructions to the patient.
C. Writing out the instructions and having a family member read them to the patient.
D. Demonstrating the procedure and having the patient return the demonstration.
Correct Answer: D. Demonstrating the procedure and having the patient return the demonstration
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. One of the leading causes of medical errors in the United States is miscommunication between patients and providers. When patients with limited English proficiency (LEP) cannot adequately communicate their needs, they are less likely to comply with medical instructions and receive vital services.
Option A: Patients may claim to understand discharge instruction when they do not. In-person translation services are preferred when complex medical information or end-of-life decisions are to be discussed. Studies show in-person professional interpretation increases patient satisfaction and outcomes of care. Interpreters use visual cues to enhance communication. However, in-person interpreters can be costly and can limit the number of languages that can be adequately staffed.
Option B: An interpreter of family members may communicate verbal or written instructions inaccurately. In some cases, patients prefer to use their family and friends as medical interpreters, but experts recommend against the practice because vital information may be lost.
Option C: Internet-based apps for smartphones and tablets help medical professionals interpret information quickly so they can be used in emergency settings. Experts warn, however, that the one-sided nature of such applications can lead to missed or misconstrued information.
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
A. Discard the syringe to avoid a medication error.
B. Obtain a label for the syringe from the pharmacy.
C. Use the syringe because it looks like it contains the same medication the nurse was prepared to give.
D. Call the day nurse to verify the contents of the syringe.
Correct Answer: A. Discard the syringe to avoid a medication error.
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
Option B: Since there are no labels on the syringe, obtaining a label from the pharmacy does not guarantee that they would be able to identify the medication inside the syringe.
Option C: Giving an unidentified medication could cause unwanted effects on the patient instead of desired effects.
Option D: The day nurse would not be able to guarantee that she could identify the medication without its label.
When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients have adverse drug effects?
A. Faster drug clearance
B. Aging-related physiological changes
C. Increased amount of neurons
D. Enhanced blood flow to the GI tract
Correct Answer: B. Aging-related physiological changes
Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. ADEs are estimated to be indicated in 5% to 28% of acute geriatric medical admissions. Preventable ADEs are among one of the serious consequences of inappropriate medication use in older adults.
Option A: Renal and hepatic changes cause drugs to clear more slowly in these patients. Aging leads to a reduced number of functional glomeruli and an increased prevalence of sclerotic changes within the glomeruli or renal vasculature. Additionally, there is a normal decrease in GFR observed in advanced age, but this places the elderly at much higher risk for complications in the event that they develop chronic or acute kidney disease, as they have less functional glomeruli as a result of normal aging physiology.
Option C: With increasing age, neurons are lost. Abnormal compensatory mechanisms predispose individuals to neurodegeneration and dementia, Parkinson disease, and overall cerebral atrophy are observable in aging individuals.
Option D: Blood flow to the GI tract decreases. The weakening of smooth muscle in the intestinal tract can promote the development of diverticular disease and can play a role in bowel obstructions or constipation. Decreased metabolic activity, specifically in the liver, can lead to alterations in drug metabolism.
A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role?
A. Manager
B. Educator
C. Caregiver
D. Patient advocate
Correct Answer: B. Educator
When teaching a patient about medications before discharge, the nurse is acting as an educator. They provide educational leadership to patients and care providers to enhance specialized patient care within established healthcare settings. Assists patients and caregivers with educational needs, problem resolution, and health management across the continuum of care.
Option A: The nurse acts as a manager when performing such activities as scheduling and making patient care assignments. Great nurse managers are able to work in coordination with other departments. They must also possess the ability to oversee an array of practice functions including staff supervision, clinical tasks, and appointments. It is also part of their jobs to liaise with pathology labs, suppliers, and other health facilities.
Option C: The nurse performs the caregiving role when providing direct care, including bathing patients and administering medications and prescribed treatments. Healthcare should address a patient’s cultural, spiritual and mental needs. Increasing diversity in a growing patient population requires nurses to demonstrate cultural awareness and sensitivity. Patients may have specific needs and preferences due to their religion or gender, for example. Nurses need to be respectful of, and knowledgeable about, diverse backgrounds while remaining vigilant in providing quality care.
Option D: The nurse acts as a patient advocate when making the patient’s wishes known to the doctor. A nurse advocate is a nurse who works on behalf of patients to maintain quality of care and protect patients’ rights. They intervene when there is a care concern, and following the proper channels, work to resolve any patient care issues. Realistically, every nurse is an advocate.
A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient’s anxiety?
A. “Everything will be fine. Don’t worry.”
B. “Read this manual and then ask me any questions you may have.”
C. “Why don’t you listen to the radio?”
D. “Let’s talk about what’s bothering you.”
Correct Answer: D. “Let’s talk about what’s bothering you.”
Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the patient to express feelings. The nurse should be supportive and develop goals together with the patient to give the patient some control over an anxiety-inducing situation. Because the other options ignore the patient’s feelings and block communication, they would not reduce anxiety.
Option A: Recognize awareness of the patient’s anxiety. Since a cause of anxiety cannot always be identified, the patient may feel as though the feelings being experienced are counterfeit. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings.
Option B: Converse using a simple language and brief statements. Allow patients to talk about anxious feelings and examine anxiety-provoking situations if they are identifiable. Talking about anxiety-producing situations and anxious feelings can help the patient perceive the situation realistically and recognize factors leading to the anxious feelings.
Option C: Assist the patient in developing new anxiety-reducing skills (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). Discovering new coping methods provides the patient with a variety of ways to manage anxiety.
A scrub nurse in the operating room has which responsibility?
A. Positioning the patient
B. Assisting with gowning and gloving
C. Handling surgical instruments to the surgeon
D. Applying surgical drapes
Correct Answer: C. Handling surgical instruments to the surgeon
The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze, sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the patient, applies appropriate equipment and surgical drapes, assists with gowning and gloving, and provides the surgeon and scrub nurse with supplies.
Option A: The circulating nurse is responsible for managing all nursing care within the operating room, observing the surgical team from a broad perspective, and assisting the team to create and maintain a safe, comfortable environment for the patient’s surgery.
Option B: A circulating nurse is responsible for coordinating care, obtaining supplies, and liaising with the patient’s family.
Option D: Assessing the patient right before surgery is critical to making sure that all required prep was completed. Serving as a patient advocate and safety monitor, the circulating nurse observes the surgery and ensures that no aspect of patient care is missed.
A patient is in the bathroom when the nurse enters to give a prescribed medication. What should the nurse in charge do?
A. Leave the medication at the patient’s bedside.
B. Tell the patient to be sure to take the medication. And then leave it at the bedside.
C. Return shortly to the patient’s room and remain there until the patient takes the medication.
D. Wait for the patient to return to bed, and then leave the medication at the bedside.
Correct Answer: C. Return shortly to the patient’s room and remain there until the patient takes the medication
The nurse should return shortly to the patient’s room and remain there until the patient takes the medication to verify that it was taken as directed. With the growing reliance on medication therapy as the primary intervention for most illnesses, patients receiving medication interventions are exposed to potential harm as well as benefits. Benefits are effective management of the illness/disease, slowed progression of the disease, and improved patient outcomes with few if any errors. Harm from medications can arise from unintended consequences as well as medication error (wrong medication, wrong time, wrong dose, etc.).
Option A: The nurse should never leave medication at the patient’s bedside unless specifically requested to do so.
Option B: With inadequate nursing education about patient safety and quality, excessive workloads, staffing inadequacies, fatigue, illegible provider handwriting, flawed dispensing systems, and problems with the labeling of drugs, nurses are continually challenged to ensure that their patients receive the right medication at the right time.
Option D: Examples of errors that can be initiated at the transcribing, dispensing, and delivering stages include failure to transcribe the order, incorrectly filling the order, and failure to deliver the correct medication for the correct patient.
The physician orders heparin, 7,500 units, to be administered subcutaneously every 6 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?
A. ¼ ml
B. ½ ml
C. ¾ ml
D. 1 ¼ ml
Correct Answer: C. ¾ ml
The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000 X = 7,500
X= 7,500/10,000 or ¾ ml
Option A: There are 3 primary methods for the calculation of medication dosages, as referenced above. These include Desired Over Have Method or Formula, Dimensional Analysis and Ratio and Proportion.
Option B: Desired over Have or Formula Method is a formula or equation to solve for an unknown quantity (x) much like ratio proportion. Drug calculations require the use of conversion factors, such as when converting from pounds to kilograms or liters to milliliters. Simplistic in design, this method allows us to work with various units of measurement, converting factors to find our answer. Useful in checking the accuracy of the other methods of calculation as above mentioned, thus acting as a double or triple check.
Option D: The Ratio and Proportion Method has been around for years and is one of the oldest methods utilized in drug calculations (as cited in Boyer, 2002)[Lindow, 2004]. Addition principals is a problem-solving technique that has no bearing on this relationship, only multiplication, and division are used to navigate through a ratio and proportion problem, not adding.
The nurse in charge measures a patient’s temperature at 102 degrees F. what is the equivalent Centigrade temperature?
A. 39 degrees C
B. 47 degrees C
C. 38.9 degrees C
D. 40.1 degrees C
Correct Answer: C. 38.9 degrees C
To convert Fahrenheit degrees to centigrade, use this formula: C degrees = (F degrees – 32) x 5/9 C degrees = (102 – 32) 5/9 \+ 70 x 5/9 38.9 degrees C
Option A: Fahrenheit and Celsius both use different temperatures for the freezing and boiling points of water, and also use differently sized degrees. Water freezes at 0 degrees Celsius, and boils at 100 degrees C, while in Fahrenheit, water freezes at 32 degrees F and boils at 212 degrees F.
Option B: Use the relationship in degree size to convert between Celsius and Fahrenheit. Because Celsius degrees are larger than those in Fahrenheit, to convert from Celsius to Fahrenheit, multiply the Celsius temperature by 1.8, then add 32.
Option D: The Fahrenheit and Celsius scales are the two most common temperature scales. However, the two scales use different measurements for the freezing and boiling points of water, and also use different sized degrees.
To evaluate a patient for hypoxia, the physician is most likely to order which laboratory test?
A. Red blood cell count
B. Sputum culture
C. Total hemoglobin
D. Arterial blood gas (ABG) analysis
Correct Answer: D. Arterial blood gas (ABG) analysis
All of these tests help evaluate a patient with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about a patient’s oxygenation status. An acceptable normal range of ABG values of ABG components are the following,[5][6] noting that the range of normal values may vary among laboratories, and in different age groups from neonates to geriatrics: pH (7.35-7.45) PaO2 (75-100 mmHg) PaCO2 (35-45 mmHg).
Option A: A red blood cell count is a blood test that the doctor uses to find out how many red blood cells (RBCs) a person has. It’s also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to the body’s tissues. The number of RBCs one has can affect how much oxygen the tissues receive. The tissues need oxygen to function.
Option B: A sputum culture is a test that checks for bacteria or another type of organism that may be causing an infection in the lungs or the airways leading to the lungs. Sputum, also known as phlegm, is a thick type of mucus made in the lungs.
Option C: The normal range for hemoglobin is: For men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter.
