week 11 sherpath Flashcards by Monica Galvan-Valencia

In which situation related to medication administration is the use of the teach-back method essential?

Patient refuses a medication.

New medication is prescribed.

Dosage of a medication is changed.

More than one medication is taken at the same time.

Patient refuses a medication.

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To confirm the right drug, medication labels are checked against the medication administration record (MAR) at least how many times before the medication is administered to the patient? Record your answer as a whole number.

Use numbers only.

3 times

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At which times does the nurse check for the “right drug”?

Select all that apply.

When removing the drug from the dispensing unit

When preparing the medication

Just before entering the patient’s room

At the bedside immediately before administration

On completion of documentation that the medication was given

When removing the drug from the dispensing unit

When preparing the medication

At the bedside immediately before administration

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Match the prescription abbreviation with its meaning.

Before meals

Milliliter

Four times per day

Sublingual

Answer choices

PRN

qid

Before meals
ac

Milliliter
mL

Four times per day
qid

Sublingual
SL

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Which medication prescription requires clarification with the health care provider?

Cefadroxil 500 mg PO bid

Tobramycin 60 mg IM q8h

Diazepam 6 mg IM STAT

Heparin 7500 units subcutaneously

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What is the meaning of “qid” in a medication prescription?

Every day

Every other day

Four times per day

Every day as needed

Four times per day

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The metric system has a basic unit of __ .

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Which information are needed to set up a dimensional analysis equation for calculating a medication dosage?

Select all that apply.

Dose to be given

Available concentration

Frequency of administration

Unit conversion

Time of last dose given

Dose to be given

Available concentration

Unit conversion

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Which step in dimensional analysis is done first?

Set up the equation.

Identify the unit of measure needed for the answer.

Calculate the numbers to get the answer.

Simplify the units.

Identify the unit of measure needed for the answer.

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Which factors related to medication errors are considered systems factors?

Select all that apply.

Stress

Communication of prescriptions

Dispensing

Miscalculation of dosage

Product labeling, packaging, and nomenclature

Communication of prescriptions

Product labeling, packaging, and nomenclature

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At which times would the nurse perform medication reconciliation?

Select all that apply.

At least once every 72 hours

When a patient is discharged home

Whenever a new medication is prescribed

When a patient is admitted to the hospital

Whenever the dosage of a medication is changed

When a patient is discharged home

When a patient is admitted to the hospital

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Which factor best explains the need for medication reconciliation as a routine part of medication error prevention?

Cultural diversity

Population mobility

Prevalence of polypharmacy

Increase in health care options

Prevalence of polypharmacy

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Which actions are taken when a patient refuses a medication?

Select all that apply.

Notify the health care provider.

Contact a family member.

Inquire why the patient is refusing.

Explain the consequences of refusal with teach-back.

Provide at least two opportunities for the patient to reconsider.

Document the circumstances of the situation and the actions taken.

Notify the health care provider.

Inquire why the patient is refusing.

Explain the consequences of refusal with teach-back.

Document the circumstances of the situation and the actions taken.

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As a general rule, which information should be given to a patient when a drug is being administered?

Select all that apply.

Name of the drug

Why the drug has been prescribed

Risk for adverse reactions

How long the drug will be taken

Expected side effects

Whether the drug is having the expected therapeutic effect

Name of the drug

Why the drug has been prescribed

Expected side effects

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The nurse looks up an unfamiliar medication when preparing to administer it. The reference indicates the medication is on the Institute for Safe Medication Practices (ISMP) high-alert list. Which action would the nurse take?

Have a second nurse verify the dosage.

Reconfirm the prescription with the health care provider.

Schedule laboratory blood work for 1 hour after administration.

Double-check with the patient that there is no known allergy to the medication.

Have a second nurse verify the dosage.

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The nurse would contact the health care provider for clarification for which medication prescription?

Ciprofloxacin 0.5 g PO bid

Diltiazem 60 mg PO bid

Lisinopril 5 mg PO qd

Doxepin hydrochloride 30 mg PO at bedtime

Lisinopril 5 mg PO qd

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To which aspect does the abbreviation STAT refer when used in a prescription for a medication?

Drug dosage

Drug formulation

Route of administration

Frequency/time of administration

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Which medication would the nurse plan to give without first clarifying the prescription with the health care provider?

Toprol XL 100 mg PO QD

Naltrexone hydrochloride 50 mg PO daily

Pantoprazole SOD DR 40 mg by mouth

Benzonatate 200 mg PO tid PRN

Naltrexone hydrochloride 50 mg PO daily

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Medication prescription: cimetidine 0.4 g PO, q6h
Available: 400-mg tablets

How many tablets should be given to the patient?

1 tablet(s)

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Medication prescription: digoxin 0.25 mg IV stat
Available: digoxin 0.5 mg/2 mL

How many milliliters should be given to the patient?

Use numbers only.

1 mL

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Medication prescription: hydrochlorothiazide 25 mg PO daily
Available: 50-mg tablets

How many tablets should be given to the patient? (Record your answer as a decimal and include a leading zero, if applicable.)

0.5 tablet(s)

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Patient reluctance to share information is a major obstacle to which process?

Medication reconciliation

Assessment of allergic reactions

Identification of medication side effects

Determination of patient education needs

Medication reconciliation

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Match each right of medication administration to the factor that puts it at risk for being violated.

Look-alike and soundalike medications

Need to crush a tablet

Narrow window of administration

Smudged patient name on wristband

Answer choices

Right dose

Right route

Right drug

Right patient

Right time

Look-alike and soundalike medications
Right drug

Need to crush a tablet
Right dose

Narrow window of administration
Right time

Smudged patient name on wristband
Right patient

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Which questions are answered by the medication reconciliation process?

Select all that apply.

Are all prescribed medications available in generic forms?

Does the patient’s insurance cover all prescribed medications?

Are any of the prescribed medications duplicates of each other?

Does the patient currently need every medication that is prescribed?

Are there any medications that the patient needs that are not prescribed?

Do any of the prescribed medications interact with one another, requiring an adjustment in dosage or a change in the medications themselves?

Are any of the prescribed medications duplicates of each other?

Does the patient currently need every medication that is prescribed?

Are there any medications that the patient needs that are not prescribed?

Do any of the prescribed medications interact with one another, requiring an adjustment in dosage or a change in the medications themselves?

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Which statements describe a medication history and its function? Select all that apply. Helps identify areas where patient education is needed Focuses on both current and recently used medications Can guide decisions on future medications if accurate and complete Gathers data about herbal preparations but not dietary supplements Asks questions related to patient adherence to the prescribed medication regimen.

Helps identify areas where patient education is needed Focuses on both current and recently used medications Can guide decisions on future medications if accurate and complete Asks questions related to patient adherence to the prescribed medication regimen.

Which statement best describes ongoing assessments related to medication administration? Ongoing assessments are primarily used as part of the patient’s annual physical examination in the outpatient setting. The main purpose of ongoing assessments is to document changes in the patient’s medication history. Ongoing assessments should be done every week to ensure the therapeutic effect of the medication is maintained. The main purposes of ongoing assessments are to evaluate the effectiveness of a medication and to identify any adverse effects.

The main purposes of ongoing assessments are to evaluate the effectiveness of a medication and to identify any adverse effects.

Match the category of medication with the point-of-administration assessment that it requires. Pulse Blood pressure Temperature Respiratory rate Answer choices Antipyretic Opioid analgesic Antihypertensive Anticoagulant Cardiac glycoside

Pulse Cardiac glycoside Blood pressure Antihypertensive Temperature Antipyretic Respiratory rate Opioid analgesic

Assessment of dexterity and mobility statuses could cue to which problem related to medication administration? Lack of sufficient fatty tissue for a subcutaneous injection Ability to open medication containers Risk for a rectal tear with rectal administration Need for extended- or time-release medications

Ability to open medication containers

Which factor would the nurse recognize as a cue indicating that a patient must be checked for bleeding after an intramuscular injection? Slender, nonathletic build Allergy to aspirin Current anticoagulant therapy Elevated serum creatinine levels

Current anticoagulant therapy

For which reason would the nurse ask a patient about food allergies as part of the medication history? Can cue to the need for enteric-coated tablets Can cue to the risk for an allergic reaction to the medication Can cue to the necessity of avoiding oral medication administration Can cue to the importance of monitoring levels of medication in the blood

Can cue to the risk for an allergic reaction to the medication

Which focused assessment would the nurse perform when caring for a patient with a prescription for a medication administered by transdermal patch? Assess the patient’s level of consciousness. Inspect the patient’s skin for cracks and lesions. Ensure the patient has patent intravenous access. Check to make sure the patient has adequate muscle mass.

Inspect the patient’s skin for cracks and lesions.

The nurse is caring for a patient who has digoxin prescribed for chronic heart failure. Which assessment data is needed before administering the digoxin? Blood pressure Radial pulse Apical pulse Oxygen saturation

Apical pulse

Which questions would the nurse ask a patient when obtaining the patient’s medication history? Select all that apply. “What is your alcohol intake?” “What are your current laboratory test values?” “Have you recently stopped taking any medications?” “What prescribed medications are you currently taking?” “Do you have any preferences or habits related to your cultural background that influence the medications you take?”

“What is your alcohol intake?” “Have you recently stopped taking any medications?” “What prescribed medications are you currently taking?” “Do you have any preferences or habits related to your cultural background that influence the medications you take?”

Which factor is cued by gathering information about a patient’s prior exposure to a medication that is being prescribed? Risk for kidney impairment Likelihood of side and adverse effects Probability of a medication interaction Ability to follow prescribed directions for taking the medication

Likelihood of side and adverse effects

Which factors would the nurse recognize as cues that oral administration might not be appropriate for a patient? Select all that apply. Patient must lie flat. Patient has ill-fitting dentures. Patient has difficulty swallowing. Patient reports feeling nauseated. Patient has postnasal drip and a sore throat. Patient questions the taste of the medication, saying “Are you sure it doesn’t taste bad?”

Patient must lie flat. Patient has difficulty swallowing. Patient reports feeling nauseated.

Which factors would the nurse recognize as cues indicating that a patient is at increased risk for an adverse reaction to a medication? Select all that apply. Age of 71 years History of kidney disease Admitted for a knee replacement Taking the medication for the first time Allergic to watermelon, cucumber, and peanuts

Age of 71 years History of kidney disease Allergic to watermelon, cucumber, and peanuts

Which hypothesis is the nurse addressing when the patient is assessed for urticaria, itching, and rash after administration of a medication? Risk for allergic reaction Risk for Cross-Infection Risk for Adverse Medication Interaction Risk for impaired tissue integrity

Risk for allergic reaction

Which descriptors would the nurse use in summarizing changes in a patient’s condition after a medication interaction? Critical, stable, good Satisfactory, unsatisfactory Life-threatening, urgent, immediate concern Improving, declining, unchanged

Improving, declining, unchanged

Which hypothesis is the nurse addressing by using aseptic technique as an intervention? Risk for Cross-Infection Risk for allergic reaction Risk for Adverse Medication Interaction Risk for Injury

Risk for Cross-Infection

Which types of medication cannot be administered to patients who have difficulty swallowing and require medications to be crushed? Select all that apply. Capsules Scored tablets Sublingual tablets Time-release tablets Enteric-coated tablets

Time-release tablets Enteric-coated tablets

Which direction would be given to a patient with a prescription for a swish-and-swallow medication? “Do not rinse your mouth after taking the swish-and-swallow medication.” “Tilt your head front to back while the medicine is in your mouth.” “Keep the medication away from your cheeks; bubble it in the back of your throat, almost like gargling.” “Take the swish-and-swallow medication before you swallow any other medications.”

“Do not rinse your mouth after taking the swish-and-swallow medication.”

When using a dropper to give liquid medication to an infant, where should the medication be deposited in the mouth? Middle of tongue Alongside the tongue Behind the gum under the tongue Between the gum and the lower lip

Alongside the tongue

When more than one medication must be instilled in the eye, the nurse waits a minimum of how many minutes between instillations?

3 minutes

For which purpose does the nurse push on the tragus after instilling an otic medication? Relieve pain. Straighten the ear canal. Prevent loss of medication. Reduce tinnitus.

Prevent loss of medication.

Which instruction would the nurse give a patient when a nasal medication is being administered? “Breathe in.” “Breathe out.” “Breathe normally.” “Hold your breath.”

“Breathe in.”

Which comment made by a patient wearing a transdermal patch requires further investigation by the nurse? “I feel like a checkerboard with these patches being rotated around.” “This patch itches and burns. I have to keep rubbing it to make it feel better.” “I never realized I had so much hair on my chest and back until I tried to find hairless places to put a patch.” “It seems that every one of these patches comes loose before it is time to remove it, and I have to tape around the sides with hypoallergenic tape to hold it in place.”

“This patch itches and burns. I have to keep rubbing it to make it feel better.”

The mother of a 2-year-old patient asks the nurse how far a rectal suppository prescribed for her child should be inserted. Which response by the nurse is accurate? ¼ inch ½ inch 1 inch 1½ inches

½ inch

Which patient position is preferred for insertion of a vaginal suppository? Left side-lying position with upper knee flexed (Sims position) Right side-lying position Dorsal recumbent position Prone with legs apart

Dorsal recumbent position

Which sites are used to administer intradermal injections? Select all that apply. Inner forearm Lateral upper arm Deltoid area Fatty tissue Scapular area

Inner forearm Lateral upper arm Scapular area

Which action is required when using the zigzag (Z-track) method for intramuscular medication administration? Using the vastus lateralis as the site for injection Massaging the injection site after administration Waiting 15 seconds before withdrawing the needle after injecting the medication Changing needles between drawing up the medication and administering it

Changing needles between drawing up the medication and administering it

Place the parenteral methods of medication administration in order from fastest to slowest onset of action. Intramuscular Intravenous Subcutaneous Intradermal

Intravenous Intramuscular Subcutaneous Intradermal

Which concept is the major focus of nursing interventions designed to promote safe medication administration in the home? Patient comfort Patient education Patient independence and autonomy Patient relationships with equipment providers

Patient education

Which comment made by a patient before discharge alerts the nurse that further teaching regarding home medication administration is required? “I’m switching all my prescriptions to one pharmacy.” “I’m going to keep a log of the medications and supplements I take.” “I’m putting three or four of each of my pills together in a bottle for use in an emergency.” “If I decide to try herbs, I will check first with my doctor to see if there would be a problem with my medications.”

“I’m putting three or four of each of my pills together in a bottle for use in an emergency.”

Which pieces of information should patients know about any medication prescribed for them? Select all that apply. Appearance of the medication Manufacturer of the medication Expected side effects of the medication Adverse effects of the medication to be reported Dose, route, and frequency of the medication Expected therapeutic effect of the medication

Expected side effects of the medication Adverse effects of the medication to be reported Dose, route, and frequency of the medication Expected therapeutic effect of the medication

For which patient would providing a weekly medication organizer be an appropriate intervention? Forgetful patient Near-sighted patient Wheelchair-bound patient Patient whose first language is not English

Forgetful patient

For how many minutes would a nurse monitor a patient for an immediate allergic reaction following medication administration? Record your answer as two whole numbers separated by a hyphen. ____ minutes Use numbers only.

20-30

The nurse instructs a patient for whom a transdermal patch has been prescribed to rotate sites of application. For which hypothesis is this instruction an intervention? Risk for Cross-Infection Risk for allergic reaction Risk for impaired tissue integrity Risk for Adverse Medication Interaction

Risk for impaired tissue integrity

In response to a hypothesis of Lack of Knowledge of Medication Regime, the nurse teaches the patient about a newly prescribed medication, specifically the name, dose, route of administration, time, frequency, and special instructions. Which method would the nurse use to evaluate the effectiveness of the teaching? Observe the patient correctly self-administering a dose of the new medication at least once. Request the patient to ask clarifying questions after review of written directions for use of the new medication. Ask the patient to rate his or her understanding of the directions for use of the new medication on a scale from 1 to 5, with 1 being “do not understand” and 5 being “understand completely.” Ask the patient to explain the use of the new medication, giving its name, dose, route, frequency, expected effects, and management of side and adverse effects of the new medication.

Ask the patient to explain the use of the new medication, giving its name, dose, route, frequency, expected effects, and management of side and adverse effects of the new medication.

A newly admitted patient tells the nurse “I can’t swallow medicines; they all need to be crushed.” Based on this statement, the nurse would contact the health care provider about a prescription for which form of medication? Troche Sublingual medication Enteric-coated tablet Capsule

Enteric-coated tablet

A patient has a prescription for 2.5 mL of a liquid medication to be administered orally. In accordance with best practice guidelines, which device would the nurse use when preparing this medication? Oral syringe calibrated in metric only Measuring spoon calibrated in metric Syringe calibrated in both metric and household units Medicine cup calibrated in both metric and household units

Oral syringe calibrated in metric only

Which statement made by a patient who self-administers medications through a gastrointestinal (GI) tube indicates the need for further instruction about the process? “I take one medication at a time and flush the tube before and after each one.” “If a medication seems thick and I might have a problem getting through the tube, I dilute it.” “I take my evening medications, sit up and watch television for an hour or more, and then head into bed.” “I mix my morning medication with my morning feeding to save a bit of time before leaving for work.”

“I mix my morning medication with my morning feeding to save a bit of time before leaving for work.”

When administering an otic medication to an adult, which action would the nurse take to facilitate the spread of the medication to the entire ear canal? Press on the tragus. Pull up and back on the pinna. Ask the patient to hold their breath. Tell the patient to tilt their head forward.

Pull up and back on the pinna.

The nurse directs a patient who needs two puffs of medication from a metered-dose inhaler to wait how many minutes between puff one and puff two? Record your answer as a whole number. ___ min Use numbers only.

1 min

A patient is to have an ophthalmic ointment applied to both eyes. Which information would the nurse provide? Select all that apply. “Your vision may be blurred for a while after I put the ointment in your eyes.” “You will need to keep your eyes wide open for 2 minutes after the ointment is applied.” “I’m giving you two tissues to use to wipe extra -ointment off your face; use one for each eye.” “I will be applying the ointment from the outside corner of your eye in to the corner near your nose.” “You will have a 5-minute wait between getting the ointment in the first eye and getting it in the second.”

“Your vision may be blurred for a while after I put the ointment in your eyes.” “I’m giving you two tissues to use to wipe extra -ointment off your face; use one for each eye.”

Which characteristic is an advantage of a transdermal patch? No adverse systemic effects No preparation needed for use Almost-immediate onset of action Long-term continuous administration

Long-term continuous administration

Which action would the nurse take as part of the procedure for administering a vaginal suppository? Place the patient in a high Fowler’s position. Lubricate the applicator with a water-soluble gel. Warm the suppository to room temperature before administration. Instruct the patient to remain in a side-lying position for 10 minutes.

Lubricate the applicator with a water-soluble gel.

A patient preparing to insert her prescribed vaginal suppository is reviewing the procedure with the nurse. Which statement made by the patient alerts the nurse that further explanation is required? “I need to urinate before I put the suppository in.” “I’ll watch television for the half hour I have to lie still after I put this in.” “I have a tampon ready to insert after the suppository to catch any drips.” “I need to put the suppository in along the back wall of my vagina about a finger length.”

“I have a tampon ready to insert after the suppository to catch any drips.”

Which statements are appropriate for the nurse to make to a patient who is about to receive pain medication by intravenous push? Select all that apply. “You will feel the effects quickly.” “Let me know if your arm hurts or swells.” “It may take a while for the medication to kick in.” “The medication is being injected into your muscle.” “The medication is being injected into your bloodstream.”

“You will feel the effects quickly.” “Let me know if your arm hurts or swells.” “The medication is being injected into your bloodstream.”

Which actions apply to the administration of an intradermal injection? Select all that apply. Using a 45-degree angle of insertion Monitoring the skin for a wheal Pinching the skin before needle insertion Inserting the needle into the skin with the bevel up Applying outward traction to the skin around the site

Monitoring the skin for a wheal Inserting the needle into the skin with the bevel up Applying outward traction to the skin around the site

A diagram of which injection site would be most helpful when teaching a patient how to use of an EpiPen? Deltoid Dorsogluteal muscle Ventrogluteal muscle Vastus lateralis

Vastus lateralis

Which statement by a patient who has received instructions about self-administration of medications in the home indicates a misunderstanding of information? “I will remember not to dispose of the sharps in the regular trash receptacle.” “If I miss a dose of any medication, I’ll just double the dose when I take it the next time.” “Making a chart so I can mark off when I take each medication will help me keep track of my medications.” “I will not crush my time-release tablet. If I have trouble swallowing it, I will call the health care provider.”

“If I miss a dose of any medication, I’ll just double the dose when I take it the next time.”

An older, visually impaired but proudly self-sufficient adult patient has several prescribed medications to take at home. Which action would the nurse take to assist this patient in complying with the medication regimen? Create a chart for the patient to follow, showing the times when medications should be taken. Ask a family member to come over each day to administer medications. Arrange for the medications to be put in a weekly pill organizer. Suggest the patient set an alarm clock for the times medications are to be taken.

Arrange for the medications to be put in a weekly pill organizer.

Which statement made by a nurse conducting discharge teaching indicates a review of patient education principles related to medication administration is needed? “I’m going to be explaining how to change your transdermal patch. Would you like your spouse to sit in?” “It’s really important that you feel comfortable using your nebulizer, so I want you to show me how you will do it.” “Metoprolol is your blood pressure pill. Notice it is a scored tablet, but you are not going to cut it in half. You are going to take the whole thing.” “This pink pill is digoxin, your heart medication. You will take your pulse before you take this pill. If your pulse is less than 60 beats per minute, you will not take the pill.”

“This pink pill is digoxin, your heart medication. You will take your pulse before you take this pill. If your pulse is less than 60 beats per minute, you will not take the pill.”

A nurse is training new staff to assess a patient’s activities of daily living (ADLs). Which areas would the nurse advise the new staff to include in their assessment? Select all that apply. Bathing Toileting Dressing Laundry Housekeeping

Bathing Toileting Dressing

During a patient’s hospitalization, the nurse notes that the patient is unable to perform basic self-care. Which action would the nurse take to prepare the patient for discharge? Provide additional instruction for performing activities of daily living. Keep the patient in the hospital until able to perform self-care. Arrange for a home care agency to provide assistance in the home. Encourage the patient’s family to find someone in the community to assist the patient.

Arrange for a home care agency to provide assistance in the home.

For which factors would the nurse assess while inspecting difficult-to-reach areas of the skin? Select all that apply. Debris Soiling Excessive moisture Clubbing Redness

Debris Soiling Excessive moisture Redness

The nurse would give extra attention to assessing for infections on and around the nails in a patient with which condition? Halitosis Pediculosis Diabetes Dandruff

Diabetes

Which skin conditions might be present if a patient is having an allergic reaction to something he or she touched? Select all that apply. Excoriation Contact dermatitis Hirsutism Puncture wound Dry skin Rash

Contact dermatitis Rash

Which areas are common sites for pressure injuries? Select all that apply. Heels Hips Breasts Ears Knees Shoulders

Heels Hips Ears Shoulders

Match the hair or nail condition to its cause. Pediculosis capitis Ixodes scapularis Fungus Pediculosis corporis Answer choices Ticks Paronychia Body lice Head lice Dandruff Alopecia

Pediculosis capitis Head lice Ixodes scapularis Ticks Fungus Paronychia Pediculosis corporis Body lice

Which piece of clothing would the nurse remove when looking for excoriations? Socks Pants Headband Adult diaper

Adult diaper

When reviewing a patient’s chart, the nurse notes documentation of a pressure injury. Which finding would the nurse expect upon assessment? Open wound over the sacrum Red, scaly lesion on buttocks Purplish discoloration under the cheek An infected surgical wound

Open wound over the sacrum

Which type of injury results in a puncture wound? Paper cut Dog bite Popped blister Black eye

Dog bite

A nurse is performing an initial assessment on a recently admitted patient. Which finding warrants an immediate call to the health care provider? Presence of pediculosis Halitosis related to poor oral hygiene Oily, matted, and tangled hair Warm, moist, and intact skin

Presence of pediculosis

Which assessment findings are indicative of poor hygiene? Select all that apply. Body odors Chipped fingernail polish Tangled and matted hair Excessively long and dirty toenails Noticeably warm skin

Body odors Tangled and matted hair Excessively long and dirty toenails

The nurse is asking a patient hospitalized with acute pancreatitis questions about his or her self-care capabilities. Which questions would the nurse ask to assess the patient’s activities of daily living (ADLs)? Select all that apply. “Do you know where you are?” “How many visitors did you have last week?” “Do you always make it to the bathroom on time?” “How often do you take a bath or shower?” “Can you bathe yourself without help?”

“Do you always make it to the bathroom on time?” “How often do you take a bath or shower?” “Can you bathe yourself without help?”

An immobile patient is running a fever, and the nurse suspects the patient has a pressure injury. The nurse would observe the patient’s skin for which signs of infection? Select all that apply. Redness Freckles Scars Swelling Drainage

Redness Swelling Drainage

An older adult patient with arthritis has difficulty buttoning clothing, holding an eating utensil or toothbrush, and turning a door lock. Which action would the nurse take regarding the patient’s discharge from the hospital? Notify the health care provider. Ask which family member will provide assistance. Assist the patient with community referrals. Tell the family to place the patient in a nursing home

Assist the patient with community referrals.

Which factors are potential causes of halitosis? Select all that apply. Diabetes Pediculosis Medications Poor oral hygiene Infections of the oral cavity

Diabetes Medications Poor oral hygiene Infections of the oral cavity

Which patient situation indicates that a sink bath is appropriate? Needs support while standing Requires assistance to move from bed to sink Can perform part of the sink bath independently Provides own bathing supplies

Can perform part of the sink bath independently

Which benefits are associated with bathing and skin care? Select all that apply. Removes dead skin from the body Reduces emollients Provides skin hydration Removes bacteria from the skin Reduces possibility of maceration

Removes dead skin from the body Provides skin hydration Removes bacteria from the skin Reduces possibility of maceration

Which action by a female patient lets the nurse know the patient has understood perineal care teaching? The patient washes her perineum with a circular motion beginning at the urinary meatus. The patient washes her perineum from front to back using a clean washcloth. The patient washes her perineum from back to front with a clean washcloth. The patient washes her perineum lightly to prevent tissue damage.

The patient washes her perineum from front to back using a clean washcloth.

For which reason is it contraindicated for a patient with peripheral neuropathy to soak the feet? Can cause increased circulation Can cause tissue drying and increase risk for infection Is painful for the patient May make patient unable to walk

Can cause tissue drying and increase risk for infection

Effleurage can effectively reduce which bodily functions? Select all that apply. Sleep Heart rate Anxiety Muscle strength Respiratory rate Deep vein thrombosis

Heart rate Anxiety Respiratory rate

Which type of massage is best for patients with deep muscle tension? Petrissage Effleurage Tapotement Percussion

Petrissage

Match the patient type with the appropriate oral care intervention guideline. Provide water or ice cubes to keep oral mucosa moist. Provide oral care with toothbrush, water, or moistened toothette. Have suction and oral airway available. Answer choices Nothing by mouth (NPO) patients Unconscious patients Patients with bleeding disorders Patients in chemotherapy

Provide water or ice cubes to keep oral mucosa moist. Patients in chemotherapy Provide oral care with toothbrush, water, or moistened toothette. Nothing by mouth (NPO) patients Have suction and oral airway available. Unconscious patients

Place the steps of denture care in the order they are performed. Remove dentures from the mouth. Soak dentures in denture cleaning solution. Brush dentures with denture toothpaste. Rinse dentures with water. Rinse dentures with water. Place dentures in mouth.

Remove dentures from the mouth. Rinse dentures with water. Brush dentures with denture toothpaste. Soak dentures in denture cleaning solution. Rinse dentures with water. Place dentures in mouth.

Which benefits are associated with the provision of oral care? Select all that apply. Provides emotional support Prevents infections Reduces halitosis Reduces bleeding Removes plaque Keeps the mouth dry

Prevents infections Reduces halitosis Removes plaque

Place the steps for cleaning a prosthetic eye in the correct order. Pull down on the lower lid with a gloved hand. Exert pressure on the lower edge of the artificial eye. Place the upper edge of the prosthesis under the upper lid. Clean the prosthesis and socket with saline.

Pull down on the lower lid with a gloved hand. Exert pressure on the lower edge of the artificial eye. Clean the prosthesis and socket with saline. Place the upper edge of the prosthesis under the upper lid.

Which action would the nurse take when washing a patient’s ears during bathing? Use a cotton-tipped applicator. Use a washcloth and soap. Flush the ears during the bath. Use oil drops.

Use a washcloth and soap.

Which consequences can result from harshly blowing the nose? Select all that apply. Impacted cerumen Bleeding Dry mucosa Damaging the tympanic membrane Detaching a retina

Bleeding Damaging the tympanic membrane Detaching a retina

For which patients is pediculicidal shampoo contraindicated? Select all that apply. Older adult patients Middle-aged men Pregnant women Patients with head lice Patients with seizure disorders

Pregnant women Patients with seizure disorders

Which equipment and supplies enable shampooing for immobile patients? Select all that apply. Shampoo basin Waterproof pads Shower chair No-rinse shampoos Shampoo cap

Shampoo basin Waterproof pads No-rinse shampoos Shampoo cap

Which patients must use an electric razor when shaving? Select all that apply. A patient with hemophilia A patient on an aspirin regimen A pregnant patient A patient with epilepsy A patient taking heparin

A patient with hemophilia A patient on an aspirin regimen A patient taking heparin

Which type of bath is appropriate for an older adult patient who ambulates with a cane and has a history of unsteadiness? Sink bath Chair shower Partial bed bath Complete bed bath

Chair shower

Which benefit does a sitz bath provide for a new mother? Regulates skin pH Eliminates pediculosis Decreases swelling Decreases halitosis

Decreases swelling

Which action must the nurse perform before a patient receives a shower? Ensure the patient would like to take a shower. Make sure a shower chair is available. Determine if the patient will take a stand-up shower or use a shower chair. Check the health care provider’s prescription to determine if showering is safe.

Check the health care provider’s prescription to determine if showering is safe.

Which findings would the nurse document as unexpected after providing perineal care? Select all that apply. Redness Drainage Odor Edema Blanching

Redness Drainage Odor Edema

Which actions would the nurse avoid when clipping the nails of a patient diagnosed with peripheral neuropathy and circulatory impairment? Select all that apply. Increasing circulation to the area prior to clipping Using the patient’s own nail trimmer Trimming the nails straight across Massaging each digit prior to clipping Drying the nails completely prior to trimming

Increasing circulation to the area prior to clipping Using the patient’s own nail trimmer Massaging each digit prior to clipping

Massage uses a range of techniques to provide which benefits? Select all that apply. Relaxation Weight loss Comfort Improved circulation Improved sleep Increased immunity

Relaxation Comfort Improved circulation Improved sleep

Patients with which conditions should avoid soaking their feet? Select all that apply. Peripheral neuropathy Circulatory impairments Deep vein thrombosis Diabetes Sensory deficits

Peripheral neuropathy Diabetes Sensory deficits

While assisting a patient with teeth brushing, the nurse notices the patient has difficulty grasping and maneuvering the toothbrush. Which action would the nurse take to further assist this patient? Call for the nursing assistant to help with oral care. Have the patient sit while the nurse completes oral care. Request a large-handled toothbrush. Have the patient continue brushing without assistance.

Request a large-handled toothbrush.

A patient who is scheduled for surgery has been prescribed nothing by mouth (NPO) yet wants to have her teeth brushed. Which item would the nurse use to brush the patient’s teeth? Moistened toothette Large-handled toothbrush Toothbrush with large amount of toothpaste Mouthwash swish with fluoride

Moistened toothette

Which patient condition requires the nurse to pay special attention to the oral cavity given increased susceptibility to oral infections, dryness, and tissue damage? Nothing by mouth (NPO) status Diabetes Wears dentures Undergoing chemotherapy

Undergoing chemotherapy

A nurse is instructing a newly blind patient how to clean the eyes. Which instruction would the nurse provide? Use plain water and wipe from the outer canthus to the inner canthus. Use soapy water and wipe from the inner canthus to the outer canthus. Use sterile water and wipe from the outer canthus to the inner canthus. Use plain water and wipe from the inner canthus to the outer canthus.

Use plain water and wipe from the inner canthus to the outer canthus.

Which action is taken for a patient receiving oxygen with a nasal cannula to prevent nasal passages from drying? Humidifying the oxygen Warming the oxygen Cooling the oxygen Lowering the oxygen

Humidifying the oxygen

The nurse asks a patient whether he uses cotton-tipped applicators to clean the ear canals. For which reasons would the nurse make this inquiry? Select all that apply. Cotton-tipped applicators should never be inserted into the ear canal as they can cause cerumen impaction. Using a cotton-tipped applicator to clean the ear canals indicates proper hygiene. The risk for middle ear infections increases with long-term usage of cotton-tipped applicators. The use of a cotton-tipped applicator to clean the ear canals could result in the rupturing of the tympanic membrane. The nurse can request special oil drops to help the patient get rid of excess cerumen.

Cotton-tipped applicators should never be inserted into the ear canal as they can cause cerumen impaction. The use of a cotton-tipped applicator to clean the ear canals could result in the rupturing of the tympanic membrane. The nurse can request special oil drops to help the patient get rid of excess cerumen.

A postsurgical patient is requesting hair care from the nurse. Which information would the nurse document after hair care is performed? Select all that apply. Medications used Patient’s concerns Condition of patient’s scalp Patient’s tolerance of procedure Patient’s satisfaction

Condition of patient’s scalp Patient’s tolerance of procedure Patient’s satisfaction

Which cues indicate a patient’s hair care status is declining? Select all that apply. Impacted cerumen has occurred. Patient continues to need assistance with hair care. Patient develops ingrown hairs. Dandruff is present. Hair is free from parasites.

Patient develops ingrown hairs. Dandruff is present.

A male patient with a long beard does not wish to shave. Which hair care processes would the nurse implement for this patient? Select all that apply. Pediculicidal shampoo Combing Trimming Shampooing Shaving

Combing Trimming Shampooing