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WorksheetsFUNDAMENTALS End Chapter Exam 3
Total questions: 77
Worksheet time: 1hrs 17mins
Which skills can the nurse delegate to assistive personnel (AP)?
Initiate oxygen therapy via nasal cannula
Educate the pt about the use of an incentive spirometer
Assist w/ the care of an established tracheostomy tube
Reposition a pt w/ a chest tube
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?
Start O2 at 2L/min via nasal cannula
Elevate HOB to 45 degrees
Encourage pt to use the incentive spirometer
Notify the health care provider
The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?
“Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles.”
“When I am sick, I should limit the amount of fluids I drink so that I don’t produce excess mucus.”
“I will ensure that I receive an influenza vaccine every year, preferably in the fall.”
“I will look for a smoking-cessation support group in my neighborhood.
Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention?
SpO2 values of 95%
Chest retractions
Resp rate of 28 breaths per minute
Nasal flaring
Clubbing of finger
The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient?
The pt has visible secretions in the airway
There is a sawtooth pattern on the pt's EtCO2 monitor
The pt has clear breath sounds
It has been 3 hrs since the pt was last suctioned
The pt has excessive coughing
The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?
New, vigorous bubbling in the water seal chamber
Scant amount of sanguineous drainage noted on the dressing
Clear but slightly diminished breath sounds on the rt side of the chest
Pain score of 2 one hr after admin of an analgesic
The nurse has just witnessed her patient go into cardiac arrest. The family is in the patient’s room at the time the cardiac arrest occurs. What priority interventions should the nurse perform at this time?
Perform chest compressions
Ask someone to bring the automatic external defibrillator (AED) to the room for immediate defibrillation
Apply O2 via nasal cannula
Place the patient supine
Educate the family about the need for CPR
The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?
Clear breath sounds
Pt speaking to nurse
SpO2 reading of 96%
Resp rate of 18 breaths/min
When planning patient education, it is important to remember that patients with which of the following illnesses may find relief in complementary therapies?
Lupus and diabetes
Ulcers and hepatitis
Heart disease and pancreatitis
Chronic back pain and arthritis
Which complementary therapies are most easily learned and applied by a nurse?
Therapeutic massage therapy
Traditional Chinese medicine
Progressive relaxation
Breath work and guided imagery
Therapeutic touch
While planning care for a pt, a nurse understands that providing integrative care includes treating which of the following?
Disease, spirit, and family interactions
Desires and emotions of the patient
Mind-body-spirit of patients and their families
Muscles, nerves, and spine disorders
Which cognitive skills can a patient develop while practicing relaxation?
Increasing an ability to focus attention for an extended period of time
Limiting stimuli that come into one’s field of vision
Stopping a focus on unnecessary goal-directed activity
Being able to tolerate experiences that are uncertain
Building relationships with significant others
A nurse is caring for a patient with chronic arthritis pain. The patient wants to add some complementary therapies to help with pain management. Which therapies might be most effective for controlling pain?
Biofeedback
Acupuncture
Therapeutic touch
Chiropractic therapy
Herbal medicines
A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner?
Always fail and cause illness and disease
Protect an individual from harm in the short term
React the same way for all individuals
Cause negative responses over time
Tolerate the stress response indefinitely
Meditation may intensify the effects of which of these medications?
Steroids
Insulin
Thyroid regulating
Cough syrups
Antihypertensive
Which of the following statements best explains therapeutic touch (TT)?
Intentionally mobilizes energy to balance, harmonize, and repattern the recipient’s biofield
Intentionally heals tissue damage or corrects certain disease symptoms
Is overwhelmingly effective in many conditions
Is completely safe and does not warrant any special precautions
Which statement most accurately describes intervention(s) offered by TCM providers?
Uses acupuncture as its primary intervention modality
Uses many modalities based on the individual’s needs
Uses primarily herbal remedies and exercise
Is the equivalent of medical acupuncture
When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.)
Check for needed adaptive equipment
Exaggerate lip movements to help the patient lip-read
Give the patient time to respond to questions.
Keep communication short and to the point.
. Communicate only through written information
A pt has gone through a number of treatment changes during a shift of care. During the hand-off report, the nurse plans to communicate effectively with the nurse who will be caring next for the pt for which of the following reasons?
To improve the nurse’s status with the health team members
To reduce the risk of errors to the patient
To provide an optimum level of patient care
To improve patient outcomes
To prevent issues that need to be reported to outside agencies
A nurse is using motivational interviewing with a patient. What outcomes does the nurse expect?
Gain an understanding of the patient’s health goals.
Direct the patient to avoid poor health choices.
Recognize the patient’s strengths and support the patient’s efforts.
Provide assessment data that can be shared with families to promote change.
Identify differences in patient’s health outcomes and current behaviors.
Which techniques demonstrate a therapeutic response to an adult patient who is anxious?
Matching the rate of speech to be the same as that of the patient
Providing good eye contact
Demonstrating a calm presence
Spending time attentively with the patient
Assuring the patient that all will be well
A patient states, “I don’t have confidence in my doctor. She looks so young.” What is the nurse’s therapeutic response?
Tell me more about your concern.
You have nothing to worry about. Your doctor is perfectly competent.
You can go online and see how others have rated your doctor. I do that.
You should ask your doctor to tell you her background
Which strategies should a nurse use to facilitate a safe transition of care during a patient’s transfer from the hospital to a skilled nursing facility?
Collaboration between staff members from sending and receiving departments
Requiring that the patient visit the facility before a transfer is arranged
Using a standardized transfer policy and transfer tool
Arranging all patient transfers during the same time each day
Relying on family members to share information with the new facility
What outcome demonstrates the effective use of silence as a therapeutic communication technique?
The nurse feels like there was enough time to be therapeutic when communicating with the patient.
The patient states a preference to talk with another staff member
The patient perceives having gained insight into the issue after the conversation.
The patient was able to drift off to sleep more easily
A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication?
Logging on to AMDS or unlocking medicine drawer or cart
Before going to patient’s room, comparing patient’s name and name of medication on label of prepared drugs with MAR
Selecting correct medication from ADMS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout.
Comparing MAR or computer printout with names of medications on medication labels and patient name at patient’s bedside
An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What actions should the nurse take to help the older adult patient?
Provide a dispensing system for each day of the week
Provide larger, easier-to-read labels
Tell the patient what is in each container
Have a family caregiver administer the medication
Use teach-back to ensure that the patient knows what medication to take and when
Which of the following guidelines must a nurse use for taking verbal or telephone orders?
Follow the health care agency guidelines regarding authorized staff who may receive and record verbal or telephone orders
Clearly identify patient’s name, room number, and diagnosis
Read back all orders to health care provider
Use clarification questions to avoid misunderstandings
Write “VO” (verbal order) or “TO” (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse
Which aspects of the patient’s care related to the administration of heparin can the nurse delegate to the nursing AP?
Notify the nurse if there are any signs of bleeding
Assess the vital signs for possible symptoms of bleeding
Assess bleeding sites and apply appropriate pressure to the sites
Notify the nurse if there is blood noted in the patient’s urine
Notify the nurse if there is oozing from any puncture sites
A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate?
Verifying tube placement after medications are given
Using an enteral tube syringe to administer medications
Flushing tube with 30 to 60 mL of water after the last dose of medication
Checking for gastric residual before giving the medications
Keeping the head of the bed elevated for 30 to 60 minutes after the medications are given
After receiving an IM injection in the deltoid, a patient states, “My arm really hurts. It’s burning and tingling where I got my injection.” What should the nurse do next?
Assess the injection site
Administer an oral medication for pain
Notify the patient’s health care provider of assessment findings
Document assessment findings and related interventions in the patient’s medical record
This is a normal finding, so nothing needs to be done
An IV fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing?
Infiltration at VAD site
Patient lying on tubing
Roller clamp wide open
Tubing kinked in bedrails
Circulatory overload
The nurse assesses pain and redness at a VAD site. Which action is taken first?
Apply a warm, moist compress
Aspirate the infusing fluid from the VAD
Report the situation to the health care provider
Discontinue the IV infusion
What assessments does a nurse make before hanging an IV fluid that contains potassium?
Urine output
ABGs
Fullness of neck veins
Serum potassium laboratory value in EHR
Level on consciousness
Which of the following steps are necessary when inserting a short-peripheral IV?
Apply tourniquet to arm 10 to 15 cm (4–6 inches) above the intended insertion site
Cleanse skin using an approved antiseptic agent such as alcohol-based 2% chlorhexidine and allow to dry thoroughly
Stabilize the vein by placing the thumb proximal to the insertion site, stretching the skin in the direction of insertion
Use the smallest-gauge, shortest catheter available and insert with the bevel up at a 10- to 15-degree angle
Observe for blood in the flashback chamber of the catheter and advance the catheter off the needle into the vein
A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions?
Fall prevention interventions
Teaching regarding sodium restriction
Encouraging increased fluid intake
Monitoring for constipation
Explaining how to take daily weights
A patient is admitted to the hospital with severe dyspnea and wheezing. ABG levels on admission are pH 7.26; PaO2, 68 mm Hg; PaCO2, 55 mm Hg; and HCO3 2, 24. How does the nurse interpret these laboratory values?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of ECV deficit?
Dryness of mucous membranes
Skin turgor
Fullness of neck veins when supine
Fullness of neck veins when upright
Which of the following signs or symptoms in a patient who is opioid naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?
Oxygen saturation of 95%
Difficulty arousing the patient
Respiratory rate of 12 breaths/min
Pain intensity rating of 5 on a scale of 0 to 10
A patient is being discharged home on an around-the-clock (ATC) opioid for postoperative pain. Because of this order, the nurse anticipates an additional order for which class of medication?
Opioid antagonists
Antiemetics
Stool softeners
Muscle relaxants
When using ice massage for pain relief, which of the following is correct?
Apply ice using firm pressure over the skin
Apply ice for 5 minutes or until numbness occurs
Apply ice no more than 3 times a day
Limit application of ice to no longer than 10 minutes
Use a slow, circular steady massage
When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which of the following represent an accurate description of the nonpharmacological therapy?
Turn TENS on before patient feels discomfort
TENS works peripherally and centrally on nerve receptors
TENS does not require a health care provider order
Remove any skin preparations before attaching TENS electrodes
Placing electrodes directly over or near the pain site works best
A nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE?
Allowing the patient to discuss the experience
Referring the patient to pastoral care
Having the patient talk to another patient who had an NDE
Offering to pray for the patient
Match the criteria on the with the appropriate assessment question:
Tell me if you have a higher power or authority that helps you act on your beliefs
Faith
Importance of spirituality
Community
Interventions to address spiritual needs
Match the criteria on the with the appropriate assessment question:
Describe which activities give you comfort spiritually.
Faith
Importance of spirituality
Community
Interventions to address spiritual needs
Match the criteria on the with the appropriate assessment question:
To whom do you go for support in times of difficulty?
Faith
Importance of spirituality
Community
Interventions to address spiritual needs
Match the criteria on the with the appropriate assessment question:
Your illness has kept you from attending church. Is that a problem for you?
Faith
Importance of spirituality
Community
Interventions to address spiritual needs
The nurse is planning spiritual care interventions for an 8-year-old patient. Based on the patient’s age, the nurse must consider which growth and development factor when planning the spiritual care?
This age-group’s concept of spirituality is provided by parents, and love and affection promote spirituality
This age-group begins to ask about God or a Supreme Being and is influenced by spiritual and religious stories
This age-group is fascinated with magic and mystery and often believes illness is related to bad behavior
This age-group has a clear concept of a higher spiritual being and is interested in learning about spirituality
A nurse is caring for a patient who is Muslim and has diabetes mellitus. Which of the following items does the nurse need to remove from the meal tray when it is delivered to the patient?
Small container of vanilla ice cream
A dozen red grapes
Bacon and eggs
Garden salad with ranch dressing
A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. After analyzing the assessment findings, the nurse recognizes that which statements made by the patient support a nursing diagnosis of Spiritual Distress related to loss of family members?
“I need to call my sister for support.”
“I have nothing to live for now.”
“Why would my God do this to me?”
“I need to pray for a miracle.”
“I want to be more involved in my church.”
A patient has just been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. What intervention does the nurse implement that best provides support of the patient’s spiritual well-being at this time?
Make a referral to a professional spiritual care adviser
Sit down and talk with the patient; have her discuss her feelings and listen attentively
Move the patient’s Bible from her bedside cabinet drawer to the top of the over-bed table
Ask the patient whether she would like to learn more about the implications of having this type of tumor
A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following teaching strategies are appropriate?
Encourage family members to participate in the exercise
Have the patient identify a quiet room in the home that has minimal interruptions
Suggest the use of a quiet fan running in the room
Explain that it is best to meditate about 5 minutes 4 times a day
Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer
A nursing student is developing a plan of care for a 74-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered?
Older adults do not routinely use complementary medicine to cope with illness
Older adults dislike discussing the afterlife and what might have happened to people who have passed on
Older adults achieve spiritual resilience through frequent expressions of gratitude
Have the patient determine whether her husband left a legacy behind
Offer the patient her choice of rituals or participation in exercise
A nurse used spiritual rituals as an intervention in a patient’s care. Which of the following questions is most appropriate to evaluate the efficacy of the intervention?
Do you feel the need to forgive your wife over your loss?
What can I do to help you feel more at peace?
Did either prayer or meditation prove helpful to you?
Should we plan on having your family try to visit you more often in the hospital?
The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes mellitus since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with chronic illness, which of the following principles should the nurse apply in practice?
Pay attention to the patient’s spiritual identity throughout the course of her illness
Select interventions that you know scientifically support spiritual well-being
Listen to the patient’s story each visit to the clinic, and offer a compassionate presence
When the patient questions the reason for her longtime suffering, try to provide answers
Consult with a spiritual care adviser, and have the adviser recommend useful interventions
To best assist a patient in the grieving process, which factors are most important for the nurse to assess?
Previous experiences with grief and loss
Religious affiliation and denomination
Ethnic background and cultural practices
Current financial status
Current medications
Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital?
Use therapeutic techniques when communicating with the patient
Allow the patient to determine timing and scheduling of interventions
Allow patients to have visitors at any time
Provide the patient with a private room close to the nurses’ station
Encourage the patient to eat when hungry
The nurse recognizes that which factors influence a person’s approach to death?
Culture and previous experience with death
Personal beliefs and spirituality
Gender
Level of education
Which comments made by a patient show an understanding of the teaching on palliative care completed by the nurse?
“Even though I’m continuing treatment, palliative care can help manage my symptoms and improve my quality of life.”
“Palliative care is appropriate for people with any diagnosis.”
“Only people who are dying can receive palliative care.”
“Children are able to receive palliative care.”
“Palliative care is only for people with uncontrolled pain.”
A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in “hospice.” What does the nurse tell the family member about palliative care?
Palliative care and hospice are the same thing
Palliative care is for any patient, at any time, with any disease, in any setting
Palliative care strategies are primarily designed to treat the patient’s illness
Palliative care relieves the symptoms of illness and treatment
Palliative care is started at the end of life
When planning care for a dying patient, which interventions undertaken by the nurse promote the patient’s dignity?
Providing respect
Viewing the patient as a whole
Providing symptom management
Showing interest
Being present
The nurse is caring for a patient who is near death. What assessment finding cues the nurse that death is approaching?
Skin irritation
Mottling
Increased urine output
Weakness
The nurse is assessing an older adult who is grieving after the loss of a spouse. What are normal signs of grief that the nurse would expect to find?
Loss of interest in attending outside activities
Feeling fatigued
Difficulty making decisions
Problems with remembering things
Change in appetite and eating patterns
Which actions implemented by the nurse help grieving families?
Encourage involvement in nonthreatening group social activities
Follow up with the family to make sure all their questions are answered
Remind them that feelings of sadness or pain can return around anniversaries
Encourage survivors to ask for help
Look for overuse of alcohol, sleeping aids, or street drugs
The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 157.4 cm (5 feet, 2 inches) in height. Which factors increase this patient’s risk for surgical complications?
Obesity
Prolonged bleeding time
Delayed wound healing
Ineffective vital capacity
Immobility secondary to height
Which assessment questions should the nurse ask a preoperative patient preparing for surgery?
“Are you experiencing any pain?”
“Do you exercise on a daily basis?”
“When do you regularly take your medications?”
“Do you have any medication allergies?”
“Do you use drugs and/or tobacco products?”
Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following?
Documenting assessment findings in the medical record
Using a standardized SBAR tool
Being responsive in using nonverbal communication techniques
Giving specific information to a transport technician
Listening to the OR nurse’s questions
Which postoperative intervention best prevents atelectasis?
Use of intermittent compression stockings
Heel-toe flexion
Use of the incentive spirometer
Abdominal splinting when coughing
An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery?
Stiffened lung tissue
Reduced diaphragmatic excursion
Increased laryngeal reflexes
Reduced blood flow to kidneys
Increased cholinergic transmission
A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority?
Elevate the head of the patient’s bed
Give ordered oxygen through a mask at 4 L/min
Ask the patient to use an incentive spirometer
Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.
Which is the best intervention the nurse should implement to promote bowel function?
Early ambulation
Deep-breathing exercises
Repositioning on the left side
Repositioning on the left side
Match the nursing interventions with the preventable complication:
Offering glasses or hearing aid
Deep vein thrombosis
Wound infection
Delirium
Atelectasis
Match the nursing interventions with the preventable complication:
Early ambulation
Deep vein thrombosis
Wound infection
Delirium
Atelectasis
Match the nursing interventions with the preventable complication:
Strict aseptic technique
Deep vein thrombosis
Wound infection
Delirium
Atelectasis
Match the nursing interventions with the preventable complication:
Deep breathing exercise
Deep vein thrombosis
Wound infection
Delirium
Atelectasis
Match the nursing interventions with the preventable complication:
Hydration
Deep vein thrombosis
Wound infection
Delirium
Atelectasis
A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority?
Notify surgeon
Maintain the intravenous fluid infusion
Provide 2 L/min of oxygen via nasal cannula
Provide 2 L/min of oxygen via nasal cannula
Reinforce the dressing
A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient’s pain report. Unmanaged surgical pain can lead to which of the following problems?
Delayed ambulation
Reduced ventilation
Catheter-associated urinary tract infection
Retained pulmonary secretions
Reduced appetite
