While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient’s watcher. Your appropriate action would be A. Reprimand the nursing attendant right away B. Remind the patient that gift giving to any hospital staff is not allowed C. Review with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

While making your PM shift endorsement, you saw the
nursing attendant receiving a package from a patient’s
watcher. Your appropriate action would be
A. Reprimand the nursing attendant right away
B. Remind the patient that gift giving to any hospital
staff is not allowed
C. Review with the nursing attendant the hospital
policy
D. Endorse to the incoming shift for proper action
by

1 Answer

Answer :

D. Endorse to the incoming shift for proper action
by

Related questions

A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Asking the patient questions to determine if the person understands the health teaching provided would be included during which step of the nursing process? a) Evaluation Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes. b) Assessment Assessment includes determining the patient’s readiness regarding learning. c) Planning and goals Planning includes identification of teaching strategies and writing the teaching plan. d) Implementation Implementation is the step during which the teaching plan is put into action.

Description : Asking the patient questions to determine if the person understands the health teaching provided would be included during which step of the nursing process? a) Evaluation Evaluation includes observing ... ) Implementation Implementation is the step during which the teaching plan is put into action.

Last Answer : a) Evaluation Evaluation includes observing the person, asking questions, and comparing the patient’s behavioral responses with the expected outcomes.

In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. b) pillows under the lower legs. Pillows under the legs will not prevent the hips from rotating externally. c) a hip-abductor pillow. A hip-abductor pillow is used for the patient after total hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Description : In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be ... hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Last Answer : a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings. b) interruption of GI integrity Tube feedings preserve GI integrity by intraluminal delivery of nutrients. c) disturbance in the sequence of intestinal and hepatic metabolism Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. d) interruption in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Description : The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of ... in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Last Answer : a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.

The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

Description : The patient receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS) is closely monitored for a) leukopenia and cardiac toxicity. Mitoxantrone is an ... d) hypoxia. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.

Last Answer : a) leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lyphoma but is also used to treat secondary progressive MS. Patients need to have ... ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

78. Nurse Nora is assigned on PM shift for the month of June. She requested the head nurse if she can be on night or morning instead to be able to tutor her 2 sons in the elementary. The head nurse emphasized that it is her turn to go on PM duty. The action of the head nurse exemplifies which of the following?

Description : 78. Nurse Nora is assigned on PM shift for the month of June. She requested the head nurse if she can be on night or morning instead to be able to tutor her 2 sons in the elementary. The head ... it is her turn to go on PM duty. The action of the head nurse exemplifies which of the following?

Last Answer : A. Authority

The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, “I will A. Call you when the return flow is clear” B. Stop the enema only if the return flow is without formed fecal material” C. Need 1 liter of tap water to have clear return flow” D. Put the client in left Sim’s position to achieve the desired return flow.”

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement, airway management, and standard nursing care support during the time that the patient has meningitis symptoms. a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Description : Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement ... the virus to animals and humans. There is no human-to-human transmission of virus.

Last Answer : a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting patients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient.

Description : Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, ... and cold are most appropriate because these patients tend to have strong reactions to medications.

Last Answer : a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for ... loss of strength and maintaining the physical, psychological and social well being of the patient.

Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

Description : Nursing management of the patient with acute symptoms of benign paroxysmal positional vertigo includes which of the following? a) Bed rest Bed rest is recommended for patients with acute symptoms. ... -Hallpike procedure. The Dix-Hallpike test is an assessment test used to evaluate for BPPV.

Last Answer : a) Bed rest Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo, and patients with acute vertigo may be medicated with meclizine for 1-2 weeks.

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Description : Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, ... of burn pain. Pet therapy has not proven effective in the management of burn pain.

Last Answer : a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience ... orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

Description : Which of the following guidelines is appropriate to helping family members cope with sudden death? a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse ... avoid volunteering unnecessary information (e.g., patient was drinking at the time of the accident).

Last Answer : a) Show acceptance of the body by touching it, giving the family permission to touch. The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss.

87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Description : 87. When the staff nurse on duty encounters a problem that cannot be solved using nursing knowledge, skills and available resources, it is best for the nurse to consult the

Last Answer : C. Head nurse

n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate the importance of respiratory exercises B. Give the client reassurance that can he can cough, breathe deeply and turn to sides safely C. Administer the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Description : n assisting the client to do deep breathing, coughing and turning to the sides on the first post-operative day, which nursing action would be most helpful for the client? A. Restate ... the prescribed analgesic round the clock as prescribed D. Apply abdominal splint (pillow) while coughing

Last Answer : D. Apply abdominal splint (pillow) while coughing

The percentage of patients over the age of 70 admitted to the hospital with delirium is about a) 25%. About 25% of patients over the age of 70 admitted to the hospital have delirium. The cause is often reversible and treatable (as in drug toxicity, vitamin B12 deficiency or thyroid disease) or chronic and irreversible. Depression may produce impairment of attention and memory.

Description : The percentage of patients over the age of 70 admitted to the hospital with delirium is about a) 25%. About 25% of patients over the age of 70 admitted to the hospital have delirium. The cause is ... delirium. d) 50%. About 25% of patients over the age of 70 admitted to the hospital have delirium.

Last Answer : a) 25%. About 25% of patients over the age of 70 admitted to the hospital have delirium. The cause is often reversible and treatable (as in drug toxicity, vitamin B12 deficiency or thyroid disease) or chronic and irreversible. Depression may produce impairment of attention and memory.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn? a) Do not apply water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Description : Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn? a) Do not apply water to the burn. Water should not be applied to burns from ... from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Last Answer : a) Do not apply water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Nursing management of the patient with new variant Creutzfeldt-Jakob Disease (nvCJD) includes a) providing supportive care. The nvCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of nvCJD, nursing care is primarily supportive.

Description : Nursing management of the patient with new variant Creutzfeldt-Jakob Disease (nvCJD) includes a) providing supportive care. The nvCJD is a progressive fatal disease with no treatment available. Due to ... B is used in the treatment of fungal encephalitis; no treatment is available for nvCJD.

Last Answer : a) providing supportive care. The nvCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of nvCJD, nursing care is primarily supportive.

Which of the following reflects basic nursing measures in the care of the patient with viral encephalitis? a) Providing comfort measures Providing comfort measures directed at the headache, include dimmed lights, limited noise, and analgesics are the basic nursing measures in the care of the patient with a viral encephalitis.

Description : Which of the following reflects basic nursing measures in the care of the patient with viral encephalitis? a) Providing comfort measures Providing comfort measures directed at the headache, include ... output to alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) Providing comfort measures Providing comfort measures directed at the headache, include dimmed lights, limited noise, and analgesics are the basic nursing measures in the care of the patient with a viral encephalitis.

Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Encourage the patient to repeat sounds of the alphabet. Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet.

Description : Which of the following statements reflect nursing management of the patient with expressive aphasia? a) Encourage the patient to repeat sounds of the alphabet. Nursing management of the patient with ... such as memory loss, includes frequently reorienting the patient to time, place, and situation.

Last Answer : a) Encourage the patient to repeat sounds of the alphabet. Nursing management of the patient with expressive aphasia includes encouraging the patient to repeat sounds of the alphabet.

Antimicrobial barrier?Acticoat dressings used in the treatment of burn wounds can be left in place for five days. a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

Description : Antimicrobial barrier?Acticoat dressings used in the treatment of burn wounds can be left in place for five days. a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days ... ) two days. antimicrobial barrier dressings can be left in?Acticoat place for up to five days.

Last Answer : a) antimicrobial barrier dressings can be left in place for?Acticoat up to five days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes.

Which of the following statements reflect nursing interventions in the care of the patient with osteoarthritis? a) Encourage weight loss and an increase in aerobic activity. Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening are important approaches to pain management.

Description : Which of the following statements reflect nursing interventions in the care of the patient with osteoarthritis? a) Encourage weight loss and an increase in aerobic activity. Weight loss and ... analgesics. Topical analgesics such as capsaicin and methylsalicylate may be used for pain management.

Last Answer : a) Encourage weight loss and an increase in aerobic activity. Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening are important approaches to pain management.

Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

Description : Which of the following statements reflects nursing care of the woman with mild to moderate ovarian hyperstimulation syndrome (OHSS)? a) Advise the patient to decrease her activity, monitor ... for immediate hospitalization. The patient with severe OHSS is hospitalized for monitoring and treatment.

Last Answer : a) Advise the patient to decrease her activity, monitor her urine output and to return for frequent office visits. Management in mild and moderate cases of OHSS consists of decreased activity, monitoring of urine output and frequent office visits as designated by the reproductive endocrinologist.

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

100. The client complained of generalized pruritus. The following are appropriate nursing interventions except

Description : 100. The client complained of generalized pruritus. The following are appropriate nursing interventions except

Last Answer : B. Regulate the temperature to 25 degrees centigrade or lower

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

In general, chest drainage tubes are not used for the patient undergoing a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemithorax prevents mediastinal shift. b) Lobectomy With lobectomy, two chest tubes are usually inserted for drainage, the upper for air and the lower for fluid c) Wedge resection With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak d) Segmentectomy With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

Description : In general, chest drainage tubes are not used for the patient undergoing a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty ... With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

Last Answer : a) Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemithorax prevents mediastinal shift.

The first step in decontamination is a. Removal of the patient’s clothing and jewelry and then rinsing the patient with water. To be effective, decontamination must include a minimum of two steps. The first step is removal of the patient’s clothing and jewelry and then rinsing the patient with water. The second step consists of a thorough soap and water wash and rinse.

Description : The first step in decontamination is a. Removal of the patient's clothing and jewelry and then rinsing the patient with water. To be effective, decontamination must include a minimum of two steps. The ... the patient with water. The second step consists of a thorough soap and water wash and rinse.

Last Answer : a. Removal of the patient's clothing and jewelry and then rinsing the patient with water. To be effective, decontamination must include a minimum of two steps. The first step is removal of the patient ... the patient with water. The second step consists of a thorough soap and water wash and rinse.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

Three medications referred to as the ‘ABC drugs’ are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient teaching? a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the interferons experience flu-like symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

Description : Three medications referred to as the ABC drugs' are currently the main pharmacological therapy for multiple sclerosis. Which of the following statements reflects information to be included in patient ... on an empty stomach. Glatiramer acetate is administed by intramuscular injection once a week.

Last Answer : a) Flu-like symptoms can be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) and usually resolve after a few months of therapy. Seventy-five percent of patients taking one of the ... symptoms that can be controlled with NSAIDS and usually resolve after a few months of therapy.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

The nurse reading the physician’s report of an elderly patient’s physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Description : Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the ... term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

Last Answer : a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Description : Which of the following observations regarding ulcer formation on the patient's lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ... d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Last Answer : a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. b) Dyspnea Dyspnea is the patient’s subjective statement of difficulty breathing. c) Orthopnea Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. d) Thromboangitis obliterans Thomroangitis obliterans is a peripheral vascular disease also known as Burger’s disease.

Description : Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Intermittent claudication Intermittent claudication is leg pain that is ... obliterans Thomroangitis obliterans is a peripheral vascular disease also known as Burger's disease.

Last Answer : a) Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest.

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).