In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

In order to avoid hip dislocation after replacement surgery, the
nurse teaches the patient which of the following guidelines?
a) Never cross the affected leg when seated.
Crossing the affected leg may result in dislocation of the hip joint after
total hip replacement.
b) Keep the knees together at all times.
The patient should be taught to keep the knees apart at all times.
c) Avoid placing a pillow between the legs when sleeping.
The patient should be taught to put a pillow between the legs when
sleeping.
d) Bend forward only when seated in a chair.
The patient should be taught to avoid bending forward when seated in
a chair.
by

1 Answer

Answer :

a) Never cross the affected leg when seated.
Crossing the affected leg may result in dislocation of the hip joint after
total hip replacement.
by

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Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi-mushy. With a descending colostomy, the feces are semi-mushy. c) mushy. With a transverse colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

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 nurse teaches the patient about glargine (Lantus), a “peakless” basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Description : The nurse teaches the patient about glargine (Lantus), a peakless basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a ... action Glargine is a peakless basal insulin that is absorbed very slowly over a 24-hour period.

Last Answer : a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering ... to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

Description : The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the ... , and pustules appear. The child remains contagious when the rash is changing into vesicles and pustules.

Last Answer : a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Description : Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or ... for short periods of time. Difficulty in waking the patient should be reported or treated immediately.

Last Answer : a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

Description : The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a ... is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

Last Answer : a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

The nurse teaches the patient with allergies about anaphylaxis including which of the following statements? a) The most common cause of anaphylaxis is penicillin. The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the U.S., is penicillin.

Description : The nurse teaches the patient with allergies about anaphylaxis including which of the following statements? a) The most common cause of anaphylaxis is penicillin. The most common ... 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

Last Answer : a) The most common cause of anaphylaxis is penicillin. The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the U.S., is penicillin.

The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. b) slowed heart rate. Nicotine has stimulant effects. c) depression of the cough reflex. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Description : The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the ... the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Last Answer : a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities.

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.

Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances? a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Description : The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression ... contraindicated when injury is suspected, and examination, while indicated, does not provide treatment.

Last Answer : a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes. b) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. c) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger. d) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Description : Which nerve is assessed when the nurse asks the patient to dorsiflex the ankle and extend the toes? a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to ... the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

Last Answer : a) Peroneal The motor function of the peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes while the sensory function is assessed by pricking the skin between the great and center toes.

Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve. b) Peroneal The peroneal nerve is assessed by asking the patient to dorsiflex the ankle and extend the toes. c) Radial The radial nerve is assessed by asking the patient to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. d) Median The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Description : Which nerve is assessed when the nurse asks the patient to spread all fingers? a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation ... The median nerve is assessed by asking the patient to touch the thumb to the little finger.

Last Answer : a) Ulnar Asking the patient to spread all fingers allows the nurse to assess motor function affected by ulnar innervation while pricking the fat pad at the top of the small finger allows assessment of the sensory function affected by the ulnar nerve.

The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

Description : The nurse teaching the patient with a cast about home care includes which of the following instructions? a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin ... A broken cast should be reported to the physician; the patient should not attempt to fix it.

Last Answer : a) Dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems. Instruct the patient to keep the cast dry and to dry a wet fiberglass cast thoroughly using a hair dryer on a cool setting to avoid skin problems; do not cover it with plastic or rubber.

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).

Surgical fusion of a joint is termed a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain. b) open reduction with internal fixation (ORIF). ORIF refers to surgery to repair and stabilize a fracture. c) heterotrophic ossification. Heterotrophic ossification refers to formation of bone in the periprosthetic space. d) arthroplasty. Arthroplasty refers to surgical repair of a joint or joint replacement.

Description : Surgical fusion of a joint is termed a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain. b) open reduction with internal fixation (ORIF). ORIF refers to ... periprosthetic space. d) arthroplasty. Arthroplasty refers to surgical repair of a joint or joint replacement.

Last Answer : a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain.

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.

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.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity. b) Vital capacity The nurse anticipates decreased vital capacity. c) Gas exchange and diffusing capacity The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. d) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Description : When assessing the older adult, the nurse anticipates increase in which of the follow components of respiratory status? a) Residual lung volume As a result, patient experience fatigue ... ) Cough efficiency The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

Last Answer : a) Residual lung volume As a result, patient experience fatigue and breathlessness with sustained activity.

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

When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

Description : When providing care to the patient with bilateral nephrostomy tubes, the nurse never does which of the following? a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a ... saline q8h as ordered The nurse may irrigate a nephrostomy tube with specific orders to do so.

Last Answer : a) Clamps each nephrostomy tube when the patient is moved The nurse must never clamp a nephrostomy tube because it could cause obstruction and resultant pyelonephritis.

75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Description : 75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Last Answer : A. 3, 4, 5, and 6

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.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

To prevent footdrop, the patient is positioned in: a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. b) A semi-sitting position in bed Semi-fowlers positioning is used to decrease the pressure of abdominal contents on the diaphragm. c) A sitting position with legs hanging off the side of the bed In order to prevent footdrop, the feet must be supported. d) A side-lying position Side-lying positions do not provide support to prevent footdrop.

Description : To prevent footdrop, the patient is positioned in: a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used. b) ... must be supported. d) A side-lying position Side-lying positions do not provide support to prevent footdrop.

Last Answer : a) Order to keep the feet at right angles to the leg When the patient is supine in bed, padded splints or protective boots are used.

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.

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 the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

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.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.