Exam 1 V1: PNR105 / PNR 105 (Latest Update 2025 / 2026) Pharmacology | Questions and Verified Answers | 100% Correct | Grade A - Fortis

Exam 1 V1: PNR105 / PNR 105 (Latest Update 2025 / 2026) Pharmacology | Questions and Verified Answers | 100% Correct | Grade A - Fortis • Question: A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are." Answer: B - Empathy is the ability to understand and accept another person's reality. Question: When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?" Answer: D - Therapeutic communication are responses that encourage the expression of feelings and ideas and convey acceptance and respect. Question: How can the nurse best identify that a client needs clarification with discharge information? a. Ask the client's significant other if the discharge instructions seem clear. b. Provide the client with written discharge instructions. c. Talk to the client about discharge instructions while PT is in the room. d. Watch for nonverbal clues that indicate the client might have misunderstood the discharge instructions. Answer: D - You determine the need for clarification by watching the listener for nonverbal cues that suggest confusion or misunderstanding. Question: Which of the following indicates the nurse is actively listening to her client? Choose all that apply. a. The nurse focuses in on the clients verbal and nonverbal cues. b. The nurse communicates a sense of being relaxed. c. The nurse crosses her arms while talking to the client. d. The nurse leans forward towards the patient. Answer: A, B, D - Active listening means to be attentive to what the client is saying both verbally and nonverbally. Question: Which of the following statements represents the nurse using the technique: clarifying? a. "Your Chest X-ray shows that you have pneumonia." b. "I can understand your concern about being the caretaker for your Mother." c. "I heard you are having difficulty getting to your PCP appointments on time." d. "When you said you were sicker than usual, what did you mean?" Answer: D - Clarifying is when the nurse checks whether understanding is accurate by restating an unclear message to clarify the sender's meaning, or by asking the other person to restate the message, explain further, or give an example of what the person means. Question: A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. A - Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks and foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient. Question: The patient is facing emergency cardiac surgery. Prior to surgery, the pre-op nurse begins talking to the patient about smoking cessation. The nurse manager overhears the conversation and understands that the nurse is making which error? a. Denotative meaning. b. Pacing. c. Intonation. d. Timing and relevance. Answer: D - Discussing smoking cessation immediately before a patient is having emergency surgery is an error in timing and relevance. The client is not likely to pay attention or comprehend. Question: The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary Answer: B - Nonverbal communication includes the five senses and everything that does no involve the spoken or written word. Question: A nurse works with a patient using therapeutic communication and the phases of the therapeutic relationship. Place the nurse's statements in order according to these phases. a. The nurse states, "Let's work on learning injection techniques." b. The nurse is mindful of his/her own biases and knowledge in working with the patient with B12 deficiency. c. The nurse summarizes progress made during the nursing relationship. d. After providing introductions, the nurse defines the scope and purpose of the nurse-patient relationship. Answer: B, D, A, C - Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. These techniques apply in a variety of different situations. Question: A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a. "I think you have had a hard day." b. "I feel uncomfortable hearing that statement." c. "I don't think you should say things like that. It is not right." d. "I have been checking on you regularly. How can you say that?" Answer: B - Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel". While all of these start with "I," the only one that is the most assertive is "I feel uncomfortable hearing that statement." An assertive nurse communicates self-assurance; communicates feelings; takes responsibility for choices; and is respectful of others' feelings, ideas, and choices. "I think you've had a hard day" is not addressing the problem. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like 'right' is not assertive or therapeutic. Question: When working with an older adult who is hearing-impaired, the use of which techniques would improve communication? (Select all that apply.) a. Check for needed adaptive equipment. b. Exaggerate lip movements to help the patient lip read. c. Give the patient time to respond to questions. d. Keep communication short and to the point. e. Communicate only through written information. Answer: A, C, D - Hearing loss and visual impairments are changes that may occur during aging that contribute to communication barriers. Communicate with older adults on an adult level and avoid patronizing or speaking in a condescending manner. Question: Nursing is defined as a profession because nurses: a. Perform specific skills. b. Practice autonomy. c. Utilize knowledge from the medical discipline. d. Charge a fee for services rendered. Answer: B - Autonomy indicates using critical thinking skills. A nursing assistant can perform specific skills. Question: A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a: a. primary care center. b. restorative care setting. c. assisted-living center. d. respite center. Answer: B - The goals of restorative care are to help individuals regain maximal functional status and enhance quality of life through promotion of independence and self-care. Question: Technological advances in health care: a. Make the nurse's job easier. b. Depersonalize bedside patient care. c. Threaten the integrity of the health care industry. d. Do not replace sound, personal judgement. Answer: D - In many ways technology makes your work easier, but it does not replace nursing judgment. For example, it is your responsibility when managing a patient's IV therapy to monitor the infusion to be sure that it infuses on time and without complications. An electronic infusion device provides a constant rate of infusion, but you need to be sure that you calculate the rate correctly. The device sets off an alarm if the infusion slows, making it important for you to respond to the alarm and troubleshoot the problem. Technology does not replace your critical eye and clinical judgment. Question: According to Maslow's hierarchy of needs, which of these needs would the patient seek to meet first? a. self-actualization b. self-esteem c. shelter d. love and belonging Answer: C - According to this model, certain human needs are more basic than others (i.e., some needs must be met before other needs [e.g., fulfilling the physiological needs before the needs of love and belonging]). Question: After evaluating a patient's external variables, the nurse concludes that health beliefs and practices can be influenced by a. Emotional factors. b. Intellectual background. c. Developmental stage. d. Socioeconomic factors. Answer: D - Emotional factors, intellectual background, and developmental stage are internal factors, not external factors. Question: You will use the concept of primary prevention when instructing a patient to: a. Get a flu shot every year. b. Take a blood pressure reading every day. c. Explore hiring a patient with a known disability. d. Undergo physical therapy following a cerebrovascular accident. Answer: A Question: Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor management? a. Precontemplation b. Contemplation c. Preparation d. Action e. Maintenance Answer: C - Preparation is making small changes in preparation for a change in the next month. Question: You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is: a. public. b. intrapersonal. c. transpersonal. d. small group. Answer: D Question: Helping relationships serve as the foundation of clinical nursing practice. Which stage are contracts for a therapeutic helping relationship formed? a. orientation stage. b. working stage. c. termination stage. d. pre-interaction stage. Answer: A Question: While admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." The communication form used by the family member is: a. focusing. b. clarifying. c. summarizing. d. paraphrasing. Answer: B Question: Information regarding a patient's health status may not be released to non-health care team members because: a. legal and ethical obligations require health care providers to keep information strictly confidential. b. regulations require health care institutions to document evidence of physical and emotional well-being. c. reimbursement issues related to patient care and procedures may be of concern. d. fragmentation of nursing and medical care procedures may be identified. Answer: A Question: A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paperwork, the nurse needs to record: a. An interpretation of patient behavior. b. Objective data that are observed. c. Lengthy entry using lay terminology. d. Abbreviations familiar to the nurse. Answer: B Question: A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: a. PIE documentation. b. SOAP documentation. c. narrative charting. d. charting by exception. Answer: C Question: A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: a. Exchange information among health care members. b. Provide information about patients from one unit to another unit. c. Ensure proper care for the patient. d. Aid in the hospital's quality improvement program. Answer: D - An incident or occurrence is any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit. An incident report aims to better maintain or improve those standards. Incident reports are confidential and are NOT part of the health care record. Question: A patient is admitted to a medical unit for a home-acquired pressure injury. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. What will the nurse identify as a link in the infection chain? a. restraints. b. poor hygiene. c. Foley catheter bag. d. improper positioning. Answer: C Question: The nurse is caring for a patient who underwent surgery 48 hours ago. On physical assessment, the nurse notices that the wound looks red and swollen. The patient's WBCs are elevated. What should the nurse do? a. Start antibiotics. b. Notify the provider. C. Document the findings and reassess in 2 hours. D. Place the patient on isolation precautions. Answer: B Question: You have re-dressed a patient's wound and now plan to administer an oral medication to the patient. How should you utilize gloves? a. Put another pair of gloves over the soiled gloves and administer the medication. b. Remove gloves and use hand hygiene before administering the medication. c. Leave the gloves on to administer the medication. d. Leave the medication on the bedside table to avoid having to remove gloves. qB - You only have to use gloves to administer oral medication if the medication is hazardous (like hormones) or if there is a risk for body fluid contact with the patient (like drooling). Question: The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) a. Apply sterile gloves. b. Keep soiled linen close to uniform. c. Advise patient will feel a lump when rolling over. d. Turn clean pillowcase inside out over the hand holding it. e. Make a modified mitered corner with sheet, blanket, and spread. C, D, E - You do not need STERILE gloves to perform a bed change, you need CLEAN gloves. Question: Which nursing documentation demonstrates the integration of patient-centered care? a. Social worker paged for consultation. b. Steady gait observed when ambulating. c. Discussed dietary preferences with patient. d. Nursing literature reviewed for best practice approaches. C - The nurse providing patient-centered care recognizes "the patient or designee as the source of control and [a] full partner in providing compassionate and coordinated care based on respect for [the] patient's preferences, values, and needs" (). The KSAs for competence in patient-centered care focus on communication, compassion, culture, patient education and empowerment, and respect for patients and their families. The nurse has demonstrated this by discussing dietary preferences with the client. Paging a social worker reflected collaboration; observing and interpreting a gait reflects clinical judgment; reviewing nursing literature reflects evidence-based practice. Question: The nurse is delegating ambulation for a patient to an experienced Patient Care Technician (PCT). Which teaching will the nurse provide to the UAP? (Select all that apply.) a. "Come and get me for lunch." b. "Ambulate the patient every four hours." c. "Each ambulation should last 10 minutes." d. "Please let me know how the patient does after each ambulation." e. "Be certain to use a gait belt when performing this activity." B, C, D, E - The nurse will observe all of the "rights" (below) of delegation. He or she will give specific information about the task to the PCT, provide supervision, and have the PCT communicate results back. Right task Right circumstances Right person Right communication Right supervision Question: The nurse observes that numerous patients on a medical-surgical respiratory unit seem to have increasingly frequent readmissions. What quality improvement step could the nurse implement to explore the readmission rate? a. Inform the unit manager of the concerns. b. Evaluate trends and develop a plan for improvement. c. Contact the hospital quality improvement nurse to create an improvement strategy. d. Post a journal article on the unit that addresses national readmission rates for respiratory disorders. B - To meet the quality improvement competency, nurses are expected to "use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems" (). Options A and D transfer the nurse's direct involvement in quality improvement processes. Option C may be an appropriate intervention at a later time, but the nurse should first evaluate the problem using data prior to developing a strategy for improvement. Question: A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: a. Evaluation. b. Data collection. c. Problem identification. d. Testing a hypothesis. B - Assessment is the first stage of the nursing process, and is the process of gathering data to formulate the nursing diagnosis and care plan. Question: The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and: a. Decision making. b. Problem solving. c. Interview process. d. Intellectual standards. C - The interview process is an integral part of patient-centered care, and is continuous throughout patient interaction, regardless of the stage of the nursing process. Question: Concept mapping is one way to: a. Connect concepts to a central subject. b. Relate ideas to patient health problems. c. Challenge a nurse's thinking about patient needs and problems. d. Graphically display ideas by organizing data. e. All of the above. E - Concept mapping helps the busy nurse, with numerous patients, focus on healing patients on an individual basis. Question: For a student to avoid a data collection error, the student should: a. Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. b. Review his or her own comfort level and competency with assessment skills. c. Ask another student to perform the assessment. d. Consider whether the diagnosis should be actual, potential, or risk. A - Data collection is an art that the nurse gets better at with experience, so asking for assistance from a colleague to help with an unsure finding can ensure that the diagnostic statement is correct. Question: A patient is suffering from shortness of breath. The correct goal statement would be written as: a. The patient will be comfortable by the morning. b. The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift. c. The patient will not complain of breathing problems within the next 8 hours. d. The patient will have a respiratory rate of 14 to 18 breaths per minute. B - Goals should be: Specific Measurable or Meaningful Attainable or Action-Oriented Realistic or Results-Oriented Timely or Time-Oriented Question: When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: a. Critical pathway. b. Nursing care plan. c. Concept map. d. Diagnostic label. C - Concept maps help the nurse organize nursing interventions for a patient with multiple problems. Question: Consultation occurs most often during which phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation C - When a nurse is unsure of how to proceed in the planning process, he or she will seek out another colleague's knowledge and experience to assist in planning interventions for the patient. Question: Nurse-initiated interventions are a. Determined by state Nurse Practice Acts. b. Supervised by the entire health care team. c. Made in concert with the plan of care initiated by the physician. d. Developed after interventions for the recent medical diagnoses are evaluated. A - Individual nurse practice acts determine nurse-initiated interventions. Question: You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? a. The patient will eat 80% of all meals. b. The nursing assistant will set the patient up for a bath every day. c. The patient will have improved airway clearance by June 5. d. The patient will identify the need to increase dietary intake of fiber by June 5. D - Outcome statements should have measurable and realistic goals. In this case, the goal is both measurable (will identify the need to increase dietary intake by June 5) and realistic. Question: Your patient has met the goals set for improvement of ambulatory status. You would now: a. Modify the care plan. b. Discontinue the care plan. c. Create a new nursing diagnosis that states goals have been met. d. Reassess the patients' response to care and evaluate the implementation step of the nursing process. B - When goals are met, the care plan for that goal is discontinued. Question: You have finished with several nursing interventions. To evaluate interventions, you need to examine the: a. Appropriateness of the interventions and the correct application of the implementation process. b. Nursing diagnoses to ensure that they are not medical diagnoses. c. Care planning process for errors in other health care team members' judgments. d. Interventions of each nurse to enable the nurse manager to correctly evaluate performance. A - When evaluating, the nurse needs to look at the patient's condition, the interventions used to improve the patient's status, and whether or not they were appropriate. Question: The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done: a. Logically. b. Haphazardly. c. Independently. d. Systematically. B Question: A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating: a. Enabling. b. Comforting. c. A sense of presence. d. Maintaining belief. C - Providing presence is a person-to-person encounter conveying a closeness and sense of caring. Presence involves "being there" and "being with." Question: When a nurse enters a patient's room and says "Good morning" before starting care, the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to: a. Establish a relationship. b. Gather assessment data. c. Treat discomfort quickly. d. Assess the patient's emotional needs. D - In Swanson's Theory of Caring, "being with" is being emotionally present for another person. By taking the time to assess the patient's emotional needs, the nurse is exhibiting caring behavior. Question: You are caring for a patient. Visitors at the bedside include the patient's life partner, widowed father, brother, and niece. The nurse acknowledges that current trends in American families include: a. Couples without children. b. More singles choosing to live alone. c. A very different look from 15 years ago. d. A mother, father, and more than one child. C - Although the institution of the family remains strong, the family itself is changing. Question: A patient comes from a close-knit family. The patient's family functions as context. You will need to evaluate: a. Attainment of patient needs. b. Family attainment of developmental tasks. c. Individual family members caring about one another. d. Family satisfaction with its new level of functioning. A - When you look at the family as context, you will want to remember that the primary focus is on the health and development of the individual members. Question: When completing the nursing data on a client, to complete the admission and develop a plan of care, the nurse will need to: a. Test the family unit's ability to cope. b. Evaluate communication patterns. c. Identify family unit form and attitudes. d. Gather health data from all family members. C Question: According to Kohlberg, moral development is a component of psychosocial development. Moral development depends on the child's ability to integrate: a. Modeling of others. b. Faith and optimism. c. Self-control and independence. d. Decisions of right and wrong. D - Kohlberg believed that moral development was dependent on the child's ability to integrate decisions of rights and wrong. Question: You are about to irrigate a patient's open wound. Besides gloves, which other item of PPE must you wear? a. a sterile gown. b. goggles. c. a face shield. d. an N95 respirator. C - A face shield protects all the rest of the face from any potential splashes of fluids. Irrigation has potential for splashing blood or fluids onto your face. Question: Which of the following is an advantage of using alcohol-based gel? a. It take less time than soap and water. b. It removes gross contamination better that soap and water. c. Its protective nature reduces the need for frequent handwashing. d. It provides adequate protection before surgical applications. A Question: A nurse is using the Plan-Do-Study-Act (PDSA) strategy to do a quality improvement project to decrease patient falls on a nursing unit. What is the correct sequence for PDSA? a. Bedside change of shift report is piloted on two medical-surgical units b. Patient satisfaction levels after implementation of the bedside report are compared to patient satisfaction levels before the change c. The nursing council develops a strategy for bedside change of shift report d. After modifications are made in the shift report elements, bedside shift report is implemented on all nursing units C, A, B, D Question: Which of the following are examples of the nurse participating in primary care activities? (Select all that apply.) a. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester. b. Assessing the nutritional status of older adults who come to the community center for lunch. c. Working with patients in a cardiac rehabilitation program. d. Providing home wound care to a patient e. Teaching a class to parents at the local grade school about the importance of immunizations. A, B, E Question: Which of the following are characteristics of managed care systems? (Select all that apply.) a. Provider receives a predetermined payment for each patient in the program. b. Payment is based on a set fee for each service provided. c. System includes a voluntary prescription drug program for an additional cost. d. System tries to reduce costs while keeping patients healthy. e. Focus of care is on prevention and early intervention. A, D, E Question: Which of the following nursing activities is provided in a secondary health care environment? (Select all that apply.) a. Conducting blood pressure screenings for older adults at the Senior Center. b. Teaching a clinic patient with chronic obstructive pulmonary disease purse-lipped breathing techniques. c. Changing the postoperative dressing for a patient on a medical-surgical unit. d. Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit. C, D - These patients are being taken care of in an E.R., as indicated by the specialized units they are in. Question: The nursing staff is developing a quality program. Which of the following are nursing-sensitive indicators from the National Database of Nursing Quality Indicators (NDNQI) that the nurses can use to measure patient safety and quality for the unit? (Select all that apply.) a. Use of physical restraints. b. Pain assessment, intervention, and reassessment. c. Patient satisfaction with food preparation. d. Registered nurse (RN) education and certification. e. Number of outpatient surgical cases per year. A, B, D Question: While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that: a. Teenagers need to practice safe sex. b. A 3-year-old can safely sit in the front seat of the car. c. Children need to wear safety equipment when bike riding. d. Children need to learn to swim even if they do not have a pool. B - Children ages 3 and younger should be in a child safety seat in the back of the car. Question: A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: a. Raise all four side rails when darkness falls. b. Use an electronic bed monitoring device. c. Place the patient in a room close to the nursing station. d. Use a loose-fitting vest-type jacket restraint. B - For wandering patients, an electronic monitoring device can be used to notify the nurse when the patient is mobile. Question: A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as: a. A poisoning accident. b. An equipment-related accident. c. A procedure-related accident. d. An accident related to time management. C - When an error occurs due to the actions of a health care provider, it is considered a procedure-related accident. Question: A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess: a. posture. b. activity tolerance. c. body mechanics d. range of joint motion. D Question: You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with: a. atelectasis. b. hypertension. c. orthostatic hypotension. d. coagulation of blood. A Question: After completing preoperative teaching for a surgical patient, you can evaluate the patient's understanding of the use of elastic stockings when the patient states: a. "I can remove them at night." b. "I can roll them no lower than my calf muscle." c. "I can wear them no longer than 4 hours at a time." d. "I can remove them for 30 minutes every 8 hours." D Question: Which client is at greatest risk for developing adverse effects of immobility? a. 3-year-old child with a fractured femur. b. 78-year-old man in traction for a broken hip. c. 48-year-old woman following a thyroidectomy. d. 38-year-old woman undergoing a hysterectomy. B Question: A nursing instructor asks you what may cause orthostatic hypotension. You correctly reply (select all that apply): a. Prolonged bed rest. b. Hypokalemia. c. Low body weight. d. Anti-hypertensives. e. Room temperature. A, B, D Question: You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene, you should: a. Use soap and water on all types of skin. b. Ensure that culture and ethnicity influence hygiene practices. c. Shave facial hair to make the patient more comfortable. d. Know that all patients need to be bathed daily. B Question: A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be: a. cutting the matted hair away. b. braiding the hair to reduce tangles. c. using a grease-type product to tame the hair. d. keeping the hair oil free by applying powder every morning. B Question: What is the proper position to use for an unresponsive patient during oral care to prevent aspiration? (Select all that apply.) a. Prone position b. Sims' position c. Semi-Fowler's position with head to side d. Trendelenburg position e. Supine position B, C - Place the unconscious patient in semi-Fowler's position with head to the side or use the Sims' position to help avoid aspiration while performing oral care. The supine and Trendelenburg positions would make it easier for a patient to aspirate. The prone position would not be suitable for accessing the oral cavity. Question: The student nurse is teaching a family member the importance of foot care for his or her mother, who has diabetes. Which safety precautions are important for the family member to know to prevent infection? (Select all that apply.) a. Cut nails frequently. b. Assess skin for redness, abrasions, and open areas daily. c. Soak feet in water at least 10 minutes before nail care. d. Apply lotion to feet daily. e. Clean between toes after bathing. B, D, E - Because of a patient's risk for infection, it is important to assess skin for redness, abrasions, and open areas daily. Apply lotion to feet daily to keep the skin hydrated, but do not leave excess lotion on the skin. Clean between toes carefully after bathing to avoid maceration. Do not cut nails or soak the feet of a patient with diabetes because this may create skin breakdown and open sores, leading to skin breakdown or infection. Question: A nurse uses long firm, strokes distal to proximal while bathing a patient's legs because: a. It promotes venous circulation. b. It covers a larger area of the leg. c. It completes care in a timely fashion. d. It prevents blood clots in legs. A - Bathing a patient with long, firm strokes distal to proximal promotes circulation and increases venous return. Question: Integrity of the oral mucosa depends on salivary secretion. Which of the following factors impairs salivary secretion? (Select all that apply.) a. Use of cough drops b. Immunosuppression c. Radiation therapy d. Dehydration e. Presence of oral airway C, D - Radiation therapy reduces salivary flow. Dehydration impairs salivary secretion in the mouth. Cough drops increase sugar or acid content in the mouth, causing caries. Immunosuppression causes inflammation and bleeding of the gums. An oral airway irritates oral mucosa. Question: A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? a. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period b. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line c. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool. D - All of the patients require careful bathing. The 44-yearold female needs good perineal hygiene. The 56-year-old patient is at risk for drying and fragility of the skin. The 60-year-old patient has reduced sensation and mobility and thus is unaware of skin problems or pressure areas. However, the 70-year-old patient has reduced circulation, which increases risk for infection, and is likely unaware of skin problems because of dementia. The presence of stool will also irritate the skin. Question: When you are assigned to a patient who has a reduced level of consciousness and requires mouth care, which physical assessment techniques should you perform before the procedure? (Select all that apply.) a. Oxygen saturation. b. Heart rate. c. Respirations. d. Gag reflex. e. Response to painful stimulus. A, C, D - Check a patient's respirations and whether there is a gag reflex present to determine risk for aspiration and to establish a baseline for the patient's condition. Question: A nurse is listening to a student provide instruction to a patient who is having difficulty with activities needed to care for soft contact lenses. Which of the following statements by the nursing student might require some correction by the nurse? a. Use tap water to clean soft lenses. b. Follow recommendations of lens manufacturer when inserting the lenses. c. Keep lenses moist or wet when not worn. d. Use fresh solution daily when storing and disinfecting lenses. A Question: The American Dental Association suggests that patients who are at risk for poor hygiene use the following interventions for oral care: (Select all that apply.) a. Use antimicrobial toothpaste. b. Brush teeth 4 times a day. c. Use 0.12% chlorhexidine gluconate (CHG) oral rinses. d. Use a soft toothbrush for oral care. e. Avoid cleaning the gums and tongue. A, C, D - The American Dental Association guidelines (2014) for effective oral hygiene include brushing the teeth at least twice a day with an American Dental Association-approved fluoride toothpaste. Use antimicrobial toothpastes and 0.12% CHG oral rinses for patients at increased risk for poor oral hygiene (e.g., older adults and patients with cognitive impairments and who are immunocompromised). Rounded soft bristles stimulate the gums without causing abrasion and bleeding. Patients should clean gum and the surface of the tongue. Question: While planning morning care, which of the following patients would have the highest priority to receive his or her bath first? a. A patient who just returned to the nursing unit from a diagnostic test b. A patient who prefers a bath in the evening when his wife visits and can help him c. A patient who is experiencing frequent incontinent diarrheal stools and urine d. A patient who has been awake all night because of pain 8/10 C - A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling, whereas patients who are normally inactive during the day and have skin that tends to be dry may need to bathe only twice a week. Question: An 88-year-old patient comes to the medical clinic regularly. During a recent visit the nurse noticed that the patient had lost 10 lbs in 6 weeks without being on a special diet. The patient tells the nurse that he has had trouble chewing his food. Which of the following factors are normal aging changes that can affect an older adult's oral health? (Select all that apply.) a. Dentures do not always fit properly. b. Most older adults have an increase in saliva secretions. c. With aging the periodontal membrane becomes tighter and painful. d. Many older adults are edentulous, and remaining teeth are often decayed. A, D - Dentures or partial plates do not always fit properly, causing pain and discomfort. Many older adults are edentulous (without teeth), and the teeth that are present are often diseased or decayed. An age-related decline in saliva secretion is common. The periodontal membrane weakens with aging, making the area prone to infection. Normally aging does not affect temperature sensitivity. Question: A patient with a malignant brain tumor requires oral care. The patient's level of consciousness has declined, with the patient only being able to respond to voice commands. Place the following steps in the correct order for administration of oral care. a. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway. b. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up to 30 degrees. c. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces first. d. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral cavity. e. Remove partial plate or dentures if present. f. Gently brush tongue but avoid stimulating gag reflex. B, E, A, C, F, D Question: The nurse delegates needed hygiene care for an elderly stroke patient. Which intervention would be appropriate for the nursing assistive personnel to accomplish during the bath? a. Checking distal pulses b. Providing range-of-motion (ROM) exercises to extremities c. Determining type of treatment for stage 1 pressure ulcer d. Changing the dressing over an intravenous site B - ROM may be delegated to nursing assistive personnel. The other activities should be performed by the nurse. Question: The nurse observes an adult Middle Eastern patient attempting to bathe himself with only his left hand. The nurse recognizes that this behavior likely relates to: a. Obsessive compulsive behavior. b. Personal preferences. c. The patient's cultural norm. d. Controlling behaviors. C - Cultural beliefs often influence patients' hygiene practices. Middle Eastern practices encourage one hand to be kept clean at all times. Question: When a nurse delegates hygiene care for a male patient to a nursing assistive personnel, the NAP must use an electric razor to shave the patient with the following diagnosis: a. Congestive heart failure b. Pneumonia c. Arthritis d. Thrombocytopenia D - Patients prone to bleeding (e.g., those receiving anticoagulants or high doses of aspirin or those with low platelet counts) need to use an electric razor. Question: A patient receiving chemotherapy experiences stomatitis. The nurse advises the patient to use: a. Community mouthwash. b. Alcohol-based mouth rinse. c. Normal saline rinses. d. Firm toothbrush. C - Normal saline is the safest solution to use in caring for a patient with stomatitis. Alcohol and community mouthwashes can be irritating and burning. A soft toothbrush should be used. Question: Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain comfort, safety, and hygiene to prevent infection. 1. Ruth enters Mr. Epstein's room to perform a skin assessment. She will check for which of the following components of the skin? (Select all that apply.) a. Color b. Texture c. Temperature d. Turgor e. Symmetry A, B, C, D - A skin assessment includes assessing the color, texture, temperature, turgor, thickness, and hydration of the skin. Question: Mr. Gabriel Epstein is a 68-year-old Israeli male admitted to the cardiac unit after undergoing open-heart surgery for a coronary artery bypass graft (CABG) caused by blocked vessels in his heart. His procedure was invasive; his breastbone was cut, and the chest opened to expose the heart. After the surgery he is groggy and weak. He is a bachelor and has no family to visit him at the hospital.Ruth is the nursing student assigned to Mr. Epstein. Her priority nursing goals for him are to maintain comfort, safety, and hygiene to prevent infection. 2. Mr. Epstein is too groggy to brush his own teeth. Ruth knows that it is important to keep his mouth clean to prevent infection. When performing oral care for Mr. Epstein, Ruth notices that his tongue is red and swollen. Which oral condition does he have? a. Halitosis b. Glossitis c. Alopecia d. Cerumen B - Glossitis is the condition of an inflamed tongue. Question: 3. Ruth prepares to give Mr. Epstein a bed bath since he is not able to bathe independently. Which of the following are guidelines that she should follow while giving him a bed bath? (Select all that apply.) a. Maintain safety. b. Provide privacy. c. Maintain warmth. d. Promote independence. e. Hydrate skin. A, B, C, D - Guidelines for giving a bed bath are to maintain safety, provide privacy, maintain warmth, promote independence, and anticipate needs. Question: When bathing a patient's extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique: a. Provides an opportunity for skin assessment. b. Avoids undue strain on the nurse. c. Increases venous blood return. d. Causes vasoconstriction and increases circulation. C - Washing from distal to proximal areas stimulates venous blood flow, thereby preventing venous stasis. Question: Nursing interventions that can help the patient to relax and sleep restfully include all of the following except: a. Have the patient take a 30- to 60-minute nap in the afternoon. b. Turn on the television in the patient's room. c. Provide quiet music and interesting reading material. d. Massage the patient's back with long strokes. A - Napping in the afternoon is not conducive to nighttime sleeping. There are few considerations about naps. For example, a short daytime nap of 15-30 minutes can be restorative for elders and will not interfere with nighttime sleep. On the other hand, insomniacs are cautioned to avoid naps. Quiet music, watching television, reading, and massage usually will relax the patient, helping him to fall asleep. Question: Restraints can be used for all of the following purposes except to: a. Prevent a confused patient from removing tubes, such as feeding tubes, I.V. lines, and urinary catheters. b. Prevent a patient from falling out of bed or a chair. c. Discourage a patient from attempting to ambulate alone when he requires assistance for his safety. d. Prevent a patient from becoming confused or disoriented. D - By restricting a patient's movements, restraints may increase stress and lead to confusion, rather than prevent it. Restraints in a medical setting are devices that limit a patient's movement. Restraints can help keep a person from getting hurt or doing harm to others, including their caregivers. They are used as a last resort. Question: Which of the following is the nurse's legal responsibility when applying restraints? a. Document the patient's behavior. b. Document the type of restraint used. c. Obtain a written order from the physician except in an emergency, when the patient must be protected from injury to himself or others. d. All of the above. D Question: A nurse caring for a patient with an infectious disease who requires isolation should refers to guidelines published by the: a. National League for Nursing (NLN) b. Centers for Disease Control (CDC) c. American Medical Association (AMA) d. American Nurses Association (ANA) B Question: To institute appropriate isolation precautions, the nurse must first know the: a. Organism's mode of transmission b. Organism's Gram-staining characteristics c. Organism's susceptibility to antibiotics d. Patient's susceptibility to the organism A - Before instituting isolation precaution, the nurse must first determine the organism's mode of transmission. For example, an organism transmitted through nasal secretions requires that the patient be kept in respiratory isolation, which involves keeping the patient in a private room with the door closed and wearing a mask, a gown, and gloves when coming in direct contact with the patient. Question: An autoclave is used to sterilize hospital supplies because: a. More articles can be sterilized at a time. b. Steam causes less damage to the materials. c. A lower temperature can be obtained. d. Pressurized steam penetrates the supplies better. D - An autoclave, an apparatus that sterilizes equipment by means of high-temperature pressurized steam, is used because it can destroy all forms of microorganisms, including spores. Autoclaves operate at high temperature and pressure in order to kill microorganisms and spores. They are used to decontaminate certain biological waste and sterilize media, instruments, and labware. Question: The best way to decrease the risk of transferring pathogens to a patient when removing contaminated gloves is to: a. Wash the gloves before removing them. b. Gently pull on the fingers of the gloves when removing them. c. Gently pull just below the cuff and invert the gloves when removing them. d. Remove the gloves and then turn them inside out. C Question: A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by: a. Writing down all assignments. b. Making changes after evaluating the situation and having discussions with the staff. c. Telling the staff nurses that she is making changes to benefit their performance. d. Evaluating the clinical performance of each staff nurse in a private conference. B - A new assistant nurse manager should not make changes until she has had a chance to evaluate staff members, patients, and physicians. Changes must be planned thoroughly and should be based on a need to improve conditions, not just for the sake of change. Question: Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications? a. Decreased plasma drug levels b. Sensory deficits c. Lack of family support d. History of Tourette syndrome B - Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Age-related decline of the five classical senses (vision, smell, hearing, touch, and taste) poses significant burdens on older adults. Question: The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data? a. Vital signs b. Laboratory test result c. Patient's description of pain d. Electrocardiographic (ECG) waveforms C Question: A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal? a. A palpable radial pulse b. A palpable ulnar pulse c. Cool, pale fingers d. Pink nail beds C - A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings. Question: A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction? a. Asking frequently if the patient understands the instruction. b. Asking an interpreter to replay the instructions to the patient. c. Writing out the instructions and having a family member read them to the patient. d. Demonstrating the procedure and having the patient return the demonstration. D - Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Question: A female patient is being discharged after cataract surgery. After providing medication teaching, the nurse asks the patient to repeat the instructions. The nurse is performing which professional role? a. Manager b. Educator c. Caregiver d. Patient advocate B - When teaching a patient about medications before discharge, the nurse is acting as an educator. Question: A female patient exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the patient's anxiety? a. "Everything will be fine. Don't worry." b. "Read this manual and then ask me any questions you may have." c. "Why don't you listen to the radio?" d. "Let's talk about what's bothering you." D - Because the other options ignore the patient's feelings and block communication, they would not reduce anxiety.