Dewitt 31, 37, questions and answers with verified content

Dewitt 31, 37, questions and answers with verified content The nurse assesses a patient's sleep for NREM (non-rapid eye movement) sleep because this sleep has the characteristics of: a. daytime activity. b. offering the most rest. c. irregular respirations. d. increased heart rate. B p609 A patient experiencing discomfort because of severe arthritis would be described as having _______ pain. a. acute b. chronic c. phantom d. episodic B p549 A patient is beginning treatment for pain with a transcutaneous electrical nerve stimulator (TENS) unit. The nurse will initially: a. apply conductive jelly to uncoated electrodes. b. turn the unit on before attaching it to the patient. c. place electrodes on all four extremities. d. adjust the settings below the level at which a tingling sensation is felt. A p601 The patient with a recent abdominal incision has an abdominal binder applied. The nurse explains that this appliance helps reduce pain by: a. increasing warmth to the incision site. b. keeping sutures and staples in place. c. supporting surface and internal tissues. d. adding back support to enhance early ambulation. C p601 A nurse evaluating the effectiveness of an Aquathermia K pad for the leg is aware that the patient who has the least risk for burn injury from this device would be the patient with: a. impaired peripheral circulation. b. severely sprained ankle. c. decreased level of consciousness from a stroke. d. neuritis secondary to diabetes. B p602 A nurse caring for a patient who suffered a severe sprain and has an order for a cold pack application to the injured area would prevent patient injury by: a. using heavy pressure on the cold pack for greater effectiveness. b. preparing to apply heat instead if cold is not effective. c. leaving the pack in place for over 30 minutes at a time. d. placing a towel between the pack and the skin. D p602 A nurse is instructing a patient about relaxation techniques for pain management. The patient should: a. keep bright lights on in the room. b. use this technique as a way to wake up in the morning. c. tense and relax individual muscle groups, starting with the toes and feet. d. try to tense and relax all of the muscles of the body at the same time. C p602 A patient is receiving an ice massage for relief of muscle spasms in the neck. The patient complains that the ice is making the pain worse. Most helpful response from the nurse would be: a. "I know it is uncomfortable right now, but it will get better in a few minutes." b. "I will go get an ice pack to pace on your neck." c. "The alteration of hot and cold application is very helpful for your spasms." d. "I will stop these cold applications. Not everyone is helped by them." D p602 A patient experiencing pain states that guided imagery has made the pain more manageable in the past. To assist this patient, the nurse should: a. find a focal point in the room. b. bring a newspaper or deck of cards according to patient choice. c. obtain skin lotion and a towel to give a back rub. d. read from a script that helps the patient visualize a restful place. D p603 The nurse takes into consideration that when the patient has an order for a patient-controlled analgesia (PCA) the pump will be programmed by the: a. registered nurse. b. primary care provider. c. LPN/LVN. d. pharmaceutical company. A p606 The nurse is aware that the new order for indomethacin (Indocin) involves the administration of a(n): a. COX-2 inhibitor. b. adjuvant analgesic. c. narcotic analgesic. d. nonsteroidal anti-inflammatory medication. D p604 The nurse appreciates the principal advantage in using patient-controlled analgesia (PCA) is that it: a. reduces patient anxiety about pain by giving the patient more control in its management. b. reduces the workload of the nurse, because it does not have to be checked often. c. eliminates the risk of adverse drug effects from the medication. d. completely eliminates any pain the patient is experiencing. A p605 A nurse caring for a patient with a Fentanyl patch assesses that the patient is abnormally sleepy, is slurring words and is unsteady when ambulating. The nurse should: a. put up the side rails on the bed. b. elevate the head of the bed 45 degrees and offer coffee or cola drink. c. remove the patch and wipe off the skin. d. apply ice to skin around the patch. C p605 A nurse is assisting in the care of a patient who is receiving pain medication by the epidural route. It is most important to monitor this patient for which adverse drug effects? a. Constipation b. Headache c. Nausea d. Hypoventilation D p607 A patient with an epidural catheter needs to have the dressing at the insertion site changed. When cleaning the insertion site with povidone iodine swabs, the nurse should: a. use a circular motion working from the insertion site outward. b. use a circular motion working from the outside to the insertion site. c. start above the insertion site and swab in a downward motion. d. start below the insertion site and swab in an upward motion. A p608 A nurse is assessing the status of a patient who is sleeping. Which assessment data indicate that the patient is most likely in stage 3 of non-rapid eye movement (NREM) sleep? a. Rapid respirations, rapid heart rate b. Rapid respirations, slow heart rate c. Decreased respirations, slow heart rate d. Decreased respirations, rapid heart rate C p609 The nurse recommends that normal sleepatchesp patterns can best be acquired by suggesting to the patient that they: a. smoke cigarettes. b. drink wine. c. take a nap during the day. d. exercise in the mornings. D p610 A sleeping patient has periodic pauses in breathing, then starts to breathe again. The nurse recognizes this sleep pattern is consistent with: a. insomnia. b. sleep apnea. c. narcolepsy. d. excessive NREM sleep. B p610 The suggestion by the nurse which is most helpful to a patient who complains of chronically not feeling rested after sleep would be: a. avoid going to bed hungry or overly full. b. try to exercise just before going to bed. c. sleep late the next morning if possible if you are tired on awakening. d. take a nap during the day to help relieve overall fatigue. A p611 The most helpful intervention by the nurse for a hospitalized child who is having difficulty falling asleep would be to: a. keep a night light on in the room. b. turn off all the lights in the room. c. have the parents bring a favorite blanket or pillow from home. d. give of juice and cookies before being put to bed. C p611 A patient who has difficulty falling asleep at night because of anxiety over family problems asks if he should start taking sedative pills from the pharmacy to sleep better. The best advice to give this patient is that these pills can be used for: a. long periods of time, but it is best to check with the primary care provider first. b. short periods of time, but it is best to check with the primary care provider first. c. long periods of time without primary care provider approval, because they are nonprescription medications. d. short periods of time without physician approval, because they are nonprescription medications. B p612 A natural supplement that can enhance sleep for many people is: a. melatonin. b. calcium. c. magnesium. d. oil of lavender. A p612 The nurse takes into consideration the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain assessment and treatment include: a. pain treatment is based on objective data collected by the nurse. b. pain treatment ends at discharge. c. pain is assessed only for patients who complain of pain. d. all patients have the right to appropriate assessment of pain. D p594 A relative complains that an older adult patient takes frequent naps late in the day and awakens frequently during the night, and wants to know if this is normal. The nurse explains that an older adult: a. will awaken more often during the night, but may nap more often during the day. b. needs at least 10 hours of sleep a day to prevent fatigue. c. requires less napping during the day to sleep better at night. d. should be given hypnotics to induce better sleep. A p609 A nurse explains that endorphins are capable of reducing pain: a. as a naturally occurring morphine like enzyme. b. in conditions that are physiological only. c. by attaching to opioid receptors. d. when psychological stressors are the cause of pain. C p595 A nurse is preparing a patient for home care following cancer treatment. He is discussing the use of the fentanyl patch. Which of the following would be the most important instruction regarding safety? a. Apply as directed by the primary care provider. b. Store fentanyl patches in a locked cabinet. c. Prepare the skin by cleaning with an antiseptic scrub solution. d. Use as needed for break through pain. B p605 The nurse outlines the four phases of nociceptive pain as: (Select all that apply.) a. translation. b. transduction. c. transmission. d. modulation. e. perception. B, C, D, E p597 The nurse attempts to help an 86-year-old patient describe his pain because the nurse is aware the older adult may not express pain because they: (Select all that apply.) a. are unaware of their discomfort. b. believe pain is a natural consequence to aging. c. are reluctant to bother the nursing staff. d. have been culturally trained not to complain. e. tear taking pain medication. B, C, D p598 The nurse performing a focused assessment on pain will assess: (Select all that apply.) a. history of pain. b. verbal indicators. c. psychological factors. d. culture. e. contributing factors. A, B, C, E p598 ___________ is considered to be the fifth vital sign. Pain p594 A type of pain that is of short duration, lasting from a few hours to a few days, is known as _________ pain. acute p594 The _______________ is based on the premise that by stimulating large diameter nerve fibers pain is diminished or totally controlled. Gate Control Theory p595 A pain scale FLACC is used in assessing pain in________. preverbal children and noncommunicacive adults p599 Travelers can combat "jet lag" by exposure to _______ for several hours. sunlight p610 A nurse removed a pain medication patch that has a metal clip before the patient goes to have a(n) _________. MRI p605 The circulating nurse notes that the anesthetized patient has tensed muscles and irregular respirations. The nurse is aware that the patient has reached stage: a. I and the patient's hearing is amplified. b. II and the surgical environment should be kept quiet. c. III and the patient has depressed reflexes. d. IV and the patient will not depend on the anesthesia machine of oxygenations. B p736 In order for the anesthesiologist to accurately calculate the amount of anesthesia needed for an 82-year-old patient, the nurse should have data available on the medical record, such as: a. time of last meal. b. pulse rate and blood pressure. c. respiratory rate and oxygen saturation. d. height and weight. D p736 The illiterate patient signs the surgical consent form with an "X." The nurse is aware that this "X" is: a. not an acceptable signature. b. required to be accompanied by a picture identification. c. legal if it is witnessed. d. acceptable if the surgeon is willing. C p737 A 16-year-old boy injured in a motorcycle accident is unconscious and cannot sign the emergency surgical consent form; no family members can be located. The nurse anticipates that: a. the hospital social worker can sign the permit. b. the surgeon will write a detailed note about the need for surgery and a registered nurse will then sign the consent. c. the opinion of a second surgeon is sought regarding the necessity of the surgery. d. the hospital attorney must authorize the surgery and sign the consent form. C p737 The nurse discovers that the signed operative permit has misspelled the patient's name. The nurse must: a. request a corrected consent form to be signed. b. inform the surgeon of the error. c. have the new form attached to the old incorrect one and document it. d. allow the patient to be taken to surgery after notifying the circulating nurse. A p737 A patient who has recently arrived on the surgical unit after being transferred from the postanesthesia care unit asks for a drink. The nurse should first check the: a. status of the IV fluids. b. ability to swallow. c. nursing progress notes. d. anesthesia record. B p752 A patient scheduled for surgery has an order for a preoperative surgical skin preparation. The nurse may be required to: a. shave the entire surgical site. b. spray the surgical area with an antimicrobial solution. c. scrub the surgical area for 1 minute with antibacterial solution. d. instruct the patient in the use of an antimicrobial soap in the shower. D p741 To help prevent errors in the surgical procedure, the National Patient Safety Goal instituted a directive that prior to presurgical medication, each patient must: a. verbally state the location of the surgical site and the expected procedure. b. when still conscious participate in marking the surgical site. c. have the unit nurse confirm their identity. d. have a photograph of the surgical site in the medical record. B p737 While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should: a. tape it in place on his finger. b. remind him it must be removed, and lock it in the narcotic cabinet. c. ask a family member to take care of it. d. inform him that the hospital cannot be responsible for its loss. A p741 The nurse is aware that in both the very young and the older adult surgical patient, the risk is much higher for: a. nausea and vomiting. b. hydration issues. c. delayed healing. d. anorexia. B p734 A patient undergoing preadmission testing before same day surgery asks how long he will remain in the recovery area before being allowed to go home. The nurse's most informative response would be: a. 30 to 60 minutes. b. 2 to 6 hours. c. 5 to 6 hours. d. 6 to 8 hours. B p748 The circulating nurse is responsible for: a. preparing the sterile field. b. assisting with sterile draping of the patient. c. maintaining an accurate count of sponges. d. pointing out the observation of contamination immediately to the personnel involved. D p748 When the patient is ready to return from the postanesthesia care unit (PACU), a minimal Aldrete score of _______ is an indicator that the patient is ready to return to the floor. a. 2 to 4 b. 4 to 8 c. 9 to 10 d. 11 to 12 C p748 A patient who has returned to the surgical nursing unit from the postanesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is: a. supine. b. side lying. c. head of bed at 30 degrees with head and neck midline. d. head of bed at 45 degrees with head and neck midline. B p751 The nurse is assessing the surgical dressing of a patient who arrived on the unit an hour ago. The surgical dressing has serosanguineous drainage on the dressing. The nurse should: a. make a note of the drainage on the worksheet to report it at the end of shift. b. change the surgical dressing immediately to prevent infection. c. outline the area of drainage with a pen and mark it with the date and time. d. reinforce the dressing with clean gauze sponges and tape. C p751 A nurse is instructing a patient who had surgical removal of a brain tumor on how to prevent respiratory complications from surgery. The nurse would teach the patient to: a. turn, cough, and deep breathe. b. use humidified oxygen. c. turn gently from side to side. d. use deep breathing and an incentive spirometer. D p751 A postoperative surgical patient asks how the sequential pneumatic compression boots applied in the operating room will help lower the risk of blood clots forming in the legs. The nurse's most appropriate response would be that the boots: a. measure pressure in the leg blood vessels and sound an alarm if pressure rises. b. alternately compress and release to help blood flow through vessels. c. provide gentle continuous compression at low pressure. d. provide firm continuous compression at high pressure. B p752 A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the postanesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to: a. increase the flow rate of the IV for 10 to 15 minutes. b. irrigate the indwelling urinary catheter. c. apply manual pressure to the patient's bladder. d. notify the surgeon of the findings. D p752 A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to eat. The diet order indicates clear liquids can be taken. Before giving a Jell O to the patient, the nurse should check for the presence of: a. clear lung sounds. b. adequate urinary drainage. c. bowel sounds in all quadrants. d. palpable peripheral pulses. C p754 A patient who had abdominal surgery is complaining of "gas pains" and has distention of the abdomen and flatus. To promote patient comfort, the nurse should advise: a. early ambulation. b. turning to the left side. c. drinking fluids that are very hot. d. lying supine with knees flexed. A p755