FUNDAMENTALS TEST FOR NURSING QUESTION AND ANSWERS 100%

. A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations - ANSWERS-a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations .. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles. 2. Perform hand hygiene, leave room, and close door. 3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside of mask. 6. Dispose of all contaminated supplies and equipment in designated receptacles. a. 3, 1, 4, 5, 6, 2 b. 1, 4, 5, 3, 6, 2 c. 1, 4, 5, 3, 2, 6 d. 3, 1, 4, 5, 2, 6 - ANSWERS-d. 3, 1, 4, 5, 2, 6 .. The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take? a. Leave the foreskin alone because there is little chance of infection. b. Retract the foreskin for cleansing and allow it to return on its own. c. Retract the foreskin and return it to its natural position when done. d. Leave the foreskin retracted after cleansing the penis - ANSWERS-c. Retract the foreskin and return it to its natural position when done. .A 55-year-old patient is preparing to start an exercise program. The health care provider wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add to the care plan as the target heart rate. Record answer as a whole number. _________ maximum heart rate - ANSWERS-99 .A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which action will the nurse take to prevent the spread of infection? a. Position the patient comfortably on the stretcher. b. Explain the procedure for dressing change to the patient. c. Review the medication list that the patient brought from home. d. Don gloves and other appropriate personal protective equipment - ANSWERS-d. Don gloves and other appropriate personal protective equipment .A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? a. "When was the last time you visited your primary health care provider?" b. "Has this condition affected your eating habits in any way?" c. "What medications are you currently taking?" d. "Are you able to sleep at night? - ANSWERS-c. "What medications are you currently taking?" .A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome? a. Patient is lying on side. b. Patient is lying on back. c. Patient is lying semiprone. d. Patient is lying on abdomen - ANSWERS-a. Patient is lying on side. .A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain - ANSWERS-d. Visceral pain .A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? a. Blood pressure sitting 120/64; blood pressure 140/70 standing b. Blood pressure sitting 126/64; blood pressure 120/58 standing c. Blood pressure sitting 130/60; blood pressure 110/60 standing d. Blood pressure sitting 140/60; blood pressure 130/54 standing - ANSWERS-c. Blood pressure sitting 130/60; blood pressure 110/60 standing .A nurse is assessing a patient's skin. Which patient is most at risk for impaired skin integrity? a. A patient who is afebrile b. A patient who is diaphoretic c. A patient with strong pedal pulses d. A patient with adequate skin turgor - ANSWERS-b. A patient who is diaphoretic .A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Pregnancy status d. Race e. Age - ANSWERS-a. Skeletal abnormalities b. Emotional factors c. Pregnancy status e. Age .A nurse is assessing body alignment. What is the nurse monitoring? a. The relationship of one body part to another while in different positions b. The coordinated efforts of the musculoskeletal and nervous systems c. The force that occurs in a direction to oppose movement d. The inability to move about freely - ANSWERS-a. The relationship of one body part to another while in different positions .A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe? a. Chin, elbow, hips b. Ileum, clavicle, humerus c. Shoulder, anterior iliac spine, ankles d. Occipital region of the head, coccyx, heels - ANSWERS-b. Ileum, clavicle, humerus .A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient's temperature is 113° F (45° C) with hot, dry skin. b. Patient's blood pressure sitting is 130/60 and 110/40 standing. c. Patient's pulse is 110 beats/min. d. Patient's temperature is 93.2° F (34° C). e. Patient's blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke 4. Orthostatic hypotension 5. Tachycardia - ANSWERS-1. D 2. E 3. A 4. B 5. C .A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed "S" pattern. b. When observed posteriorly, the hips and shoulders form an "S" pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out. - ANSWERS-a. When observed laterally, the spinal curves align in a reversed "S" pattern. .A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of fluid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care. - ANSWERS-c. Use a standardized tool such as the Braden Scale. .A nurse is assisting the patient to perform isometric exercises. Which action will the nurse take? a. Encourage wearing tight shoes. b. Set the pace for the exercise session. c. Stop the exercise if pain is experienced. d. Force muscles or joints to go just beyond resistance. - ANSWERS-c. Stop the exercise if pain is experienced. .A nurse is caring for a group of patients. Which patient will the nurse see first to best manage patient needs? a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg. b. A patient lying very still in bed who reports no pain but is pale with warm, dry skin. c. A patient with severe pain who is nauseated and feels like he or she is about to vomit. d. A patient writhing and moaning from abdominal pain after abdominal surgery. - ANSWERS-a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg. .A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken. b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60. c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74. d. An 87-year-old male suspected of hypothermia whose temperature is below normal. - ANSWERS-b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60. .A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 - ANSWERS-c. A calm adolescent with P-95 and R-26 .A nurse is caring for a patient diagnosed with chronic pain. Which statement by the nurse indicates an understanding of pain management? a. "This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication." b. "I need to reassess the patient's pain 1 hour after administering oral pain medication." c. "It wasn't time for the patient's medication, so when it was requested, I gave a placebo." d. "The patient is sleeping, so I pushed the PCA button." - ANSWERS-b. "I need to reassess the patient's pain 1 hour after administering oral pain medication." .A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement? a. Encourage dairy products. b. Monitor intake of vitamin D. c. Increase intake of caffeinated drinks. d. Try to do as much as possible for the patient. - ANSWERS-b. Monitor intake of vitamin D. .A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record? a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain - ANSWERS-b. Somatic pain .A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management? a. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." b. "You should take your medication after you walk to make sure you do not fall while you are walking." c. "We should work together to create a schedule to provide regular dosing of medication." d. "When you experience severe pain, you will need to take oral pain medications." - ANSWERS-c. "We should work together to create a schedule to provide regular dosing of medication." .A nurse is caring for a patient who is experiencing some symptoms related to arthritis. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? a. This will affect synovial fluid. b. This will affect the body systemically. c. This involves mostly non-weight-bearing joints. d. This involves an increased risk for impaired weight bearing - ANSWERS-d. This involves an increased risk for impaired weight bearing .a nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any physical distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "OK, I will go get you some narcotic pain relievers immediately." c. "What would you like to try to alleviate your pain?" d. "You do not look like you are in pain. - ANSWERS-c. "What would you like to try to alleviate your pain?" .A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The primary health care provider did not prescribe the correct amount of medication. d. The nurse is allowing personal beliefs about pain to influence pain management at this time. - ANSWERS-b. The patient's culture is possibly influencing the patient's experience of pain. .A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement - ANSWERS-c. Smoking result in vasoconstriction, falsely elevating BP. .A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a. Give pain medications around the clock. b. Administer pain medication before any activity. c. Give pain medication after the pain is a 7/10 on the pain scale. d. Administer pain medication only when nonpharmacological measures have failed. - ANSWERS-a. Give pain medications around the clock. .A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally uses marijuana. d. Patient takes antianxiety medications. - ANSWERS-a. Patient drinks 1 to 2 glasses of wine every night. .A nurse is caring for an older, immobile patient whose condition requires a supine position. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Increased pulse rate - ANSWERS-d. Increased pulse rate .A nurse is completing an assessment of the patient. Which principle is a priority? a. Foot care will always be important. b. Daily bathing will always be important. c. Hygiene needs will always be important. d. Critical thinking will always be important. - ANSWERS-d. Critical thinking will always be important. .A nurse is developing an exercise plan for a middle-aged patient. In which order will the nurse instruct the patient to execute the plan, beginning with the first step? 1. Design the fitness program. 2. Assemble equipment. 3. Assess fitness level. 4. Monitor progress. 5. Get started. a. 5, 1, 3, 2, 4 b. 1, 2, 3, 5, 4 c. 2, 5, 3, 1, 4 d. 3, 1, 2, 5, 4 - ANSWERS-d. 3, 1, 2, 5, 4 .A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take? a. Establish goals that are measurable and realistic. b. Set goals that are a little beyond the capabilities of the patient. c. Use the nurse's own judgment and not be swayed by family desires. d. Explain that without taking alignment risks, there can be no progress. - ANSWERS-a. Establish goals that are measurable and realistic. .A nurse is evaluating care of an immobilized patient. Which action will the nurse take? a. Focus on whether the interdisciplinary team is satisfied with the care. b. Compare the patient's actual outcomes with the outcomes in the care plan. c. Involve primarily the patient's family and health care team to determine goal achievement. d. Use objective data solely in determining whether interventions have been successful. - ANSWERS-b. Compare the patient's actual outcomes with the outcomes in the care plan. .A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees. - ANSWERS-c. Place a cap on their heads. .A nurse is following the no-lift policy when working to prevent personal injury from twisting. Which type of personal back injury is the nurse most likely trying to prevent? a. Thoracic b. Cervical c. Lumbar d. Sacral - ANSWERS-c. Lumbar .A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. The absence of which finding will indicate goal achievement for the nurse's action? a. Atelectasis b. Renal calculi c. Pressure ulcers d. Joint contractures - ANSWERS-d. Joint contractures .A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? a. "As adults age, their ability to perceive pain decreases." b. "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." c. "Patients who have dementia probably experience pain, and their pain is not always well controlled." d. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." - ANSWERS-a. "As adults age, their ability to perceive pain decreases." .A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for? a. Loss of bone mass b. Loss of strength c. Loss of weight d. Loss of hope - ANSWERS-d. Loss of hope .A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a. Thermometer b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices - ANSWERS-c. Blood pressure cuff .A nurse is preparing to move a patient who is able to assist. Which principles will the nurse consider when planning for safe patient handling? (Select all that apply.) a. Keep the body's center of gravity high. b. Face the direction of the movement. c. Keep the base of support narrow. d. Use the under-axilla technique. e. Use proper body mechanics. f. Use arms and legs. - ANSWERS-b. Face the direction of the movement. e. Use proper body mechanics. f. Use arms and legs. .A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? a. Hygiene care is always routine and expected. b. No two individuals perform hygiene in the same manner. c. It is important to standardize a patient's hygienic practices. d. During hygiene care do not take the time to learn about patient needs. - ANSWERS-b. No two individuals perform hygiene in the same manner. .A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1. Face 2. Eyes 3. Perineum 4. Arm and chest 5. Hands and nails 6. Back and buttocks 7. Abdomen and legs a. 1, 2, 5, 4, 7, 6, 3 b. 2, 1, 4, 5, 7, 3, 6 c. 2, 1, 5, 4, 6, 7, 3 d. 1, 2, 4, 5, 3, 7, 6 - ANSWERS-b. 2, 1, 4, 5, 7, 3, 6 .A nurse is providing AM care to patients. Which action will the nurse take? a. Soaks feet of patient with peripheral vascular disease. b. Applies CHG solution to wash perineum of patient with a stroke. c. Cleanses eye from outer canthus to inner canthus of patient with diabetes. d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder. - ANSWERS-b. Applies CHG solution to wash perineum of patient with a stroke. .A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea b. A bedridden patient who has a reddened area on the buttocks who needs to be turned c. A patient on bed rest who has renal calculi and needs to go to the bathroom d. A patient after knee surgery who needs range of motion exercises - ANSWERS-a. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea .A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide? a. "You need to drink plenty of fluids and eat a diet high in fiber." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." d. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections." - ANSWERS-a. "You need to drink plenty of fluids and eat a diet high in fiber." .A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. d. Dry thoroughly between skin folds. e. Use two wipes for each area of the body - ANSWERS-a. Do not rinse. b. Clean under breasts. c. Inform that the skin will feel sticky. .A nurse is providing medication education to a patient who just started been prescribed ibuprofen. Which information will the nurse include in the teaching session? a. Ibuprofen helps to depress the central nervous system to decrease pain perception. b. Ibuprofen reduces anxiety, which will help you cope with your pain. c. Ibuprofen binds with opiate receptors to reduce your pain. d. Ibuprofen inhibits the development of inflammation. - ANSWERS-d. Ibuprofen inhibits the development of inflammation .A nurse is providing oral care education to a patient with stomatitis. Which instructions will the nurse provide? a. Avoid commercial mouthwashes. b. Avoid normal saline rinses. c. Brush with a hard toothbrush. d. Brush with an alcohol-based toothpaste. - ANSWERS-a. Avoid commercial mouthwashes. .A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? a. Each movement is repeated 5 times by the patient. b. Each movement is performed until the patient reports pain. c. Each movement is completed quickly and smoothly by the nurse. d. Each movement is moved just to the point of resistance by the nurse - ANSWERS-d. Each movement is moved just to the point of resistance by the nurse .A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? a. Cleansing from back to front b. Washing using a circular motion c. Cleansing from pubic area to rectum d. Cleansing upward from rectum to pubic area - ANSWERS-c. Cleansing from pubic area to rectum .A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a. Moves patient's arm in a full circle. b. Moves patient's arm cross the body as far as possible. c. Moves patient's arm behind body, keeping elbow straight. d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed - ANSWERS-d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed .A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg - ANSWERS-d. 50 mm Hg .A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care? a. A patient with neck surgery b. A patient with hypostatic pneumonia c. A patient with a total knee replacement d. A patient with a stage IV pressure ulcer - ANSWERS-a. A patient with neck surgery .A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? a. Swimming, jogging, and bicycling b. Tightening or tensing of muscles without moving body parts c. Quadriceps set exercises and contraction of the gluteal muscles d. Push-ups, hip lifting, pushing feet against a footboard on the bed - ANSWERS-a. Swimming, jogging, and bicycling .A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a. "I will only need to be on this pain medication." b. "I feel less anxiety about the possibility of overdosing." c. "I can receive the pain medication as frequently as I need to." d. "I need the nurse to notify me when it is time for another dose." - ANSWERS-b. "I feel less anxiety about the possibility of overdosing." .A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene? a. Mechanical lifts are in a locked closet. b. Algorithms for patient handling are available. c. Ergonomic assessment protocols are being followed. d. A no-lift policy is in place with adherence by all staff. - ANSWERS-a. Mechanical lifts are in a locked closet. .A nurse is working in a facility that uses no-lift policies. Which benefits will the nurse observe in the facility? (Select all that apply.) a. Reduced number of work-related injuries b. Increased musculoskeletal accidents c. Reduced safety of patients d. Improved health of nurses e. Increased indirect costs - ANSWERS-a. Reduced number of work-related injuries d. Improved health of nurses e. Increased indirect costs .A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery - ANSWERS-b. Tympanic c. Esophagus e. Pulmonary artery .A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient's medical record? a. Scoliosis b. Arthritis c. Osteomalacia d. Osteogenesis - ANSWERS-a. Scoliosis .A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? a. Eccentric tension and isotonic contraction b. Eccentric tension and isometric contraction c. Concentric tension and isotonic contraction d. Concentric tension and isometric contraction - ANSWERS-a. Eccentric tension and isotonic contraction .A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's next best action? a. Give the medication to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider for a nonsteroidal antiinflammatory drug (NSAID) order. c. Ask the health care provider to verify the dosage and frequency of the medication. d. Give the medication in addition to playing soothing music for the patient. - ANSWERS-c. Ask the health care provider to verify the dosage and frequency of the medication. .A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal stones c. Pressure ulcers d. Thrombus formation - ANSWERS-b. Renal stones .A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult - ANSWERS-c. 120/80 in a middle-aged adult .A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate." c. "Meditation will help me sleep through the pain because it opens the gate." d. "Meditation stops the occurrence of pain stimuli." - ANSWERS-a. "Meditation controls pain by blocking pain impulses from coming through the gate." .A nurse writes the following outcomes for a patient who has chronic obstructive pulmonary disease to improve activity level: Diastolic blood pressure will remain below 70 mm Hg with systolic below 130 mm Hg. Resting heart rate will range between 65 and 75. The last goal is that the patient will exercise 3 times a week. Which evaluative findings indicate successful goal achievement? (Select all that apply.) a. Resting heart rate 70 b. Blood pressure 126/64 c. Blood pressure 140/90 d. Reports doing stretching and flexibility exercises 2 times this week e. Reports doing resistive training 1 time and aerobics 2 times this week - ANSWERS-a. Resting heart rate 70 b. Blood pressure 126/64 e. Reports doing resistive training 1 time and aerobics 2 times this week .A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene? a. Not offering a backrub to a patient with fractured ribs b. Not offering to wash the hair of a patient with neck trauma c. Turning off the television while giving a backrub to the patient d. Turning patient's head with neck injury to side when giving oral care - ANSWERS-d. Turning patient's head with neck injury to side when giving oral care .A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Reassures the patient that the provider will come to the emergency department soon. b. Softly plays music that the patient finds relaxing. c. Frequently reassesses the patient's pain scores. d. Teaches the patient how to do yoga. - ANSWERS-b. Softly plays music that the patient finds relaxing. .A patient diagnosed with diabetes mellitus is starting an exercise program. Which types of exercises will the nurse suggest? a. Low intensity b. Low to moderate intensity c. Moderate to high intensity d. High intensity - ANSWERS-b. Low to moderate intensity .A patient diagnosed with type 2 diabetes 26 years ago is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." c. "The neurological gates open when wearing shoes, which protects your feet." d. "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot." - ANSWERS-d. "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot." .A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure - ANSWERS-c. Temperature .A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a. Impaired balance b. Hemiplegia c. Muscle sprain d. Lower extremity paralysis - ANSWERS-a. Impaired balance .A patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? a. Assess the patient's body language. b. Ask the patient to rate the level of pain. c. Observe the cardiac monitor for increased heart rate. d. Have the patient describe the effect of pain on the ability to cope - ANSWERS-b. Ask the patient to rate the level of pain. .A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff? a. Dandruff b. Alopecia c. Pediculosis d. Xerostomia - ANSWERS-a. Dandruff .A patient injured in a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at a level of 2 on a 0 to 10 scale. c. The patient has sufficient medication left in the PCA syringe. d. The patient presses the control button to deliver pain medication. - ANSWERS-b. The patient rates pain at a level of 2 on a 0 to 10 scale. .A patient is admitted after having experienced a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? a. Heart rate decreased. b. Contractures developed. c. Muscle strength improved. d. Joint mobility maintained. - ANSWERS-d. Joint mobility maintained. .A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cuff d. Sphygmomanometer - ANSWERS-b. Thermometer .A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take to protect the patient's safety? a. Restrict fluid intake. b. Label the tubing that leads to the epidural catheter. c. Apply a gauze dressing to the epidural catheter insertion site. d. Ask the nursing assistive personnel to check on the patient at least once every 2 hours - ANSWERS-b. Label the tubing that leads to the epidural catheter. .A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation - ANSWERS-c. Convection .A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a. Observe the patient for decreased activity tolerance. b. Assume the patient is in pain and treat accordingly. c. Provide the patient ice chips as requested. d. Maintain the room temperature at 65° F. - ANSWERS-a. Observe the patient for decreased activity tolerance. .A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation - ANSWERS-b. Changing the patient's position .A patient uses an in-the-canal hearing aid. Which assessment is a priority? a. Eyeglass usage b. Cerumen buildup c. Type of physical exercise d. Excessive moisture problems - ANSWERS-b. Cerumen buildup .A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care? a. Adolescent b. Preschooler c. Older adult d. Adult - ANSWERS-b. Preschooler .A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? a. Bag bath b. Sponge bath c. Partial bed bath d. Complete bed bath - ANSWERS-c. Partial bed bath .A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? a. Transcutaneous electrical nerve stimulation (TENS) b. Herbal supplements with analgesic effects c. Pudendal block (regional anesthesia) d. Relaxation and guided imagery - ANSWERS-d. Relaxation and guided imagery .After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe? a. Corns b. A callus c. Plantar warts d. Athlete's foot - ANSWERS-c. Plantar warts .After taking the patient's temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse's action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures. - ANSWERS-a. Temperatures vary depending on the route used. .An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? a. Tendon b. Ligament c. Synergistic muscle d. Antagonistic muscle - ANSWERS-b. Ligament .The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct? (Select all that apply.) a. Ties the back of own gown. b. Touches only the inside of gown. c. Slips arms into arm holes simultaneously.