Review for 1871

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation?

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.)

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.)

An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her?

A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed?

Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia?

An intravenous (IV) fluid is infusing more slowly than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.)

Which patients does a nurse plan to teach regarding water restriction?

When delegating input and output (I&O) measurement to nursing assistive personnel, a nurse instructs them to record what information for ice chips?

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does a nurse program into the infusion pump?

A patient has severe hypercalcemia. What are the priority nursing interventions? (Select all that apply.)

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and image, 24. The nurse interprets these laboratory values to indicate:

For which of the following health problems is a patient who has a 40-year history of smoking at risk?

. A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia?

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation?

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication?

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action?

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.)

A patient is admitted through the emergency department (ED) after a serious car accident. The nurse assesses the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which interventions would be appropriate at this time? (Select all that apply.)

How can a nurse work on developing cultural awareness? (Select all that apply.)

Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.)

The primary reason that you need to include family members when you teach a patient preoperative exercises is so they can:

In the postanesthesia care unit (PACU) a nurse notes that a patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse's priority intervention at this time is:

Because an older adult is at increased risk for respiratory complications after surgery, the nurse needs to:

You are caring for a patient after surgery who had a liver resection. His prothrombin time (PT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions do you perform? (Select all that apply.)

You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply.)

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because:

You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, his heart rate is 110. What is your next action?

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?

An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?

The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply.)

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:

Which of the following signs or symptoms in a patient who is opioid-naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid?

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of:

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain?

A postoperative patient currently is asleep. Therefore the nurse knows that:

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider?

Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day?

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention?

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?

The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention?

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient?

Which of the following cause Clostridium difficile infection? (Select all that apply.)

.A toddler is to receive 2.5 mL of an antipyretic by mouth. Which equipment is the most appropriate for medication administration for this child?

What statement made by a 4-year-old patient's mother indicates that she understands how to administer her son's eardrops?

A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority?

A nurse knows that the people most at risk for accidental hypothermia are: (Select all that apply.)

What is your role as a nurse during a fire? (Select all that apply.)

You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. His wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. Which factors increase his fall risk at this time? (Select all that apply.)