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41 .The nurse helps a patient to cough and deep breathe after surgery. It is desirable for the patient to assume which of the following positions? side-lying prone supine high fowlers Ans High fowlers 2.which of the following actions is essential for the nurse to take after administration of a preoperative medication to a patient? raise the side rails of the bed tell the pt what to expect in the aperating room discuss the pt's feelings about surgery ensure the operative permit is signed Ans raise the side rails of the bed 3.the nurse understands the purpose of a drain in a wound is to: prevent infection as a mean for bacteria to escape keep the tissues close together so that healing can occur evaluate the effectiveness of homeostasis create a space that will facilitate reconstructive surgery ata later date Ans keep the tissues close together so that healing can occur 4.a client returns from abdominal surgery with an order for morphine sulfate IV q 3 hours prn for pain. During the first 24 hours of surgery, which action by the nurse is BEST? offer pain medication every 4 hours offer pain medication every 3 hours Administer pain meds every 4 hours Administer pain meds every 3 hours Ans Administer pain meds every 3 hours 5.A client is admitted to the hospital with a temperature of 101 and WBC of 3,000mm3. the nurse should institute which of the following precautions? contact precautions airborne precautions droplet precautions Neutropenic precautions Ans Neutropenic precautions 6,a client comes to the ER a foot with a dirty, rusty nail. The client states the last TD was 6 years ago. which of the following actions should the nurse take first? administer tetanus toxoid determine how many TD immunizations the client has received administer tetanus immune globulin monitor for lockjaw Ans determine how many TD immunizations the client has received 7.a patient requires a dressing change. the LPN nurse assigned to care for the patient reports to the registered nurse that she had once observed a similar dressing change while in nursing school, but has never performed the procedure. The RN should take which action? Ask the LPN to review the hospitals procedure manual regarding dressing changes. Review the steps of the dressing change with the LPN complete the dressing change while the LPN observes assigned a more experienced LPN to the patient Ans complete the dressing change while the LPN observes 8.The nurse counsels a patient about how to maintain an adequate intake of protein. The nurse determines that further teaching is required if the patient chooses which of the fallowing foods? peanut butter on whole white bread rice and red beans orange toast and white toast spaghetti and meat sauce Ans orange toast and white toast 9.the nurse knows which statement is important about warfarin? it has a prolonged action it is never given for prolonged periods of time it must be given several Ans daytime activities 14. the nurse prepares 4 patients for surgery. the nurse is MOST concerned about the psychological adjustment of which of the following patients? a 13 year old girl having a wart removed from her nose a 26 year ald man scheduled for a Whipple procedure due to cancer of the pancreas a 42 year ald scheduled to have a begin cyst removed from her breast a 80 year old man scheduled to have a colostomy due to diverticular disease Ans a 26 year old man scheduled for a Whipple procedure due to cancer of the pancreas 15. the nurse understands that which of the following behaviors is helpful to facilitate a patient to have a bowel elimination? engage in sedentary activity increase dietary bulk decrease fluid intake use oral laxatives Ans increase dietary bulk 16. the nurse identifies which of the following lab findings reflects the signs and symptoms of infection? a creatine serum level of 2.4 mg/dL AST (SGOT) 15 u/L white blood cell count of 16,000mm3 white blood cell count of 4,000mm3 Ans white blood cell count of 16,000mm3 17. in which situation would the nurse consider withholding morphine until further assessment is done? patient reports acute pain of deep partial thickness burn affecting the lower extremities Patient's BP is 140/90, P 90, R28 patient's level of consciousness fluctuates from alert to lethargic patient exhibits restlessness, anxiety, and cold, clammy skin Ans patient's level of consciousness fluctuates fram alert to lethargic 18. the nurse identifies which finding is characteristic of chronic pain? weight loss or gain, fatigue obesity, restlessness, _ thirst anxiety, memory loss, insomnia quick response to analgesics Ans weight loss or gain, fatigue 17.the nurse identifies which diet best meet the needs of a person with multiple wounds? high protein and iron, low fat high vit c, protein, carbs high vit a, protein, carbs high vit b, protein, low carb Ans high vit c, protein, carbs 19.the nurse performs discharge teaching for a client receiving warfarin. the nurse determines further teaching is required if the client makes which of the following statements? | should look for yellow tinged complexion | will wear a medic-alert bracelet | should tell a health care provider if | have black stools | should consult the health care provider before taking any medication Ans | should look for yellow tinged complexion 20 the nurse cares for a post-op client with a NG tube. which observation by the nurse is MOST reliable indication the NG tube is placed correctly? absence of respiratory distress the tube is securely taped the marking on the tube designating the correct length remains visible just outside the nares PH of aspirate is 3 Ans PH of aspirate is 3 heart failure thrombophlebitis pulmonary embolism Atelectasis Ans atelectasis 26 a patient with acute pain has a physician's order for morphine 8 mg IV every 3-4 hours prn for pain. The patient asks for the medication at bed time. Prior to administering the medication, the nurse should take which of the following actions? assume the pain is psychological check to see if the patient has a history of addiction try several other pain relief measures assess location, character and intensity of pain Ans assess location, character and intensity of pain 27 the nurse instructs a patient about how to successfully establish a regular exercise program. The nurses determines further teaching is needed if the patient makes which of the following statements? | should chose an exercise that suits my lifestyle | should incorporate exercise into my daily routine | should make a commitment to exercise regularly | should start by running 5 miles every day Ans I should start by running 5 miles every day 28 the nurse observes a staff member enter the patients room wearing a protective respiratory device. the nurse determines care is appropriate if the staff member is caring for which of the following patients? a patient diagnosed with varicella a patient diagnosed with mumps a patient diagnosed with VRE A patient diagnosed with pneumonia Ans a patient diagnosed with varicella 29 ~=—« The nurse cares for a client with a BMI of 38. what is the BEST description of the clients body weight? underweight obese normal weight overweight Ans obesity 30 ~~ which of the following nursing actions is MOST important when caring for a client in pain? teach the patient about pain establish a trusting relationship with the patient determine how various relaxation techniques affect pain administer pharmacological agents Ans establish a trusting relationship with the patient 31 when witnessing the patients signature during informed consent, it is most important for the nurse to make which of the following assessments? does the pt understand the procedure? does the pt have any questions? does the pt give consent voluntarily? is the pt able to write his name? Ans does the pt give consent voluntarily? 32 ~+the nurse identifies which of the following changes in the pattern of urinary elimination is usually associated with aging? decreased frequency incontinence sphincter reflexes decrease formation of bladder stones Ans _— sphincter reflexes decrease 33. the nurse which of the following statements describe an important consideration with spinal anesthesia is used? partial paralysis is a serious but frequent complication patients must be protected from injury since sensation is impaired patients should try to ambulate as soon as possible spinal headache may be prevented by restricting intake of oral and IV fluids 37 > =Awoman has a left radial mastectomy. Upon transfer from the recovery room to the surgical unit, the nurse notices that the Hemovac drain is half filled with blood. Which of the fallowing actions should the nurse take FIRST? contact the physician increase the rate of IV fluids look at the recovery room record measure the patients output Ans look at the recovery room record 38 = aliver scan is ordered for a patient prior to surgery. the nurse understand that which statement BEST describes the procedure? The pt will be strapped to a table and irradiated by a cobalt scanner the pt will stand in front of a large machine that takes x-ray pictures the pt will be asked to lie still while a scanning probe is passed back and forth over the body the pts skin will be lubricated with oil and ultrasound pictures will be taken Ans the pt will be asked to lie still while a scanning probe is passed back and forth over the body 39. the nurse knows that serum albumin is used as an indicator of malnutrition because: albumin from eggs is usually ingested and can be assumed to be constant in the American diet albumin is the first result on a protein electrophoresis, and often found on the hospital chart serum albumin is easy to measure, and can indicate a protein deficiency that can not be indicated on a physical exam serum albumin has a short half-life, so it is an easy protein to measure Ans serum albumin is easy to measure, and can indicate a protein deficiency that can not be indicated on a physical exam 40 ‘the patient cares for a patient with an abdominal wound. the nurse notes there is purulent drainage from the wound. which of the following actions should the nurse take FIRST? contact the physician place the pt on contact precautions irrigate the wound ask the pt to identify the level of pain on a numeric scale Ans place the pt on contact precautions 41 the nurse cares for a patient beginning intermittent heparin therapy. the nurse knows which of the following lab tests is used to monitor the effectiveness of heparin? partial thromboplastin time prothrombin time bleeding time protein electrophoresis Ans partial thromboplastin time 42 the nurse understands which is the PRIMARY reason that elderly adults have constipation? they eat a small volume of food with decreased bulk they have less activity and decreased muscle tone they have neurological changes in the Gl tract they have decreased sensation in the Gl tract Ans they have less activity and decreased muscle tone 43 following surgery, the nurse becomes concerned because the patient has not voided since before surgery, which was 10 hours ago. which of the following nursing actions is MOST appropriate? insert a catheter into the bladder encourage the pt to take sips of water inform the physician immediately palpate the bladder for distention Ans palpate the bladder for distention 44. the nurse asses the client in the outpatient clinic. which statement does the nurse expect the client to make? | seem to get less upper respiratory infections as | did before I think that | am a little taller than | use to be eating just does not appeal to me anymore I've been sleeping with fewer blankets lately notify the physician about the patients decision inform the patient he has delayed the operating room schedule encourage the patient for discussing reasons for canceling the surgery ask the patients family to encourage the patient to have surgery Ans encourage the patient for discussing reasons for canceling the surgery 49 which of the following fears is most important for the nurse to consider when planning care for a 4-year old about to have surgery? fear of losing independence fear of losing control fear of separation fear of mutilation Ans fear of mutilation 50 the clinic nurse interviews a middle aged adult who comes to the clinic complaining of difficulty sleeping and ongoing fatigue. The nurse learns the client works nights. Which of the following is the best initial response by the RN? tell me about your unusual sleep habits you probably sleep when you can during your night tour this is normal for your age group working night shifts is known to disrupt sleep patterns Ans tell me about your unusual sleep habits 51 At discharge, the nurse advises a patient about a calorie restricted diet. which of the following is an ideal rate of weight loss? one half pound per day one half pound per week one pound per week one pound per day Ans one pound per week 52 The nurse cares for a patient with a BMI of 17. what is the best description of the clients body weight? underweight normal weight obese overweight Ans underweight 53 the nurse identifies a staff member is using standard precautions accurately if which of the following is happening? the nurse wears gloves when taking BP for a client diagnosed with AIDS the staff member irrigates an abdominal wound wearing glaves and a gown the staff member places contaminated linens in a leak proof bag the nurse removes gloves after bathing a patient and puts on a clean pair of gloves to bathe another patient Ans the staff member places contaminated linens in a leak proof bag 54 A 5 year old is scheduled for a tonsillectomy and adenoidectomy. The child is given midazolam preoperatively. For which purpose is the nurse administering medication? decrease the gag reflex provides sedation and anxiety reduction enhance wound healing promote vasoconstriction of the mucous membranes Ans provides sedation and anxiety reduction 55 the nurse expects which of the following psychological changes to occur to a patient during episodes of acute pain? decreased BP decreased skin temperature decreased heart rate decreased respiration Ans decreased skin temperature 56 while the patient is being treated for a wound infection, it is MOST important for the nurse to routinely perform which of the following actions? Cdiff. Clostridium difficile Contact Precautions gown, gloves (wash hands prior) Droplet/Contact Precautions gloves, gown, mask, eye protection Airborne Precautions N95 respirator, negative pressure When do we use standard precautions? for the care of all patient **apply to: blood non-intact skin mucous membranes all body fluids, secretions, and excretions EXCEPT SWEAT Standard Precautions 1. Wash hands 2. Wear gloves 3. Wear mask 4. Wear gown 5. Sharps disposal Neutropenic Precautions -strict hand washing before patient care 1. Private room with closed door 2. Hand washing required upon entry 3. No gown or gloves are required 4. No fresh fruits, vegetables, or flowers may be taken into the room 5. No visitors or staff with infectious illness may enter the room 6. No special precautions must be taken with articles LEAVING the room Medical Asepsis -reduces number of pathogens -referred to as "clean techniques" -used in administration of: medications enemas tube feedings daily hygiene Surgical Asepsis -eliminates all pathogens -referred to as "sterile technique" -used in: dressing changes catheterizations surgical procedures Newborn Vital Signs Temp. 36-37 Pulse 70-190 Respirations 30-55 BP 73/55 Infant Vital Signs Temp. 37-38 Pulse 80-150 Respirations 20-40 BP 85/37 Toddler Vital Signs Temp. 37-38 Pulse 70-120 Respirations 20-30 BP 89/46 -background -assessment -recommendation -read back Body Systems Involved in Movement -skeletal -neurological -musculoskeletal Skeletal Types of joints:Ball-and-Socket, Condyloid, Gliding, Hinge, Pivot, Saddle Neurological Efferent neurons convey response from CNS to skeletal muscles Musculoskeletal Creates movements, maintain posture Isotonic involves muscle shortening and active movement. Example: Lifting a weight Isometric muscle contraction without shortening Examples: Planks, yoga Isokinetic muscle contraction with resistance. Examples: Exercise bike Body Alignment (Posture) how the head, shoulders, spine, hips, knees and ankles line up with each other. Proper alignments causes less stress to the spine and gives you good posture. Nursing Diagnoses for Mobility Issues Impaired Physical Mobility -defined: limitations in independent movement of the body Activity Intolerance -defined: not enough energy to endure desired activity Body Mechanics use of proper body positions to provide protection from stress of movement and activity in regards to structure, function and position of the body. Prevent injury and maintain body alignment. Use of Cane (COAL) cane opposite affected leg Use of Walker (WWAL) walker with affected leg Forearm Crutches vs. Axillary Crutches forearm: used for long-term support for ambulation. axillary: support of body weight is on the hands and arms not the axillary area. **Good foot goes to heaven, bad foot goes to hell** Hazards of Immobility **Respiratory Atelectasis Pneumonia **Cardiovascular- increased cardiac workload orthostatic hypotension venous stasis-thrombosis (Deep Vein Thrombosis, Pulmonary Embolism, Cerebrovascular Accident) **Musculoskeletal Atrophy(decreased muscle size) Decreased muscle tone, strength and flexibility Bone demineralization Contractures or immobilization of joint Pressure ulcers Pressure ulcers-prolonged pressure over body prominences causing skin More Hazards of Immobility ***Metabolic Negative nitrogen balance *“Gastrointestinal Weight gain Constipation 
