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despite a national focus on health promotion, nurses working with patients in inner-city clinics continue to see disparities in healthcare for vulnerable populations. which patients would be considered vulnerable populations? SATA
a. a white make diagnosed with HIV
b. an african american teenager who is 6 months pregnant
c. a hispanic male who has type II diabetes
d. a low income family living in rural America
e. a middle class teacher living in a alrge city
f. a white baby who was born with cerebral palsy
b c d f
A nurse has volunteered to give influenza immunizations at a local clinic. What level of care is the nurse demonstrating?
a. tertiary
b. secondary
c. primary
d. promotive
c
Which clinic patient is most likely to have annual breast examinations and mammograms based on the physical human dimension?
a. jane, whose best friend had a benign breast lump removed
b. sarah, who lives in a low income neighborbood
c. tricia, who has a family history of breast cancer
d. Nancy, whose family encourages regular physical exams
c
A nurse working in an ambulatory care center provides care for patients experiencing varying levels of health and illness. the nurse bases care on which concepts of health and illness? SATA
a. health and illness are the same for all people
b. health and illness are individually defined by each person
c. people with acute illnesses may consider themselves healthy
d. people with chronic illnesses have poor health beliefs
e. health is more than an absence of illness
f. illness is the response of a person to a disease
b c e f
A community health nurse is developing a support group for patients coping with chronic health problems. what chronic health conditions does the nurse anticipate group members might want to discuss? SATA
a. diabetes mellitus
b. bronchial pneumonia
c. rheumatoid arthritis
d. ulcerative colitis
e. fractured hip
f. otitis media
a c d
a community nurse cares for vunerable populations. what problem will the nurse prioritize for a patient who is homeless?
a. love and belonging
b. safety
c. self esteem
d. self actualization
b
a nursing student is writing a paper about nurses performing health promotion activites at the teritary level. which nursing actions will the student include? SATA
a. running an immunization clinic in a lower income area of the city
b. teaching a patient with an amputation how to care for the residual limb
c. providing range of motion exercises for a patient who is paralyzed
d. teaching parents of toddlers how to childproof their homes
e. providing screening for scoliosis for school students.
f. teaching new parents how to choose and use an infant care seat
b c
a nurse is caring for a patient who has been managing their chronic spasticity well for 10 years. the patient states having had increasing spasticity and few falls due to unremitting muscle spasms. the nurse, patient, and health care provider discuss the possibility the patient may be experiencing which phase of illness?
a. acute onset of illness
b. permanent complication
c. need for hospice care
d. exacerbation of disease
d
a nurse incorporates concepts from current models of health when providing health promotion classes for patients. what is a key concept of both the health illness continuum and the high level wellness models?
a. illness as a fixed point in time
b. the importance of family
c. wellness as a passive state
d. health as a dynamic state
d
a public health nurse is planning interventions for a community and plans to determine the frequency of diseases in the area. what information will best guide the nurse?
a. morbidity table
b. disease eradication statistics
c. mortality rates
d. annual hospital admissions
a
A client with a known history of panic disorder comes to the emergency department and states to the nurse, “Please help me. I think I’m having a heart attack.” What is the priority nursing action?
a. check the client’s vital signs
b. encourage the client to use relaxation techniques
c. identify the manifestations related to the panic disorder
d. determine what the client’s activity involved when the pain started
a
Which role of the nurse takes on more emphasis in the delivery of health care in the home than in acute care?
a. coordinating the efforts of the health care team
b. delivering skilled nursing care
c. providing for healthy meals
d. modifying the environment
d
Nurses in a long-term care facility use Maslow’s hierarchy of basic human needs to plan care for their patients. What is the expected outcome when using this hierarchy?
a. accurate nursing diagnoses
b. clear priorities of care
c. concerns communicated concisely
d. integration of science into nursing care
b
A nurse is prioritizing nursing care for patients on a medical-surgical unit. Which nursing interventions address patients’ physiologic needs? Select all that apply.
a. Preventing falls during admission
b. Administering oxygen to a patient with shortness of breath
c. Providing a magazine for a patient without visitors
d. Assisting a patient who had a stroke eat their dinner
e. Facilitating a visit from the patient’s significant other
f. Referring a patient to a cancer support group
b d
A nurse provides care for postoperative patients using meticulous hand hygiene and aseptic technique. Which of Maslow’s basic human needs is the nurse addressing? a.Physiologic
b. Safety and security
c. Self-esteem
d. Love and belonging
b
A nurse caring for patients in a long-term care facility develops strategies to help patients achieve Maslow’s highest level of needs: self-actualization. Which concepts will the nurse incorporate when planning care? Select all that apply.
a. Humans are born with a fully developed sense of self-actualization.
b. Self-actualization needs are met by depending on family, friends, and others for help.
c. No matter the patient’s age, the self-actualization process continues throughout life.
d. Loneliness and isolation occur when self-actualization needs are unmet.
e. A person achieves self-actualization by focusing on problems outside self.
f. Self-actualization needs may be met by creatively solving problems.
c e f
A nurse in a family-centered health clinic is assessing a new family composed of two parents and three preschool children. Which value does the nurse include in a family-centered approach to health care?
a. Each person in the family will be evaluated and treated independently of the others.
b. Time will be saved as there is only one clinic to contact for health problems.
c. All members of the family can be part of health-related decisions.
d. Interdependence of family members affects them in illness and health.
d
A nurse performs an assessment of a family consisting of a single parent, a grandparent, and two children. What interview questions will the nurse direct toward the mother to best determine the family’s affective and coping functions? Select all that apply.
a. Who is the person you depend on for emotional support? b. Who is the person you depend on for financial support in your family?
c. Do you plan on having any more children?
d. Who keeps your family together in times of stress?
e. What family traditions do you pass on to your children?
a d
A nurse caring for families in a free health care clinic assesses for psychosocial risk factors for altered family health. Which example best describes one of these risk factors?
a. The family does not have dental care insurance or resources to pay for it.
b. Both parents work and leave a 12-year-old child to care for his younger brother.
c. Both parents and their children are considerably overweight.
d. The youngest member of the family has cerebral palsy and needs assistance from community services.
b
A nurse working in an “Aging in Place” facility interviews a married couple in their late 70s. Based on Duvall’s Developmental Tasks of Families, what developmental task is most appropriate for the nurse to assess?
a. Maintenance of a supportive home base
b. Strength of the marital relationship
c. Ability to cope with loss of energy and privacy
d. Adjustment to retirement years
d
A nurse working in a new community performs an assessment to determine the health of the community. What finding indicates a healthy community?
a. Meets all the needs of its inhabitants
b. Mixes residential and industrial areas
c. Offers access to health care services
d. Consists of modern housing and condominiums
c
A nurse is practicing community-based nursing in a mobile health clinic. Which example best demonstrates community-based nursing?
a. Caring for a mother and her child who have diabetes
b. Providing shelter for vulnerable populations within the community
c. Providing local same-day surgery facilities
d. Assisting families in crisis and overseeing the crisis hotline
a
After receiving a change-of-shift report, the nurse on a medical-surgical unit sets initial priorities for care. According to Maslow’s hierarchy of needs, which patient requires immediate assessment?
a. Patient requesting help to phone family to ask them to visit
b. Patient who needs education on changing their wound dressing prior to discharge
c. Patient who calls for assistance because they are breathing fast and feel faint
d. Patient who needs assistance to walk to the bathroom to void
c
An American nurse tries to speak with a Korean client who cannot understand the English language. To effectively communicate to a client with a different language, which of the following should the nurse implement?
a)Have an interpreter to translate
b)Speak slowly
c)Speak loudly and closely to the client
d)Speak to the client and family member
a
Which of the following clients has the lowest risk of diabetes mellitus and stroke?
a)A 45-year-old African-American woman.
b)A 35-year-old Native-American man.
c)A 30-year-old Hispanic woman.
d)A 25-year-old Asian-American woman.
d
The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action?
a)Walk around the client so that the nurse can constantly face the client
b)Call the attention of the client by speaking loudly
c)Continue with the instruction, then confirm client’s understanding.
d)Hand over a written instruction and discuss only what the client doesn’t understand.
c
A nurse is preparing to deliver a food tray to a Jewish client. The nurse checks the food on the tray and notes that the client has received a hamburger and whole milk as a beverage. Which is the appropriate action for the nurse?
a)Ask the dietary department to replace the hamburger with crab.
b)Replace the whole milk with fat-free milk.
c)Call the dietary department and ask for a new meal tray.
d)Deliver the designated food tray to the client.
c
A nurse is preparing a plan of care for a client who is a Jehovah’s Witness. The client has been told that the surgery is necessary. The nurse considers the client’s religious preferences in developing the plan of care and documents that:
a)Giving any medication is not allowed.
b)Surgery is strictly prohibited.
c)Blood products can not be administered.
d)Alternative medicines can be advised.
c
A Chinese-American client experiencing cough with clear white phlegm, which is believed to be a yin disorder, is likely to treat it with:
a)Foods considered being yin.
b)Foods considered being yang.
c)Aromatherapy.
d)Touch therapy.
b
A nurse is caring for patients of diverse cultures in a community health clinic. Which concepts will the nurse incorporate to guide the plan of care? Select all that apply. a.The United States has become less inclusive of same-sex couples.
b. Cultural diversity is limited to people of varying cultures and races.
c. Cultural diversity is separate and distinct from health and illness.
d. People may be members of multiple cultural groups at one time.
e. Culture guides what is acceptable behavior for people in a specific group.
f. Cultural practices may evolve over time but mainly remain constant.
d e f
At the last staff meeting, the nurse manager discussed the organizational initiative to improve provision of culturally competent care. During rounds, which behaviors inconsistent with this goal require the manager to intervene? Select all that apply.
a. A staff nurse tells the AP that patients should not be given a choice, but should shower or bathe daily.
b. A nurse asks the family of a patient who has died if they would like to wash their loved one’s body.
c. A nurse tells another nurse that Jewish dietary restrictions are just a way for them to get special foods.
d. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence.
e. A nurse obtains a translator to speak to the patient in their native language.
f. A nurse refuses to care for a married gay patient who is HIV positive because the nurse is against same-sex marriage.
a d
An ambulatory care nurse serving a large, culturally diverse population is planning a free blood pressure screening clinic. Based on the nurse’s understanding of racial differences in health and illness, which groups will the nurse target for screening? Select all that apply.
a.Native American people
b.African American people
c.Alaska Native people
d.Asian people
e.White people
f. Hispanic people
b c e
A nurse is using the Explanatory Model of Health and Illness (ESFT) model to assess how a patient from another culture views their diagnosis of chronic obstructive pulmonary disease (COPD). What interview question is most appropriate to assess the E aspect of this model?
a.How do you get your medications?
b.How does having COPD affect your lifestyle?
c.Are you concerned about the side effects of your medications?
d. Can you describe how you will take your medications?
b
A nurse tells a patient, “tonight’s menu selection is pork. I understand many people in your culture do not eat pork; may I order something else for you?” When the patient states they no longer observe this dietary practice, the nurse understands that the patient has experienced what transition?
a.Cultural assimilation
b.Cultural imposition
c.Culture shock
d. Ethnocentrism
a
The charge nurse overhears a nurse state, “That patient is 78 years old—too old to learn how to change a dressing.” How should the charge nurse respond?
a.“Please don’t impose your view of the patient’s culture on them.”
b.“I wish you would try to demonstrate more cultural sensitivity.”
c.“Try to be open to your patient’s culture, to make the biggest impact.”
d.“Grouping all older adults as having trouble learning is a form of stereotyping.”
d
A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish, and the nurse speaks only English. Which action should the nurse take next?
a.Use short words and speak loudly
b.Obtain a medical interpreter
c.Explain why care cannot be provided
d.Provide instructions in writing
b
A nurse is interviewing a newly admitted patient from another culture. What question best displays cultural sensitivity?
a.“Do you think you’ll be able to eat the food we have here?” b.“You do understand that we can’t prepare special meals?” c.“What types of food do you typically prepare for meals?” d.“Could you make an exception on what food you eat while you are here?”
c
A nurse tells a new mother from Africa that she should not carry her infant in a sling because bassinets are safer. The charge nurse suggests the nurse is displaying which behavior?
a. Cultural imposition
b. Clustering
c. Cultural competency
d. Stereotyping
a
A community organization includes provision of culturally competent care in their mission. Which action has the organization set as a priority?
a. Learning the predominant language of the community
b. Obtaining significant information about the community
c. Treating each patient at the clinic as an individual
d. Recognizing the importance of the patient’s family
c
A surgeon will not attempt a life-saving repair of a ruptured aneurysm unless the patient agrees to receive blood transfusions. Although receiving blood products is against the patient’s religious beliefs, the surgeon ordered four units of packed red blood cells. What action will the nurse take first?
a. Administer the blood transfusion
b. Call the patient’s family and ask them to reason with the patient
c. Discuss obtaining a court order to save the patient’s life
d. Maintain the patient’s comfort and support their decision
d
A nurse is concerned about a patient’s ability to withstand exposure to pathogens. Which blood component should the nurse monitor?
a)Platelets (clotting)
b)Hemoglobin
c)Neutrophils
d)Erythrocytes (carries O2)
c
A nurse is caring for the following group of patients with infections. Which infection is classified as a hospital-acquired infection?
a)Respiratory infection contracted from a visitor
b)Vaginal canal infection in a postmenopausal woman
c)Urinary tract infection in a patient who is sedentary
d)Wound infection caused by unwashed hands of a caregiver
d
Which primary defenses protect the body from infection? Select all that apply.
a)Tears in the eyes
b)Healthy intact skin
c)Cilia of respiratory passages
d)Alkalinity of gastric secretions
e)Bile in the gastrointestinal system
f)Moist environment of the epidermis
a b c e
A nurse is caring for a group of hospitalized patients. Which should the nurse do first to prevent patient infections?
a)Provide small bedside bags to dispose of used tissues
b)Encourage staff to avoid coughing near patients
c)Administer antibiotics as prescribed
d)Identify patients at risk
d
A nurse is caring for a group of patients experiencing various medical conditions. The patient with which condition is at the greatest risk for a wound infections?
a)Surgical creation of a colostomy
b)First-degree burn on the back (potentially but C more likely)
c)Puncture of the foot by a nail
d)Paper cut on the finger (superficial)
c
a nurse is changing a patient’s bed linens after drainage from an infected abdominal wound leaked. which nursing action reflects proper use of medical asepsis?
a. carrying soiled bed linens close to the body to prevent spreading microorganisms into the air
b. placing soiled bed linens and hospital gowns on the floor when making the bed
c. moving the patient patient table away from the body when wiping it off
d. cleaning the most soiled items at the bedside first, followed by cleaner items
c
An outbreak of measles has occurred at the local elementary school. The parents of a child in the prodromal phase of the illness are told the child should stay home until well. What is important for the nurse to teach the parents about the prodromal phase?
a. The organisms enter the body and multiply while the patient is asymptomatic.
b. A person typically has vague, nonspecific symptoms and is highly contagious.
c. The presence of infection-specific signs and symptoms develop, manifesting as local or systemic responses.
d. The signs and symptoms of the illness disappear, and the person returns to their preillness state.
b
A nursing unit has multiple patients with MRSA infections requiring contact isolation. In which situations is it appropriate for the nurses to use an alcohol-based hand sanitizer to decontaminate their hands? Select all that apply.
a. Before providing a bed bath
b. Having visibly soiled hands after patient contact
c. Removing gloves after patient care
d. Inserting a urinary catheter
e. Assisting with a surgical placement of a cardiac stent
f. Removing old magazines from a patient’s table
a c d f
A nursing student is performing hand hygiene after providing care to a patient who is in isolation for C. diff related to antibiotic therapy. Which actions by the nursing student will the primary nurse need to correct? Select all that apply.
a. Removing all jewelry including a platinum wedding band
b. Decontaminating the hands with an alcohol-based hand sanitizer
c. Using approximately 1 teaspoon of liquid soap
d. Keeping hands higher than elbows when placing under the faucet
e. Using friction motion when washing for at least 20 seconds
f. Rinsing thoroughly with water flowing toward the fingertips
b d
When performing a dressing change requiring surgical asepsis, a nurse opens sterile supplies and dons sterile gloves. What additional action by the nurse is appropriate?
a. Avoiding splashing while pouring irrigant onto the sterile field
b. Covering the nose and mouth with gloved hands if a sneeze is imminent
c. Using forceps soaked in a disinfectant to place dressings on the sterile field
d. Considering the outer 1 inch of the sterile field sterile
d
The nurse on a medical-surgical unit is admitting a patient with a diagnosis of active tuberculosis. Which infection control precautions will the nurse put in place?
a. Wearing sterile gloves for patients with visible body fluids
b. Placing the patient on airborne precautions
c. Wearing an N95 respirator mask when in the room
d. Placing the patient in a single-occupancy room
e. Ensuring the room provides positive pressure
f. Restricting visitors for the duration of the patient’s stay
b c d
Nursing students enrolled in a medical-surgical nursing course are learning about infection control measures. They have learned that nurses use droplet precautions for patients with which infections? Select all that apply.
a. Rubella
b. Herpes simplex
c. Varicella
d. Tuberculosis
e. MRSA
f. Adenovirus
a b f
A nurse and health care provider are preparing for insertion of a central venous catheter when the patient accidentally touches the sterile field. What action will the nurse take next?a. Ask another nurse to hold the patient’s hand and continue setting up the field
b. Remove any objects the patient touched and resume setting up the sterile field
c. Have someone hold the patient’s hand, discard the supplies, and prepare a new sterile field
d. No action since the patient has touched their own sterile field
c
When performing sterile wound irrigation and dressing change for a postoperative patient, a new graduate nurse creates a sterile field. Which actions require correction by the preceptor? Select all that apply.
a. Placing the bottle cap for the irrigating solution off the sterile field with the edges down
b. Holding the bottle of irrigating solution inside the edge of the sterile field
c. Applying the second sterile glove by lifting it from beneath the cuff with the thumb held away from the glove
d. Pouring the irrigating solution into a sterile container from a height of 4 to 6 inches (10 to 15 cm)
e. Opening packages of sterile gauze dressings, prior to applying sterile gloves
d e
A nurse is preparing to admit a patient with urinary sepsis related to vancomycin-resistant enterococci (VRE). While awaiting the patient’s arrival, which of these actions will the nurse take?
a. Prepare a negative-pressure room
b. Ask the AP to get a supply of protective gowns
c. Post a sign that visitors must wear a mask
d. Obtain sterile gloves for personal care
b
You are the nurse caring for a patient with Parkinson disease who is experiencing difficulty swallowing. Which potential problem associated with dysphagia has the greatest influence on the plan of care?
a)Anorexia
b)Aspiration
c)Self-care deficit
d)Inadequate intake
b
Which should the nurse do to prevent a confused patient from falling?
a)Encourage the patient to use the corridor handrails
b)Place the patient in a room near the nurses’ station
c)Reinforce how to use the call bell
d)Maintain close supervision
d
Which of the following questions has the highest priority for the nurse when talking with parents about the safety of a 4-year-old ?
a)“Can you talk to the parents of your child’s friend to find out why they are getting in fights?”
b)“Would the families in your neighborhood share your concern about reporting strangers when they see them?”
c)“Do you have the kitchen cleaning supplies locked in the cupboard?”
d)“Does your child have the appropriate protective equipment for the games he plays?”
c
The best overall rule for avoiding accidents with equipment in the hospital is for the nurse to:
a)Always lock wheels on movable equipment
b)Never operate equipment without prior instruction
c)Always unplug equipment when moving the client
d)Never use equipment without a person to assist you
b
A 79-year-old resident in a long-term care facility is known to “wander at night” and has fallen in the past. Which of the following is the most appropriate nursing intervention?
a)A loose abdominal restraint should be placed on the client during sleeping hours.
b)The caregivers should check the client frequently during the night.
c)A radio should be left playing at the bedside to assist in reality orientation.
d)Reassign the client to a room that is close to the nursing station.
d
A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation?
a.A toddler playing with his older brother’s wooden blocks
b.A 4-year-old eating yogurt and strawberries for lunch
c.An infant sleeping in the prone position
d. A 3-year-old drinking a glass of juice
c
A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply.
a.Choking
b. Diving accidents
c.Car accidents
d.Suicide
e. Intimate partner violence
f. Cigarette smoking
c d
During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority?
a.Explaining how to use the telephone
b.Introducing the patient to their roommate
c.Reviewing the hospital policy on visiting hours
d.Demonstrating how to operate the call bell
d
A school nurse is teaching parents about home and fire safety. What information will be included in the teaching plan? Select all that apply.
a.Sixty percent of U.S. fire deaths occur in the home.
b.Most fatal fires occur when people are cooking.
c.Most people who die in fires die of smoke inhalation.
d.Fire-related injury and death have declined due to the availability and use of smoke alarms.
e.Fires are more likely to occur in homes without electricity or gas.
f.Fires are less likely to spread if bedroom doors are kept open when sleeping.
c d e
The nurse manager and nurses in an acute care hospital are participating in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine require follow-up? Select all that apply.
a.Age >50 years
b.History of falling
c.Taking antibiotics
d.Presence of postural hypotension
e.Nausea from chemotherapy
f.Transferred from long-term care
b d f
The nurse is assisting a patient with rheumatoid arthritis to bathe at the sink. During the bath, the patient states that she is tired. The nurse notices the patient is breathing rapidly and the pulse is rapid. What is the nurse’s best response?
a)Finish the bath quickly
b)Help the patient return to bed
c)Leave the patient alone to rest in the chair at the sink for a few minutes
d)Instruct the patient to take deep breaths and try to relax
b
Which of the following actions would best help prevent skin breakdown in a patient who is incontinent of stools and very weak and drowsy?
a)Checking frequently for soiling
b)Washing the perineal area with strong soap and water
c)Placing the call light within easy reach à might not be able to reach because they area weak and drowsy
d)Keeping a pad under the patient
a
When providing oral care, what does the nurse recognize as the most important component of the oral care process?
a)Using enough toothpaste to cover the toothbrush
b)Always use mouthwash
c)A thorough, mechanical cleaning
d)Use peroxide while in the hospital instead of toothpaste
c
While planning morning care , which of the following patients would receive the highest priority for a bath?
a)A patient who is experiencing frequent incontinent diarrheal stools
b)A patient who has just returned from who just returned to the unit from surgery
c)A patient who prefers a bath in the evening when his wife can help
d)A patient who has just returned from a diagnostic test
a
The nurse is caring for a patient who has reduced sensation in both feet. Which of the following should the nurse do? Select all that apply.
a)Avoid cleaning the feet until an order from the health care provider is received
b)Wash the feet with lukewarm water and then dry well
c)Apply moisturizing lotion to the feet, except for between the toes
d)File the toenails straight across
b c d
A nurse is scheduling hygiene for patients on the unit. What is the priority the nurse uses to guide planning for patient’s personal hygiene?
a. When the patient had their most recent bath
b. The patient’s usual hygiene practices and preferences
c.Where the bathing fits in the nurse’s schedule
d.The time that is convenient for the AP
b
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply.
a.Promoting the patient’s sense of well-being
b. Preventing deterioration of the oral cavity
c. Contributing to decreased incidence of aspiration pneumonia
d. Eliminating the need for flossing
e. Decreasing oropharyngeal secretions
f. Compensating for an inadequate diet
a b c
A nurse assisting a patient with a bed bath observes the older adult has dry skin, which the patient states is “itchy.” Which intervention is appropriate?
Bathe the patient more frequently.
Use an emollient on the dry skin.
Explain that this is expected as people age.
Limit the patient’s fluid intake.
b
A home care nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure?
Adding bath oil to the water to prevent dry skin
Allowing the patient to lock the door to guarantee privacy
Assisting the patient in and out of the tub to prevent falling
Keeping the water temperature very warm because older adults chill easily
c
A nurse is teaching a nursing student how to perform perineal care for patients. What actions are appropriate when performing this procedure? Select all that apply.
For male and female patients, wash the groin area with a small amount of soap and water and rinse.
For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area.
For male and female patients, always proceed from the most contaminated area to the least contaminated area.
For male and female patients, use a clean portion of the washcloth for each stroke.
For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward.
In an uncircumcised male patient, avoid retracting the foreskin (prepuce) while washing the penis.
a d e
A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential to good patient outcomes, especially for those receiving mechanical ventilation. What are positive outcomes expected from this care? Select all that apply.
Promoting the patient’s sense of well-being
Preventing deterioration of the oral cavity
Contributing to decreased incidence of aspiration pneumonia
Eliminating the need for flossing
Decreasing oropharyngeal secretions
Compensating for an inadequate diet
a b c
You’re the nurse caring for a 26-year-old patient who has been hospitalized for a spinal cord injury following a motor vehicle crash. Which action would you perform when logrolling the patient to reposition him on his side?
a)Have the patient extend his arms outward and cross his legs on tip of a pillow
b)Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side
c)Have the patient cross his arms on his chest and lace a pillow between his knees
d)Place a cervical collar on the patient’s neck and gently roll him to the other side of the bed
c
A nurse is caring for an 82-year-old woman in a long-term care facility who has had 2 UTI’s in the past 6 months related to immobility. Which finding would the nurse expect in this patient?
a)Improved renal blood supply to the kidneys
b)Ureteral stenosis
c)Decreased urinary calcium
d)Urinary stasis
d
An elderly patient with pneumonia experiencing dyspnea should be placed in which position to promote maximal breathing in the thoracic cavity?
a)Dorsal recumbent position
b)Lateral position
c)Fowler’s position
d)Sims’ position
c
A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient’s feet to prevent footdrop?
a.Supination
b.Dorsiflexion
c.Hyperextension
d.Abduction
b
a nurse is developing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply.
Teach the patient to avoid sudden position changes that may cause dizziness.
Recommend that the patient restrict fluid intake until after exercise.
Instruct the patient to push a little further beyond fatigue each session.
Tell the patient to avoid exercising in very cold or very hot temperatures.
Encourage the patient to modify exercise if weak or ill.
Recommend that the patient consume a high-carb, low-protein diet.
a d
A nurse caring for patients in a pediatric office assesses children’s achievement of developmental milestones. Which patient finding requires follow-up with the pediatrician?
4-month-old infant who is unable to roll over
6-month-old infant who is unable to hold head up
11-month-old infant who cannot walk unassisted
18-month-old toddler who cannot jump
b
A nurse on a medical-surgical unit notes a patient with pneumonia and is experiencing dyspnea. What action will the nurse take to improve the dyspnea?
Encourage the patient to ambulate.
Suggest the patient use music or television as distraction.
Place the patient in Fowler’s position.
Tell the patient to take several deep breaths, then hold their breath for 5 seconds.
c
A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position?
Side-lying
Fowler’s
Sims’
Prone
d
A nurse assists a patient with ambulation for the first time following a knee replacement. Shortly after beginning to walk, the patient tells the nurse that they are dizzy and feel like they might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient:
Grasp the gait belt.
Stay with the patient and call for help.
Place feet wide apart with one foot in front.
Gently slide the patient down to the floor, protecting their head.
Pull the weight of the patient backward against your body.
Rock your pelvis out on the side of the patient.
a b d c e f
A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply.
Do full-body pushups in bed six to eight times daily.
Breathe in and out smoothly during quadricep-setting exercises.
Place the bed in the lowest position or use a footstool for dangling.
Dangle on the side of the bed for 30 to 60 minutes.
Allow the nurse to bathe you completely to prevent fatigue.
Perform quadriceps two to three times per hour, four to six times a day.
b c f
A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?
“Stand on the weaker leg and pivot toward the chair.”
“I will call the lift team to carry you to the chair.”
“The chair is by your non-affected leg for smoother movement.”
“Avoid putting your hospital socks on, as that will restrict your feet moving.”
c
Note
Flashcard