Ouch, my back!
An older adult may need to be reeducated on how to lift safely because: (SATA)
1. Muscles and bones lose strength as one ages
2. Bone density is decreased
3. Muscle mass is decreased, and posture has changed.
4. Memory decreases with age.
1. Muscles and bones lose strength as one ages
2. Bone density is decreased
3. Muscle mass is decreased, and posture has changed.
You are dangling your patient in preparation for getting them out of bed. Your plan is to dangle the patient for 2 minutes and then transfer them to the chair. After 1 minute, they complain of nausea and state that they see "stars." What should you do?
1. Reassure them that this will pass.
2. Get the blood pressure cuff from across the room.
3. Gently lie them back down.
4. Wait 2 more minutes and then check their BP.
3. Gently lie them back down.
Which patient is at greatest risk for developing a pressure injury?
1. A 40-year-old paraplegic man who is obese and uses a self-propelling wheelchair.
2. An 80-year-old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence.
3. A 55-year-old man who had surgery this afternoon and is difficult to arouse.
4. A 75-year-old woman who is postoperative day 2 for hip replacement surgery.
2. An 80-year-old woman with Alzheimer disease, peripheral neuropathy, and urinary incontinence.
Prevention of pressure injuries is promoted by: (SATA)
1. Changing the patient's position every 2 hours.
2. Directly massaging reddened areas.
3. Keeping the heels of the immobile patient off the bed.
4. Using lift devices such as a trapeze bar to move patients.
1. Changing the patient's position every 2 hours.
3. Keeping the heels of the immobile patient off the bed.
4. Using lift devices such as a trapeze bar to move patients.
A nurse receives a prescription for phenobarbital for a client who has a seizure disorder. The medication has a long half-life of 4 days. How many times per day should the nurse expect to administer this medication?
1. One
2. Two
3. Three
4. Four
1. One
Medications with long half-lives remain at their therapeutic levels between doses for long periods of time. Expect to administer this medication once a day.
A nurse checking a patient's medication record notices a change in the dose and route for a medication given earlier in the day. What would be the appropriate action by the nurse?
1. Administer the medication as it appears on the medication record.
2. Check for new orders by the licensed prescriber
3. Change te medication record back to the dose and route that was administered with the morning dose.
4. Ask the patient to verify the change in the order.
2. Check for new orders by the licensed prescriber
A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication, I do not want one more pill." Which of the following responses should the nurse make?
1. "Your physician prescribed it for you, so you really should take it."
2. "Well, let's just get it over quickly then."
3. "Okay, I'll just give you your other medications."
4. "Tell me your concerns about taking this medication."
4. "Tell me your concerns about taking this medication."
Forgetting to reposition a patient in a wheelchair for more than one hour may lead to:
1. The beginning of a pressure injury.
2. Muscle atrophy.
3. Pooling of lung secretions
4. Skin abrasions from shearing forces.
1. The beginning of a pressure injury.
When a patient experiences a fall, you document in the nurse's notes:
1. Your best guess about what happened.
2. A statement concerning how you believe the hospital was negligent.
3. Any patient-stated cause of the fall.
4. As little as possible to avoid liability.
3. Any patient-stated cause of the fall.
Any patient statement about the fall is important to document, especially if the fall was not witnessed. You must document "just the facts." Your conclusion and the other choices are inappropriate to document.
A factor in skin problems common to older adults is: (SATA)
1. Skin tends to be dry because of increased gland activity.
2. Hair becomes thicker and grows more slowly.
3. Nails become thin and more brittle
4. Fewer nutrients are available from the reduced diet.
5. Skin is less elastic and more fragile.
3. Nails become thin and more brittle
5. Skin is less elastic and more fragile.
When making a bed it is important to remember to: (SATA)
1. Place soiled linens on the floor to avoid contaminating the bed.
2. Unfold linens on the bed to avoid stirring up air currents.
3. Return unused linens to the floor's clean linen area to prevent waste.
4. Raise the bed during the linen change to prevent back pain.
2. Unfold linens on the bed to avoid stirring up air currents.
4. Raise the bed during the linen change to prevent back pain.
A nurse is reviewing medication metabolism. Which of the following factors should the nurse determine as a reason to administer lower medication dosages? (SATA)
1. Increased renal excretion
2. Increased medication-metabolizing enzymes
3. Liver Failure
4. Peripheral vascular disease
5. Concurrent use of medication the same pathway metabolizes.
3. Liver Failure
5. Concurrent use of medication the same pathway metabolizes.
While the nurse is administering morning medications, the patient asks, "What is the pill for?" When the nurse explains the pill is for high cholesterol, the patient responds, " I have never had a problem with high cholesterol." What is the appropriate action by the nurse?
1. Encourage the patient to take the medication.
2. Leave a note in the patient's chart for the licensed prescriber.
3. Repeat the three checks for the medication.
2. Check for new orders by the licensed prescriber
2. Check for new orders by the licensed prescriber
A nurse is reviewing a client's prescribed medications. Which of the following situations represents a contraindication to medication administration?
1. The client drank grapefruit juice, which could reduce a medication's effectiveness.
2. The medication has orthostatic hypotension as an adverse effect.
3. A medication is approved for ages 12 and older, and the client is 8-years-old.
4. An antianxiety medication that has an adverse effect of drowsiness is prescribed as a preoperative sedative.
3. A medication is approved for ages 12 and older, and the client is 8-years-old.
When preparing to move a patient who can assist up in the bed, you would first:
1. Pull the bed covers down to the foot of the bed.
2. Raise the bed to an appropriate working height.
3. Ask the patient to grab the upper side rails.
4. Ask the patient to bend the knees and plant the feet on the mattress.
2. Raise the bed to an appropriate working height.
A newly admitted client is asking to get up out of the bed to use the bathroom. Before the client gets up for the first time, what must the nurse do? (SATA)
1. Nothing, if a client feels they can ambulate safely, they can.
2. The nurse must check the physician's order
3. Assess the patient's physical and mental liabilities, if any.
4. Ask the UAP to assist the patient out of bed and to the restroom.
5. The nurse should assist the client out of bed.
2. The nurse must check the physician's order
3. Assess the patient's physical and mental liabilities, if any.
Your patient has an area at the left trochanter that is reddened with slightly abraded skin. You would stage this as a _____________pressure injury.
1. Stage 1
2. Stage 2
3. Stage 3
4. Unstageable
2. Stage 2
Which patient might be most likely to suffer a burn if left to bathe in a tub alone?
1. An adult patient who is to have abdominal surgery tomorrow.
2. An adult patient who is having back pain after a cystoscopy.
3. A patient taking medications that alter mental awareness.
4. An alert older adult patient who prefers tub bathing.
3. A patient taking medications that alter mental awareness.
A nurse reviewing a client's medical record notes a new prescription for verifying the trough level of the client's medication. Which of the following actions should the nurse take?
1. Obtain a blood specimen immediately prior to administering the next dose of medication.
2. Verify that the client has been taking the medication for 24 hours before obtaining a blood specimen.
3. Ask the client to provide a urine specimen after the next dose of medication.
4. Administer the medication, and obtain a blood specimen 30 min later.
1. Obtain a blood specimen immediately prior to administering the next dose of medication.
Which of the following is an example of an appropriate order?
1. Furosemide 40 mg by mouth qd
2. Furosemide 40 mg by mouth Q.D.
3. Furosemide 40 mg by mouth daily
4. Furosemide 40 mg by mouth QD
3. Furosemide 40 mg by mouth daily
The nurse is preparing DULoxetine. How do the capital letters "DUL" assist the nurse in safe medication administration?
1. They help in alphabetizing the medications in the automated medication dispensing machine.
2. They alert the nurse of a sound-alike/look-alike medication.
3. They are the initials for the medication classification.
4. They are the letters that start both the generic and trade name for the medication.
2. They alert the nurse of a sound-alike/look-alike medication.
You have assisted your patient to the prone position. Which intervention is most important?
1. Ask if they have any neck discomfort.
2. Count the respirations.
3. Offer them a magazine.
4. Place the call light within reach.
2. Count the respirations.
A nurse cares for a patient who cannot turn by using an overhead lift. The nurse knows that which of the following is the MOST important actions to follow in terms of safety?
1. Tell the patient to rock back and forth to propel themselves.
2. Allow the patient to hook themselves up to the sling so that they feel involved in their care.
3. Ensure the sling is removed from the patient after they are seated in the chair.
4. When using the lift, raise the patient above the bed before laterally positioning the lift over the intended chair.
4. When using the lift, raise the patient above the bed before laterally positioning the lift over the intended chair.
The extremities are washed from distal to proximal because this:
1. Promotes safety
2. Cleanses the skin better than proximal to distal does.
3. Supplies vital skin oils.
4. Promotes venous return to the heart.
4. Promotes venous return to the heart.
Which action would help prevent the most frequent cause of injury to the older adult patient?
1. Keeping pathways clear of papers and objects
2. Grounding all electrical equipment in use.
3. Checking temperatures of fluids before serving them.
4. Reviewing the dose and frequency for all ordered medications with the client.
1. Keeping pathways clear of papers and objects
A nurse is preparing a client's medications. Which of the following actions should the nurse take in following legal practice guidelines? (SATA)
1. Reinforce teaching with the client about the medication.
2. Determine the dosage.
3. Monitor for adverse effects.
4. Lock compartments for controlled substances.
5. Determine the client's insurance status.
1. Reinforce teaching with the client about the medication.
3. Monitor for adverse effects.
4. Lock compartments for controlled substances.
A dosage calculation answer is 5.02 mcg with directions to round to the nearest tenth place. How would the final answer be documented?
5 mcg
The nurse is caring for a patient who was admitted for a serious bacterial infection. In addition, the patient has a history of high blood pressure, high cholesterol, and a duodenal ulcer. Which medication is the nurse most likely to question if it is included in the admission orders?
1. Metoprolol
2. Acyclovir
3. Esomeprazole
4. Ciprofloxacin
2. Acyclovir
When changing the patient's position, it is most important to:
1. Use only those muscles necessary.
2. Stand with feet close together for greater strength.
3. Work at the same level or height as the patient.
4. Push rather than pull, as your weight helps.
3. Work at the same level or height as the patient.
A patient arrives in the ER with suspected appendicitis. Which of the following actions, if performed by the UAP caring for the patient, would require further teaching in regard to safety?
1. The UAP reminds the patient to stay in bed.
2. The UAP gives the patient a heat pack for comfort.
3. The UAP allows the patient to lay in whatever position is most comfortable.
4. The UAP does not give the patient any fluids or food.
2. The UAP gives the patient a heat pack for comfort.
The primary reason some hospitals prefer a bag bath to a traditional bed bath is:
1. Cost savings
2. Time savings
3. Infection control
4. Less mess.
3. Infection control
What is the most appropriate triage question for an alert, oriented, and mobile patient with an obvious broken arm?
1. Immediate
2. Delayed
3. Minimal
4. Expectant
2. Delayed
What are the six rights of medication administration?
Right Drug
Right Dose
Right Patient
Right Route
Right Time
Right Documentation
Which of following are actions in verifying the "right patient" before medication administration? (SATA)
1. Ask the patient to state their name and date of birth.
2. Scan the bar code on the patient's armband.
3. Compare the patient's name with the eMAR.
4. Skip this step if the patient is asleep.
1. Ask the patient to state their name and date of birth.
2. Scan the bar code on the patient's armband.
3. Compare the patient's name with the eMAR.
The nurse has administered morning medications, and several patients are experiencing effects related to the medications. Which patient should the nurse attend to first?
1. The patient who received an antihypertensive and complains of dizziness.
2. The patient who received an antihistamine and reports feeling drowsy and sleepy.
3. The patient who received an antibiotic and now has hives and welts all over the trunk, face and lips.
4. The patient who received an anticholinergic and now has a dry mouth and feels thirsty.
3. The patient who received an antibiotic and now has hives and welts all over the trunk, face and lips.