Know Your Rights
What is the best way for the nurse to make sure that the right patient is receiving a prescribed medication when the patient is alert and oriented?
A. Ask the patient to state their name
B. Check the patient's wrist band
C. Look at the patient's chart
D. Have the patient state his or her name and birth date.
D. Have the patient state his or her name and birth date.
Collaborative interventions are therapies that require:
A. Physician and nurse interventions
B. Nurse and client intervention
C. Client and physician interventions
D. Multiple health care professionals
D. Multiple health care professionals
A sublingual drug is administrated by placing the medication in what part of the body?
A. Between the cheek and the upper jaw
B. Under the tongue
C. In the nose
D. In the eye
B. Under the tongue
A patient has a 3cm x 3cm x 0.5cm pressure ulcer to his coccyx through all layers of the epidermis with the dermis exposed. What will be a priority of care for this patient?
A. Application of a heating blanket
B. Administration of Analgesic
C. Implementation of fluid restriction
D. Implementation of a turning restriction
B. Administration of Analgesic
Intact, non-blistered
Non-blanched Redness
Discoloration of skin, warmth, edema, hardness of skin may be present
For darker pigmented skin this area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue
Stage I Pressure Ulcer
The nurse uses a mortar and pestle to crush a medication before giving it to her patient. Which of the five rights is the nurse ensuring?
A. The right route
B. The right client
C. The right time
D. The right drug
A. The right route
The planning step of the nursing process includes which of the following activities:
A. Assessing and diagnosing
B. Evaluating goal achievement
C. Performing nursing actions and documenting them
D. Setting goals and selecting interventions
D. Setting goals and selecting interventions
Which of the following represents the proper way for a nurse to administer an oral capsule?
a. tell the patient to swallow it whole
b. pierce it with a needle and squeeze into the mouth
c. crush and dilute it in warm water.
d. tell the patient to chew it completely
a. tell the patient to swallow it whole
Which external factors can result in pressure ulcers? Select all that apply
A. Friction
B. Massage
C. Pressure
D. Movement
E. Shear Force
A. Friction
C. Pressure
E. Shear Force
Full-thickness skin and tissue loss.
Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling.
Stage III Pressure Ulcer
A nurse is administering daily medications when a patient states, "I never took a little yellow pill before." What is the nurse's best action?
A. Tell the patient it is the correct pill and they have to take it
B. Stop and recheck the medication that it is correct according to the health care provider's order.
C. Throw the pill away
D. Call the patient's provider
B. Stop and recheck the medication that it is correct according to the health care provider's order.
The following statements appear on a nursing care plan for a client after a mastectomy: incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of:
A. Nursing interventions
B. Short-term goals
C. Expected outcomes
D. Long-term goals
C. Expected outcomes
The nurse instructs a clinic patient on using an inhaler for his asthma attacks. Which of the following is correct about the use of an inhaler?
a. the medication must go into the back of the nose
b. the medication must go directly into the throat
c. the medication must get to the ears
d. the medication must go into the lungs.
d. the medication must go into the lungs.
What is the first phase of wound healing?
A. Maturation
B. Coagulation
C. Proliferative
D. Inflammatory
D. Inflammatory
Depth Unknown.
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
For darker pigmented skin the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
Deep Tissue Injury
what is the most important role of the nurse in preventing drug errors?
a. always checking the patient's diagnosis before giving a drug
b. always following the "six rights" of drug administration
c. being the one defense for detecting and preventing drug errors
d. being most likely to detect a drug error that has occurred.
b. always following the "six rights" of drug administration
The nurse writes an expected outcome statement in measurable terms. An example is:
A. Client will be pain free by end of shift
B. Client will have less pain by end of shift
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock
C. Client will report pain acuity less than 4 on a scale of 0-10.
An elderly patient is scheduled to take six medications each morning. The nurse administering these medications knows to do which of the following?
a. allow extra time to administer all of the medications
b. allow the patient to take only the medications she can swallow.
c. crush all of the medications before giving them
d. leave the medication at the bedside so the patient can take them slowly.
a. allow extra time to administer all of the medications
What characteristics related to skin may reflect an overall health problem?Select all that apply
A. Dryness
B. Turgor
C. Wounds
D. Odor
E. Skin tone
A. Dryness
B. Turgor
C. Wounds
D. Odor
Two Stages:
A. Full-thickness tissue loss with exposed bone, tendon, or muscle. Fat may be visible. Slough and eschar may be present often includes undermining and tunneling
B. Partial thickness loss of dermis. Shallow open ulcer with red pink wound bed. NO bruising or slough but may have some serum-filled or serosanguinesou filled blister. Shiny or dry shallow ulcer
A. Stage IV Pressure Ulcer
B. Stage II Pressure Ulcer
When giving a drug to a patient who is awake but confused, what is the best way for the nurse to identify the patient?
a. check the room and bed number that the patient occupies.
b. ask the patient to state his or her name and birth date.
c. check the name on the patient's wristband.
d. ask the patient if he or she is Mr. or Ms. (name).
c. check the name on the patient's wristband.
Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problem or alterations. Priorities are determined by the client's:
A. Physician
B. Non-emergent, non-life threatening needs
C. Future well-being
D. Urgency of problem
D. Urgency of problem
When giving a medicine through a nasogastric (NG) tube, the nurse will first do which of the following?
a. flush the tube with 30 mL of water
b. Check placement of the tube
c. take the vital signs
d. ask the patient if the tube is painful
b. Check placement of the tube
The nurse is caring for a patient with a recent, minor injury. As the nurse assesses the site of the injury, she notes that the new tissue has a granular, bumpy texture. The patient reports that the injured site still "bleeds easily." The nurse understands the phase of wound healing by documenting which stage in the patient chart?
A. Maturation
B. Unstagable
C. Proliferative
D. Inflammatory
C. Proliferative
Depth Unknown
Full-Thickness Tissue loss
Actual depth of ulcer might be completely obscured by slough, eschar, in wound bed
Unstageable/Unclassified