Med Admin and Activity, Exercise, and Immobility
A patient is prescribed a medication to be taken "sublingually." The nurse instructs the patient to place the medication:
B. Sublingual administration occurs under the tongue.
A patient is being discharged on around-the-clock (ATC) opioids. The nurse expects an order for which type of medication to manage a common side effect?
C. Constipation is a nearly universal side effect of chronic opioid use, necessitating stool softeners.
While performing a skin assessment during a bath, the nurse identifies a reddened area over the patient's sacrum. What is the nurse's priority action?
A. Massage the area to increase circulation.
B. Apply a heating pad to the reddened area.
C. Document the finding and notify the provider.
D. Clean the area with an alcohol-based solution.
C: The nursing process requires analyzing assessment findings to identify risks for impaired skin integrity and implementing appropriate clinical judgment.
A patient presents with a serum sodium level of 150 mEq/L. Which IV solution should the nurse anticipate the provider will order?
A. 3% Sodium Chloride (Hypertonic)
B. 0.9% Sodium Chloride (Isotonic)
C. 0.45% Sodium Chloride (Hypotonic)
D. Lactated Ringers (Isotonic)
C: A sodium level of 150 mEq/L indicates hypernatremia. Hypotonic solutions (0.45% NaCl) move water into cells to dilute the extracellular fluid.
Which laboratory value is the best indicator of a patient's short-term nutritional status?
A. Serum Albumin.
B. Hemoglobin.
C. Prealbumin.
D. Total Cholesterol
C: Prealbumin has a shorter half-life than albumin and is a more sensitive indicator of recent nutritional changes.
The nurse is administering an intramuscular (IM) injection to an adult. What is the correct angle of insertion for this route?
C. IM injections are administered at a 90-degree angle.
A nurse is assessing a patient 1 hour after administering an opioid. Which finding is of the greatest concern?
C. Oversedation (difficulty arousing) is a major red flag for respiratory depression when using opioids.
When providing oral care for an unconscious patient, which safety intervention is most important?
A. Use a large amount of water to rinse the mouth thoroughly.
B. Position the patient in a side-lying position to prevent aspiration.
C. Place the patient in a Trendelenburg position.
D. Use a firm-bristle toothbrush to remove plaque.
B: Adapting oral care for an unconscious patient requires interventions that prevent aspiration, such as proper positioning.
A 70-year-old client with severe dehydration is being assessed. Which finding requires immediate intervention?
A. Deep furrows on the tongue.
B. Poor skin turgor with tenting.
C. Urine output of 950 mL in 24 hours.
D. Change in behavior from anxious to lethargic.
D: A change in level of consciousness (lethargy) indicates a potential worsening of the condition or a serious electrolyte/acid-base imbalance affecting neurological status.
A patient is diagnosed with dysphagia. Which intervention should the nurse include in the plan of care?
A. Provide thin liquids to make swallowing easier.
B. Encourage the patient to eat quickly to avoid fatigue.
C. Sit the patient upright at 90 degrees during meals.
D. Discourage the use of thickeners in drinks.
C: Proper positioning (upright) is essential to reduce the risk of aspiration in patients with swallowing difficulties.
Which of the following is one of the "Seven Rights" of medication administration?
B. The seven rights include: Right medication, dose, patient, route, time, documentation, and indication.
Which characteristic is most commonly associated with chronic pain rather than acute pain?
C. Chronic pain is persistent and continues after the expected healing time.
Which factor most significantly influences a patient’s personal hygiene practices?
A. The nurse’s morning schedule.
B. The availability of hospital linens.
C. The patient's cultural variables and personal preferences.
D. The hospital’s standard policy on daily bathing.
C: Factors influencing hygiene include social practices, personal preferences, and cultural variables.
The nurse is caring for a patient with a potassium level of 2.8 mEq/L. Which is the priority assessment?
A. Daily weights.
B. Cardiac rhythm monitoring.
C. Skin integrity.
D. Bowel sounds.
B: Hypokalemia (<3.5 mEq/L) can lead to life-threatening cardiac dysrhythmias; therefore, cardiac monitoring is a critical intervention.
Using the Braden Scale, the nurse assesses a patient as having "very limited" mobility, "occasionally moist" skin, and "adequate" nutrition. What is the purpose of this tool?
A. To determine the stage of an existing pressure injury.
B. To predict the patient's risk for developing a pressure sore.
C. To measure the rate of wound healing.
D. To decide which type of dressing to apply.
B: The Braden Scale is a standardized risk assessment tool for predicting pressure sore risk.
A nurse is assisting a patient with a history of pneumonia to sit on the side of the bed. The patient becomes dizzy and their heart rate increases from 80 to 110. The nurse recognizes this as:
B. Signs of activity intolerance include increased heart rate, shortness of breath, and dizziness during activity.
When must informed consent be obtained from the patient?
B. Consent must be obtained while the patient is alert and before any mind-altering medications are given.
A patient reports feeling exhausted despite sleeping 8 hours a night. The partner reports the patient snores loudly and occasionally stops breathing. Which condition does the nurse suspect?
A. Insomnia.
B. Narcolepsy.
C. Obstructive Sleep Apnea (OSA).
D. Circadian rhythm disorder.
C: Obstructive Sleep Apnea pathophysiology involves airway obstruction, loud snoring, and pauses in breathing during sleep.
Which complication is characterized by redness, tenderness, and warmth along the course of a vein used for IV therapy?
A. Infiltration.
B. Phlebitis.
C. Extravasation.
D. Air embolism.
B: Phlebitis is the inflammation of a vein, whereas infiltration involves the leaking of non-vesicant fluid into the tissue.
The nurse observes a patient's wound and notes the presence of fresh, bright red bleeding. How should the nurse document this drainage?
A. Serous.
B. Purulent.
C. Sanguineous.
D. Serosanguineous.
C: Sanguineous drainage indicates fresh bleeding; serous is clear, purulent is thick/yellow/green (sign of infection), and serosanguineous is pale/pink/watery.
Which diet should the nurse recommend for an immobilized patient with impaired skin integrity?
A. A high-protein, high-calorie diet is essential for tissue repair and preventing further skin breakdown.
Which postoperative intervention is most effective in preventing deep vein thrombosis (DVT)?
B. Early ambulation improves circulation and is a key evidence-based practice to prevent DVT.
The nurse is assessing a patient for sleep deprivation. Which findings are consistent with this condition? (Select all that apply)
A. Increased alertness.
B. Irritability.
C. Blurred vision.
D. Decreased reflexes.
E. Improved memory.
B, C, D
Sleep deprivation leads to psychological and physiological symptoms including irritability, visual disturbances, and slowed response time.
A patient's arterial blood gas (ABG) results are: pH 7.25, CO2 50 mm Hg, and HCO3 24 mEq/L. How should the nurse interpret these findings?
A. Metabolic acidosis.
B. Metabolic alkalosis.
C. Respiratory acidosis.
D. Respiratory alkalosis.
C: A low pH (7.25) indicates acidosis, and a high CO2 (50) indicates the lungs are retaining acid, pointing to a respiratory cause.
Which intervention is most effective in preventing pressure injuries for a bedbound patient?
A. Massaging reddened bony prominences.
B. Using a donut-shaped cushion.
C. Repositioning the patient at least every 2 hours.
D. Keeping the head of the bed at a 90-degree angle.
C: Frequent repositioning minimizes pressure duration and intensity, which are key in the pathogenesis of pressure injuries.