Nursing Interventions
A patient with widely distributed chronic eczema is prescribed to receive medicated tar baths. What action should the nurse take?
1. Keep the patient in the bath for 1 hour.
2. Remove topical medications from the skin prior to the bath.
3. Provide good ventilation to the room.
4. Slowly add hot water to keep the bath temperature stable.
3. When a medicated tar bath is prescribed, the room must be well ventilated because tars are volatile.
The nurse is observing a student doing an examination of the skin. Which observation requires correction?
1. Allowing the patient to leave on underwear and socks
2. Planning to use the techniques of inspection and palpation
3. Including the hair, nails, scalp, and mucous membranes
4. Explaining the need for a pen light and magnifying glass
1. The patient needs to completely undress for a thorough inspection, especially with a history of malignant skin growths. The feet and genitalia are not immune to skin lesions or cancers.
The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse prepare?
1. A tonometer
2. Ultrasonography
3. An ophthalmoscope
4. A slit-lamp microscope
1. Estimation of intraocular pressure is measured by using one of several types of tonometers.
The nurse is helping a patient identify coping mechanisms. How would the nurse explain to the patient what coping means?
1. The way one adapts to a stressor
2. The adaptation to mental health problems
3. The use of specific mechanisms to reduce anxiety
4. The development of unconscious behaviors to reduce psychological distress
1. Coping is the way one adapts psychologically, physically, and behaviorally to a stressor.
The nurse is caring for a patient at risk for primary open-angle glaucoma (POAG). Which finding is most concerning?
1. Hypotension and bradycardia
2. Fever and reddened conjunctiva
3. Loss of central vision and dizziness
4. Headache and seeing halos around lights
4. POAG develops bilaterally. The onset is usually gradual and painless, so the patient may not experience noticeable symptoms or, after time, may experience mild aching in the eyes, headache, halos around lights, or frequent visual changes that are not corrected with eyeglasses.
The nurse is participating in a unit program aimed at preventing pressure injuries to residents in a long-term care facility. Which intervention requires revision?
1. Thoroughly dry all skin-to-skin surfaces after bathing.
2. Position patients at a 45-degree angle when in bed.
3. Place a pillow lengthwise under the calves of the legs.
4. Ensure an adequate intake of protein, calories, and fluid.
2. When positioning a patient on the side, the angle should not be more than 30 degrees to prevent pressure on the trochanter, a bony prominence, which is particularly subject to ischemia and pressure injury. The suggestion of 45 degrees requires revision.
The nurse is collecting information about a patient’s auditory system during a physical examination. Which process will the nurse perform first?
1. Observation of the patient’s behavior
2. Inspection of the external ear
3. Palpation of the mastoid process
4. Testing of the auditory acuity
1. When collecting information about a patient’s auditory system, the first action by the nurse is to observe the behaviors of the patient. Note how the patient talks and if there is any slurring of speech.
The nurse is preparing a patient for a fluorescein angiography. How should the nurse explain the purpose of this test?
1. To find leakage or damage to the blood vessels of the retina
2. To identify the dry form of macular degeneration
3. To find the amount of vision damage related to glaucoma
4. To find abnormalities of the eye structure from hypoglycemia
1. Fluorescein angiography is performed on patients with diabetes mellitus to diagnose and arrange for treatment of diabetic retinopathy.
The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?
1. Regardless of treatment, peripheral vision will be eventually lost.
2. Compliance with drug therapy is essential to prevent loss of vision.
3. Damage to the eye caused by glaucoma is reversible in early stages.
4. Eye pain is experienced until the optic nerve atrophies, causing blindness.
2. Lifelong compliance with drug therapy is essential to prevent loss of vision
The nurse is assisting with the care of a patient being prepared for emergency intervention for a detached retina requiring the patient to maintain a reclining position for 16 hours, which procedure is planned for this patient?
1. Laser surgery
2. Cryopexy
3. Pneumatic retinopexy
4. Scleral buckling
3. Pneumatic retinopexy is a procedure that involves injecting air or gas into the eyeball to hold the retina in place. Reclining for about 16 hours before the procedure is required to allow the retina to fall back toward the choroid. Three weeks of specific positioning is required to complete the process of healing.
A patient is admitted with a recent surgical wound that is infected and exhibits an open suture line. The HCP prescribes negative pressure wound therapy (NPWT). How should the nurse prepare for treatment?
1. Apply moist gauze into the open wound.
2. Loosely pack the wound with a sterile sponge.
3. Apply pressure to the wound until drainage appears.
4. Cover the wound completely with a thick, absorbent pads.
2. Gentle negative pressure is applied to allow excess drainage and infectious material to be removed. The result is less pressure on delicate new tissue and better circulation to promote healing.
The nurse is collecting data about a patient’s eye health. What should the nurse ask?
1. Have you ever had a traumatic head injury?
2. How is your kidney function?
3. Do you take blood thinners?
4. Do you have a history of diabetes?
4. A part of the health history includes asking about family history that can affect vision, as eye disorders and diseases can be genetically transmitted. Patients should be asked about general health status and disorders such as diabetes, hypertension, cancer, thyroid disorders, or rheumatoid arthritis.
The nurse is assisting with a patient who has a suspected diagnosis of tinea capitis. For which diagnostic test should the nurse prepare the patient?
1. Patch test
2. Scratch test
3. Skin biopsy
4. Wood’s light examination
4. Wood’s light examination is the use of UV rays to detect fluorescent materials in the skin and hair present in certain diseases such as tinea capitis (ringworm).
A patient presents with vertigo, tinnitus, and sensorineural hearing loss. Which patient teaching does the nurse reinforce with this patient?
1. Instruct to not turn the head quickly.
2. Emphasize the importance of taking antihistamines.
3. Instruct in using proper methods for cleaning the ear.
4. Tell the patient that hearing will return with rest and medication.
1. The patient with labyrinthitis should be reminded not to turn the head quickly to avoid vertigo.
The nurse in the emergency department is assisting with the care of a patient with a penetrating wound to the eye. What should the nurse plan for care?
1. Irrigating the eye to remove foreign particles
2. Performing eyelid eversion for closer examination
3. Stabilizing the protruding object with tape
4. Covering the eye with a protective eye patch
4. For a protruding eye wound, the patient is kept calm and relaxed to minimize eye movement and increased IOP. If a protruding object is present, the object is stabilized with tape or other supports.
A patient recovering from electroconvulsive therapy (ECT) for severe depression is confused and wants to know what has been done. What action should the nurse take?
1. Administer a sedative to help calm the patient.
2. Call the physician and report the patient’s response.
3. Explain that the patient is in the hospital and has just had ECT.
4. Encourage the patient to sleep until the preprocedure medication is worn off.
3. The patient may feel confused and forgetful immediately after ECT. This can be from a combination of the ECT and the medication that was used before the treatment.
The nurse at an HCP’s office is interviewing a patient presenting with a skin infection. Which question should the nurse ask first?
1. Do you know anyone with this infection?
2. Do you think you are contagious?
3. What aggravates or alleviates symptoms?
4. Do you get infections often?
3. It is important for the nurse to know what aggravates or alleviates the symptoms of the patient’s infection. This information can guide diagnosis and treatment.
DAILY DOUBLE!!!!
The nurse is giving instructions to a patient who is scheduled for an electronystagmogram because of vertigo and ringing in the ears. Which finding by the nurse is most concerning and requires reporting?
1. The patient has a history of alcohol abuse.
2. The patient has a pacemaker.
3. The patient takes tranquilizers.
4. The patient lives alone.
2. The test is contraindicated for patients with a pacemaker; the nurse will notify the prescribing health-care provider (HCP).
A patient who just completed an alcohol treatment program is prescribed disulfiram to help maintain sobriety. Which teaching is most important for the nurse to review with the patient?
1. Avoiding alcohol for 24 hours after taking the medication
2. The reactions that will occur if the patient ingests alcohol
3. Contacting the HCP if the patient contracts a cold or illness
4. Which nonmedication products should also be avoided
2. The effects of drinking when taking disulfiram are alarming and serious. The patient may experience chest pain, nausea, vomiting, confusion, and other symptoms. The patient needs to give a full informed consent before the drug is administered.
The nurse is performing a wet dressing change as ordered on a patient who has a crusted skin lesion. Which finding is most concerning?
1. Edema formation
2. Dry, macerated skin
3. Increased lesion oozing
4. Excessive skin oiliness
2. Wet dressings should not be prescribed for more than 72 hours because the skin may become too dry or macerated.
A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure (BP) 180/100 mm Hg, pulse 92 beats/minute, and respirations 22 breaths/minute. Which action does the nurse perform first?
1. Teach the patient a relaxation technique.
2. Administer a dose of lorazepam (Ativan).
3. Search the patient’s room for hidden alcohol.
4. Administer an antihypertensive agent as ordered.
4. According to Maslow’s hierarchy, physiological symptoms must be attended to first. The patient’s BP is at an unsafe level.
The nurse is providing care for a patient with burns covering the entire surface of one arm and the posterior trunk. Approximately what percentage of the patient’s body surface area has been affected?
1. 18%
2. 27%
3. 36%
4. 45%
2. According to the Rule of Nines, each arm is 9% and the posterior trunk is 18%, for a total of 27%.
The nurse works in an office with a dermatologist and is preparing to assist with a scratch test. What action should the nurse take?
1. Cleanse the patient’s upper back and arms with alcohol.
2. Instruct the patient to keep areas dry and free from moisture.
3. Place resuscitation equipment in the vicinity of the testing.
4. Arrange for the final reading of the testing in 2 to 5 days.
3. Resuscitation equipment should be kept in a close location for scratch testing, which elicits an immediate reaction that can lead to anaphylaxis.
The nurse is assisting with preparation for cryosurgery for a patient diagnosed with a lentigo maligna melanoma lesion on the forehead. Which information will the nurse provide in preparation for surgery?
1. Pain medication is given for expected severe pain.
2. A hemorrhagic blister will form immediately after the procedure.
3. The area will be cleaned as ordered and a prescribed ointment applied.
4. The lesion is likely to reappear and follow-up treatment is expected.
3. After cryosurgery, the area is to be cleansed as ordered and a prescribed ointment is applied.
The nurse is assisting in the care of a patient with a circumferential burn to the leg. The HCP determines that an escharotomy is necessary. What is the nurse’s priority action?
1. Checking for the return of distal pulses
2. Padding the bed for large amounts of drainage
3. Monitoring for respiratory function
4. Medicating as prescribed for pain management
1. Burned tissue can act as a tourniquet with a circumferential burn and cut off circulation. The most important intervention following an escharotomy on a leg is to monitor for the return of distal pulses, which indicates adequate circulation.