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You are caring for a client who is a sprinter on her high school track team. You should especially encourage her to consume which of the following nutrients to provide plenty of energy before running?
a) Protein
b) Carbohydrate
c) Lipid
d) Water
What is A?
Rationale: Carbohydrates, which are more easily and quickly digested than proteins and lipids, fuel strenuous short-term skeleton muscle activity and provide nearly all the energy for the brain.
The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking him to bring his fingers together?
a. Flexion
b. Abduction
c. Extension
d. Adduction
What is d?
Rationale: Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction.
You are preparing to give a handoff report to the receiving nurse. During the handoff you would like to show the receiving nurse some lesions that have appeared on the patient's arm. Which type of report would be best for you to perform?
a. Bedside report
b. Face-to-face oral report
c. Audio-recorded report
d. Standardized report
What is a?
Rationale: A bedside report, sometimes known as "walking rounds," allows you to observe important aspects of care, such as patient appearance, intravenous pumps, and wounds.
You are performing an assessment of a patient and recording normal and abnormal findings by body system. Which form should you use for this purpose?
a. Intake and output records
b. Discharge summary
c. Flowsheet
d. Checklist
What is checklist?
Rationale: Assessments and care may also be recorded on paper and electronic checklists. Common normal and abnormal findings are usually organized according to body systems.
The implementation of electronic health records (EHRs) allows the nurse to do which of the following? Select all that apply.
a. Use trend data to facilitate evidence-based nursing practice
b. Promote efficient use of time spent charting
c. Reduce the opportunity for interdisciplinary collaboration
d. Activate the system’s safeguards to promote client safety
What is a,b,d
Rationale: The implementation of electronic health records (EHR) has many advantages which includes the ability to identify trends in data to facilitate evidence-based nursing practice, promote the efficient use of the time nurses spend documenting client care, and use the system’s safeguards to minimize errors in clients care.
You are caring for a client who has developed a pressure ulcer. Because of extensive tissue loss in the area of the ulcer, this wound is being left open and allowed to granulate. Which type of healing is this?
a. Regenerative
b. Primary intention
c. Secondary intention
d. Tertiary intention
What is c?
Rationale: Healing by secondary (second) intention occurs when a wound (1) involves extensive tissue loss, which prevents wound edges from approximating, or (2) should not be closed (e.g., because it is infected). Because the wound is left open, it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Pressure ulcers and infected wounds are examples.
1.
Which of the following fluid and electrolyte transport systems involves movement of water across a membrane from an area of a less concentrated solution to an area of more concentrated solution?
a. Active transport
b. Osmosis
c. Diffusion
d. Filtration
What is b:
Rationale: Osmosis involves movement of water (or other pure solute) across a membrane from an area of a less concentrated solution to an area of more concentrated solution. Water moves across the membrane to dilute the higher concentration of solutes.
Which intervention by the nurse might help the patient maintain a sense of personhood during hospitalization? Assume that all are culturally appropriate.
a. Never offering an explanation before beginning a procedure
b. Addressing the patient by his first name
c. Making eye contact if it is comfortable for the patient
d. Speaking to others about the patient so that the patient can hear you
What is b?
Rationale: The nurse can help the patient maintain a sense of personhood by addressing the patient by his preferred name, which might be his first name or might be his surname with title.
You are caring for a client who is receiving morphine for pain relief. After the latest dose, you notice that the client's respiratory rate has declined to 10 breaths per minute. Which of the following nursing diagnoses would be most appropriate for this client?
1) Ineffective Airway Clearance (respiratory depression) related to overdose of morphine
2) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine
3) Impaired Gas Exchange related to respiratory depression secondary to overdose of morphine
4) Impaired Spontaneous Ventilation related to hypoventilation secondary to overdose of morphine
What is b?
Rationale: Ineffective Breathing Pattern is used to describe inadequate ventilation, such as hypoventilation, hyperventilation, tachypnea, or bradypnea. This diagnosis is appropriate for this case because the client is experiencing respiratory depression, also known as hypoventilation (a decreased breathing rate), related to an overdose of morphine.
You are performing a physical examination of a client when she begins to become agitated. When you ask what is wrong, she says, "I think I'm having a panic attack." Her respirations increase in rate and depth but remain regular. Which breathing pattern is this?
a. Bradypnea
b. Kussmaul's respirations
c. Biot's respirations
d. Cheyne-Stokes respirations
What is b?
Rationale: Kussmaul's respirations are regular but increased in rate and abnormally deep. These may be a compensatory mechanism for metabolic disorders that lower blood pH, as well as a form of hyperventilation caused by fear, anxiety, or panic.
Cheyne-Stokes respirations are characterized by a gradual increase in depth of respirations, followed by a gradual decrease in depth, and then a period of apnea. This pattern often results from damage to the medullary respiratory center or high intracranial pressure due to brain injury.
Which of the following is an example of a cultural stereotype, as opposed to a cultural archetype?
a. Native Americans have black hair.
b. Northern Europeans have light-colored skin
c. Asians are good at math.
d. Jewish people have prominent noses.
What is c?
A cultural stereotype is a widely held but oversimplified and unsubstantiated belief that all people of a certain racial or ethnic group are alike in certain respects. Stereotypes are not always negative. Someone may think, for example, that people of a particular heritage are "naturally intelligent" or "naturally athletic."
A client explains to you that she is currently undergoing intensive physical rehabilitation following a heart attack. Which of the following levels of prevention does this action represent?
a. Primary
b. Secondary
c. Tertiary
d. Quaternary
What is c?
Rationale: Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. Rehabilitation is the main intervention during this level.
You are flexing and extending a client's forearm at the elbow as far as it will comfortably go without any assistance from the client. This activity is known as which of the following?
a. Body alignment
b. Line of gravity
c. Passive range of motion
d. Active range of motion
What is c?
Rationale: You are flexing and extending a client's forearm at the elbow as far as it will comfortably go without any assistance from the client. This activity is known as which of the following?
Which laboratory result on a client’s health record should alert the nurse to a potential problem?
a. K+ = 5.2 mEq/L
b. Na+ = 137 mEq/L
c. Ca2+ = 9.2 mg/dL
d. Mg2+ = 1.8 mg/dL
What is a?
Rationale: A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within normal ranges.
You are reviewing the Healthy People 2020 Goals so that you can select aggregate wellness goals for your clients. Which of the following are among the broad goals for the U.S. population set by the Healthy People 2020 initiative?
SELECT ALL THAT APPLY.
a. Discover a cure for breast cancer.
b. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
c. Achieve health equity, eliminate disparities, and improve the health of all groups.
d. Create social and physical environments that promote good health for all.
e. Promote quality of life, healthy development, and healthy behaviors at all life stages.
f. Improve palliative care for all people with terminal illnesses.
What is a and b, c, d, e?
Rationale: Health People 2020 has 4 main goals which includes:
1. Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death is one of the broad goals for the U.S. population set by the Healthy People 2020 initiative.
2. Achieving health equity, eliminating disparities, and improving the health of all groups is one of the broad goals for the U.S. population set by the Healthy People 2020 initiative.
3. Creating social and physical environments that promote good health for all is one of the broad goals for the U.S. population set by the Healthy People 2020 initiative.
4. Promoting quality of life, healthy development, and healthy behaviors at all life stages is one of the broad goals for the U.S. population set by the Healthy People 2020 initiative.
When a nurse cares of patients that have many health issues. What skill must the nurse possess?
What is critical thinking?
Rationale: Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues.
The nurse just admitted a patient. What part of the nursing process will she begin?
What is assessment?
Rationale: The order of the Nursing Process is assessment, diagnosis, planning outcomes, implementation and evaluation.
The nurse is interviewing a patient. She ask the patient what occurs right before you have a seizure" What kind of question is this?
What is open-ended?
Rationale: Open-ended questions specify a topic to be explored, but is phrased broadly to encourage the patient to elaborate. For example, tell me about your symptoms.
The nurse is assessing the patient. She quickly pressing on the tip of the patients nail and releases it watching for return of blood (observing change in color). What is the nurse assessing?
What is capillary refills?
Rationale: To assess capillary refill, the nurse should briefly press the tip of the nail with firm, steady pressure, then release, and observe for changes in skin color. It provides an indirect measure of tissue perfusion.
Sedentary lifestyle and High-dose calcium therapy puts a patient at risk for what problem?
What is constipation?
Rationale:
Physical activity promotes peristalsis, whereas immobilization depresses it. High-dose calcium therapy also predisposes a patient to constipation.
The patient has a a respiration rate of 42? What vital sign would you measure to check how well a patient is being oxygenated?
What is pulse oximetry?
Rationale: A pulse oximeter permits the indirect measurement of oxygen saturation
A patient stops an infused of penicillin after noting the wheezing in the patient. What is the patient experiencing?
What is anaphylactic reaction?
Rationale: The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction.
When a nurse is assessing a patient in any culture they keep in mind that __________ is influence by a client culture
What is pain?
Rationale:Culture influences the patient's responses to pain.
When a patient is experience an metabolic acidosis this system tries to compensate.
What is respiratory system?
Rationale: In a metabolic problem, the respiratory system compensates.
The nurse is summarizing a patient's condition, progress, prognosis, rehabilitation, and teaching needs. The nurse is doing what kind of documentation?
What is a discharge summary?
Rationale: A complete discharge summary must be completed even if a complete verbal transfer report is given to ensure that all important and specific information is communicated to another healthcare provider when the client is discharged from the hospital.