Pain
Type of pain that is perceived in an area distant from its point of origin
What is referred pain
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.)
A. Home health care
B. Rehabilitation facilities
C. Diagnostic centers
D. Skilled nursing facilities
E. Oncology centers
. A. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Home health care is a type of restorative health care.
B. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Rehabilitation facilities are a type of restorative health care.
D. CORRECT: Restorative health care involves intermediate follow‑up care for restoring health and promoting self‑care. Skilled nursing facilities are a type of restorative health care.
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client?
A. Decreased subcutaneous fat
B. Muscle atrophy
C. Pressure injury
D. Fecal impaction
C. CORRECT: The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr
What can I eat on a clear liquid diet?
apple juice, broth, coffee, popsicle
A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.)
A. Blood spurting from an arterial wound splashes into a nurse’s eye. B. A nurse has a needlestick injury. C. A mosquito bites a hiker in the woods.
D. A nurse finds a hole in their glove while handling a soiled dressing.
E. A person fails to wash their hands after using the bathroom and touches a client.
A. CORRECT: Transmission from blood to the nurse’s eyes, nose, or mouth is person‑to‑person or direct transmission.
E. CORRECT: Transmission from contaminated hands to a client is person‑to‑person or direct transmission.
Type of pain that occurs below amputation. Ex. pt feels pain in right foot when pt has a right BKA. Pain is severe, crushing, burning, stabbing or feeling that limb is swelling.
What is phantom limb pain
A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.)
A. Preferred provider organization (PPO)
B. Medicare
C. Long‑term care insurance
D. Exclusive provider organization (EPO)
E. Medicaid
B. CORRECT: Medicare is federally funded.
E. CORRECT: Medicaid is federally funded.
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.)
A. Instruct the client not to perform the Valsalva maneuver.
B. Apply elastic stockings.
C. Review laboratory values for total protein level.
D. Place pillows under the client’s knees and lower extremities.
E. Assist the client to change positions often.
B. CORRECT: Elastic stockings promote venous return and prevent thrombus formation.
E. CORRECT: Frequent position changes prevents venous stasis.
What can I eat on a full liquid diet?
pudding, pureed vegetables, juice, milk
A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence
B. Malaise
C. Acute confusion
D. Fever
E. Agitation
A. CORRECT: Urinary incontinence is an atypical indication of infection in an older adult client.
B. Malaise is a typical indication of infection.
C. CORRECT: Acute confusion is an atypical indication of infection in an older adult client.
E. CORRECT: Agitation is an atypical indication of infection in an older adult client.
Most commonly used pain scale for 3 years of age to adult. Scale of pain from 1-10
What is Wong Baker Faces
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?
A. Collaborating with providers to perform obesity screenings during routine office visits
B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity
C. Providing specialized intraoperative training in surgical treatments for obesity
D. Educating acute care nurses about postoperative complications related to obesity
A. CORRECT: Identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement?
A. Encourage the client to perform antiembolic exercises every 2 hr.
B. Instruct the client to cough and deep breathe every 4 hr.
C. Restrict the client’s fluid intake. D. Reposition the client every 4 hr.
A. CORRECT: Encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation
What does NPO diet mean?
No food or fluid at all by mouth, not even ice chips, requiring a provider’s prescription before resuming oral intake
A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia?
A. Linear clusters of vesicles on the right shoulder
B. Purulent drainage from both eyes
C. Decreased white blood cell count
D. Report of continued pain following resolution of the rash
D. CORRECT: Pain that persists following resolution of the vesicular rash is an indication of postherpetic neuralgia
Name of medication that reverses effects of opioid overdose
What is Narcan
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
A. Monitoring evidence‑based practice for clients who have a specific diagnosis
B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities
D. Determining whether medications are safe for administration to clients
B. CORRECT: Identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations.
A nurse is evaluating a client’s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding?
A. “This device will keep me from getting sores on my skin.”
B. “This device will keep the blood pumping through my leg.”
C. “With this device on, my leg muscles won’t get weak.”
D. “This device is going to keep my joints in good shape.”
B. CORRECT: Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation.
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take?
A. Give the client thin liquids.
B. Instruct the client to tuck their chin when swallowing.
C. Have the client use a straw.
D. Encourage the client to lie down and rest after meals.
B. CORRECT: Tucking the chin when swallowing allows food to pass down the esophagus more easily
A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin‑resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching?
A. “I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.”
B. “MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.”
C. “I will protect others from exposure when I transport the client outside the room.”
D. “To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.
C. CORRECT: Particularly with infections due to antibiotic-resistant bacteria, protect everyone the client comes in contact with from transmission, especially when outside the isolation room
What is included in a focused pain assessment?
Intensity, frequency, quality, strength, severity and location are of the pain
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.)
A. Intensive care unit
B. Oncology treatment center
C. Burn center
D. Cardiac rehabilitation
E. Home health care
A. CORRECT: Tertiary health care involves the provision of specialized and highly technical care (the care nurses deliver in intensive care units).
B. CORRECT: Tertiary health care involves the provision of specialized and highly technical care (the care nurses deliver in oncology treatment centers).
C. CORRECT: Tertiary health care involves the provision of specialized and highly technical care (the care nurses deliver in burn centers).
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.)
A. Hold the cane on the right side. B. Keep two points of support on the floor.
C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.
A. CORRECT: The client should hold the cane on the uninjured side to provide support for the injured left leg.
B. CORRECT: The client should keep two points of support on the ground at all times for stability.
D. CORRECT: The client should advance the weaker leg first, followed by the stronger leg.
What does Intake and Output mean?
Restrict oral fluid intake (maintaining strict I&O).
What is the most important thing you can do to prevent infection?
Hand washing