Mobility
A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop?
a. Supination
b. Dorsiflexion
c. Hyperextension
d. Abduction
B. Dorsiflexion
What is the priority concern when providing oral hygiene for a patient who is unconscious?
A. Thoroughly brushing all tooth and oral surfaces
B. Preventing aspiration
C. Controlling mouth odor
D. Applying local antiseptic such as chlorhexidine
B. Preventing aspiration
A nurse is assessing a patient’s skin and finds a reddened area that does not blanch with pressure. What stage of pressure ulcer should the nurse suspect?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
A) Stage I
A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the first-pass effect?
A. "Some medications block normal receptor activity regulated by endogenous compounds or receptor activity caused by other medications."
B. "Some medications may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver."
C. "Some medications leave the body more slowly and therefore have a greater risk for medication accumulation and toxicity."
D. "Some medications have a wide safety margin, so there is no need for routine serum medication level monitoring."
B. "Some medications may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver."
A nurse is providing personal hygiene care to an elderly patient with fragile skin. What is the most appropriate action to take to prevent skin damage during bathing?
A) Use a harsh, antibacterial soap to ensure thorough cleaning.
B) Scrub the skin vigorously to remove dead skin cells.
C) Use lukewarm water and a gentle, non-fragrant soap, and pat the skin dry.
D) Bathe the patient less frequently to avoid skin irritation.
C) Use lukewarm water and a gentle, non-fragrant soap, and pat the skin dry.
A nurse working in a long-term care facility uses proper patient-care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?
a. Carefully assessing the patient care environment
b. Using two nurses to lift a patient who cannot assist
c. Wearing a back belt to perform routine duties
d. Properly documenting the patient lift
A. Carefully assessing the patient care environment
You are helping a female patient bathe. As you are about to perform perineal care, the patient says, "I can finish my bath." The patient has discomfort and burning in the perineal area. What action do you need to take initially?
A. Explain to the patient that, because of her symptoms, you need to observe the perineal area.
B. Insist that you are supposed to complete the care.
C. Honor the patient's request to complete her own perineal care to avoid any embarrassment.
D. Ask the patient if a family member can complete the care instead.
A. Explain to the patient that, because of her symptoms, you need to observe the perineal area
A patient has developed a stage III pressure ulcer. Which of the following would be the most appropriate assessment finding for this stage of ulcer?
A) Non-blanchable redness of intact skin
B) Full-thickness tissue loss with exposed bone, tendon, or muscle
C) Partial-thickness loss of dermis presenting as a shallow, open ulcer
D) Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue
D) Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue
A nurse is teaching a patient about the absorption of oral medications. Which statement should the nurse include in the teaching?
A) "The presence of food in the stomach always increases the rate of drug absorption."
B) "The rate of drug absorption can be affected by the drug's formulation and the presence of food in the stomach."
C) "Drugs absorbed through the oral route do not undergo first-pass metabolism."
D) "Oral medications are typically absorbed faster than intravenous medications."
B) "The rate of drug absorption can be affected by the drug's formulation and the presence of food in the stomach."
A nurse is assessing a patient with a spinal cord injury who is at risk for pressure ulcers. What is the most effective nursing intervention to prevent the development of pressure ulcers?
A) Reposition the patient every 2 hours and use pressure-relieving devices.
B) Encourage the patient to drink more fluids to keep the skin hydrated.
C) Apply a topical antibiotic ointment to all bony areas.
D) Use hot compresses on pressure points to increase blood flow.
A) Reposition the patient every 2 hours and use pressure-relieving devices.
Which motion occurs when the angle is reduced between the palm of the hand and forearm?
A. Flexion
B. Dorsiflexion
C. Extension
D. Abduction
A. flexion
While planning morning care, which of the following patients would receive the highest priority to receive his or her bath first?
A. A patient who just returned to the nursing unit from surgery and is experiencing pain at a level of 7 on a scale of 0 to 10
B. A patient who prefers a bath in the evening when his wife visits and can help him
C. A patient who is experiencing frequent incontinent diarrheal stools
D. A patient who has just returned from diagnostic testing and complains of being very fatigued
C. A patient who is experiencing frequent incontinent diarrheal stools
A nurse is evaluating the effectiveness of a wound care regimen for a patient with a venous leg ulcer. What key factor should the nurse monitor to assess the success of the treatment?
A) Decrease in wound size and depth
B) Increase in wound exudate
C) Presence of new scar tissue
D) Frequency of dressing changes
A) Decrease in wound size and depth
A nurse is administering a drug that has a high first-pass effect. Which route of administration would the nurse expect to be least affected by this first-pass effect?
A) Oral
B) Subcutaneous
C) Intravenous
D) Intramuscular
C) Intravenous
A patient with renal impairment is receiving a medication that is primarily excreted through the kidneys. What adjustment should the nurse anticipate in the medication regimen?
A) Increase the dose of the medication to compensate for decreased absorption.
B) Decrease the dose of the medication to avoid toxicity due to reduced excretion.
C) Administer the medication more frequently to enhance effectiveness.
D) Avoid administering the medication altogether due to potential interactions.
B) Decrease the dose of the medication to avoid toxicity due to reduced excretion.
Which stage pressure ulcer would just have partial thickness skin loss involving epidermis and dermis?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
When providing foot care for a client, the nurse would perform which of the following?
A. When washing, inspect the skin of the feet for breaks or red or swollen areas.
B. Does not cover the feet and between the toes with creams or lotions to moisten the area.
C. Does not check the water temperature before immersing the feet.
D. Wash the feet every other day, and dry them well, especially between the toes.
A. When washing, inspect the skin of the feet for breaks or red or swollen areas.
A patient with a diabetic foot ulcer is being advised on foot care. Which statement by the patient indicates a need for further teaching?
A) “I should inspect my feet daily for any cuts or blisters.”
B) “I can use over-the-counter creams to keep my feet moisturized.”
C) “I should avoid walking barefoot, even at home.”
D) “I should trim my toenails straight across to avoid ingrown toenails.”
B) “I can use over-the-counter creams to keep my feet moisturized.”
A nurse is reviewing a client's medical record notes a new prescription for verifying the trough level of the client's medication. Which of the following actions should the nurse take?
A. obtain a blood specimens immediately prior to administering the next dose of medication
B. verify that the client has been taking the med for 24 hr before obtaining a blood specimen
C. ask the client to provide a urine specimen after the dose of medication
D. administer the medication, and obtain a blood specimen 30 min later
A. obtain a blood specimens immediately prior to administering the next dose of medication
A nurse is preparing a patient for surgical debridement of a large, necrotic wound. What is the primary goal of this procedure?
A) To increase blood flow to the wound area
B) To remove all necrotic and non-viable tissue to promote wound healing
C) To apply a topical antimicrobial agent to the wound
D) To provide pain relief before starting wound care
B) To remove all necrotic and non-viable tissue to promote wound healing
Which stage pressure ulcer would require the nurse to measure the extent of undermining?
A. Stage 0
B. Stage I
C. Stage II
D. Stage III
D. Stage III
The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for
impaired skin integrity. What is the rationale for the nurse's action?
a. Inadequate blood flow leads to decreased tissue ischemia.
b. Patients with limited caloric intake develop thicker skin.
c. Pressure reduces circulation to affected tissue.
d. Verbalization of skin care needs is decreased.
c. Pressure reduces circulation to affected tissue.
A patient with a diabetic foot ulcer is instructed to perform regular foot inspections. Which statement indicates that the patient understands the instructions?
A) “I will check my feet for any injuries before going to bed each night.”
B) “I will apply a thick layer of lotion to keep my feet moist every day.”
C) “I will use a heating pad on my feet if they feel cold.”
D) “I will trim my toenails into a rounded shape to prevent ingrown nails.”
A) “I will check my feet for any injuries before going to bed each night.”
A nurse educator is reviewing medication metabolism at an in-service presentation. which of the following factors should the educator include as a reason to administer lower medication dosages (select all that apply)
a. increased renal excretion
b. increased medication-metabolizing enzymes
c. liver failure
d. peripheral vascular disease
e. concurrent use of medication the same pathway metabolizes
c. liver failure
e. concurrent use of medication the same pathway metabolizes
A physician orders 500 mg of a medication to be administered IV. The medication is available in 250 mg per 5 mL. How many milliliters of the medication should the nurse administer?
A) 10 mL
B) 20 mL
C) 25 mL
D) 50 mL
B) 20 mL