Question: A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?

a)

Study the discharge plan.

b)

Check the graphic data for vital signs.

c)

Examine the history and physical examination.

d)

Look for an advance directive.

Answer: ANS: D

The advance directive, which should be located in a special section of the patient’s medical record, should be examined first because the patient’s symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient’s wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient’s current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

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Question: A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?

a)

It involves a cooperative effort among various disciplines.

b)

The system requires diligence in maintaining a current problem list.

c)

Data may be fragmented and scattered throughout the chart.

d)

It allows the nurse to provide information in an unorganized manner.

Answer: ANS: C

A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

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Question: A student nurse makes the following comments to her preceptor: “I love getting information from the chart. Everything related to the patient’s problem is together and addressed by various members of the healthcare team.” The student nurse has been introduced to which type of charting system?

a)

Narrative

b)

Focus

c)

Source oriented

d)

Problem oriented

Answer: ANS: D

Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. Focus charting highlights the patient’s concerns, problems, and strengths in a three-column format. Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. A problem-oriented record system is organized around the patient’s problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient’s progress and integrate the interdisciplinary perspective.

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Question: The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it:

a)

Increases the time nurses spend on charting in narrative format

b)

Does not clearly identify deviations from normal expectations

c)

Requires all providers to document in the same sections of the chart

d)

Can increase the risk of omissions in patient care

Answer: ANS: D

A major disadvantage of CBE is that it can result in omissions in documenting client care because of either varying views of what is abnormal or deviations. Another disadvantage is that is does not capture the application of critical thinking by the nurse in the provision of care. CBE reduces the amount of time spent in charting because if nurses document only deviations from the normal CBE, then it is assumed that unless a separate entry is made, all standards have been met with a normal response.

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Question: Which prescription below is not consistent with the standards established by The Joint Commission?

a)

Administer Lasix 20 mg PO daily at 1000.

b)

Administer Lasix 10.0 mg PO daily at 1000.

c)

Administer digoxin 10 mg PO daily at 1000.

d)

Administer digoxin 0.3 mg IV daily at 1000.

Answer: ANS: B

The Joint Commission recommends that certain words are written out instead of using symbols and abbreviations to minimize the risk of medication errors. The trailing zero should not be used in medication prescriptions; thus, 10.0 mg is incorrect. It should be correctly written as 10 mg. The word daily should be used in place of qd or q.d., as is done in all the options. The Joint Commission does not support the lack of a leading zero; thus, 0.3 mg is correctly written.

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Question: A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement?

a)

Hypertension

b)

Rheumatoid arthritis

c)

Postoperative colon resection

d)

Follow all three plans

Answer: ANS: C

The postoperative colon resection integrated plan of care should be followed; however, modifications should be made to meet the patient’s other health needs. Therefore, portions of the hypertension and rheumatoid arthritis integrated plan of care may be added to the postoperative colon resection plan of care, or individualized nursing diagnoses and interventions may be integrated into the plan.

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Question: 7. The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order?

a)

09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN

b)

09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN

c)

09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN

d)

09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

Answer: ANS: B

Correct documentation of a telephone order is as follows: “09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN” (date, time, medication, route, frequency of dose, circumstances under which it is to be given, prescriber’s name and title, nurses name and title.) The other options demonstrate incomplete documentation of a telephone order.

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Question: A patient refuses a dose of medication. How should the nurse document the event?

a)

Patient is uncooperative and refuses the prescribed dose of digoxin.

b)

Patient refuses the 0900 dose of digoxin.

c)

Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin.

d)

0900 dose of digoxin not given.

Answer: ANS: B

“Patient refuses the 0900 dose of digoxin” objectively describes the event in which the patient refuses to take his 0900 dose of digoxin. “0900 dose of digoxin not given,” provides no explanation why the medication was not given. The other two options offer judgmental information, which should be avoided when charting.

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Question: At 1000 on 11/14/16, the nurse takes a telephone prescription for “metoprolol 5 mg intravenously now.” What is the latest date and time the nurse will expect the prescriber to countersign the order?

a)

11/14/16 at 1200

b)

11/14/16 at 2200

c)

11/15/16 at 1000

d)

11/16/16 at 1000

Answer: ANS: C

The prescriber must countersign all verbal and telephone orders within 24 hours.

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Question: The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order?

a)

Repeat the order to the prescriber even if she believes she understood the order correctly.

b)

Immediately notify the pharmacy of the order and verify it with a pharmacist.

c)

Ask the unit secretary to listen to the prescriber on the phone to verify the order.

d)

Transcribe the order on notepaper and verify the dosage in a drug handbook.

Answer: ANS: A

The nurse should repeat the order to the prescriber even if she believes she understood it entirely. If possible, she should have a second nurse (not the unit secretary) listen to the order to verify accuracy. Only the prescribing provider, not the pharmacist, can verify the order. The nurse should transcribe the order directly on the patient’s chart. Transcribing it on a piece of paper and then copying it again introduces one more chance of error.

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Question: A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds. How often must the nurse document this resident’s care?

a)

Every 2 weeks

b)

Every shift

c)

Every week

d)

Every 3 months

Answer: ANS: D

The Minimum Data Set for Resident Assessment and Care Screening (MDS) must be updated every 3 months, unless there is a significant change in the resident’s condition.

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Question: What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility?

a)

14 days

b)

3 days

c)

2 days

d)

24 hours

Answer: ANS: A

Federal regulations require that a resident be evaluated using the Minimum Data Set within 14 days of admission to a long-term care facility.

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Question: A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of:

a)

The Minimum Data Set (MDS) for assessment

b)

Situation-Background-Assessment-Recommendation (SBAR) for reporting

c)

Health Care Financing Administration guidelines prior to surgery

d)

The Joint Commission guidelines for discharge planning

Answer: ANS: A

Federal regulations require that a resident be evaluated using the Minimum Data Set (MDS) within 14 days of admission to a long-term care facility. SBAR is a technique used for communicating and organizing a handoff report. HCFA guidelines govern home healthcare documentation. Joint Commission guidelines do apply to long-term care facilities. However, only the MDS assessment is mandated by federal law.

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Question: The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon’s order? The nurse:

a)

Performs oral care

b)

Assists the patient out of bed

c)

Assists the patient with bathing

d)

Changes the patient’s operative dressings

Answer: ANS: B

OOB is the abbreviation for “out of bed.” The nurse is following the physician’s order when she assists the patient out of bed in the morning. OOB does not indicate that the nurse should perform oral care, assist with bathing, or change the patient’s postoperative dressings.

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Question: Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? “When taking off the provider’s orders, you should:

a)

Write drug names in full—rather than using abbreviations”

b)

Use apothecary units—instead of metric units”

c)

Write ‘at’ or ‘each’—rather than use the ‘@’symbol”

d)

Write ‘mL’ or ‘milliliters’—in place of the ‘cc’ abbreviation”

Answer: ANS: B

The student nurse should question the instruction to use apothecary units—instead of metric units. Nurses are encouraged to use metric units instead of the rarely used apothecary system.

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Question: The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports?

a)

“Occurrence reports track problems and identify areas for quality improvement.”

b)

“Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors.”

c)

“The Joint Commission requires occurrence reports for all client falls.”

d)

“Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence.”

Answer: ANS: A

Occurrence reports are used to track problems and identify areas for quality improvement. Occurrence reports are not used to provide legal information should a patient seek legal action. As an internal communication and documentation tool, occurrence reports are not required to be reported to the FDA or The Joint Commission.

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Question: Which of the following is the most beneficial aspect of electronic documentation systems?

a)

Assist collaboration

b)

Provide cautionary reminders

c)

Improve legibility

d)

Serve as a resource

Answer: ANS: C

One of the most beneficial aspects of electronic documentation systems is its ability to improve legibility, which reduces the risk for medication administration and other errors. Electronic documentation systems also assist collaboration, provide cautionary reminders about possible adverse reactions, and serve as a resource; but these are not the most beneficial aspects.

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Question: The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall.

a)

Patient found on floor after falling out of bed and verbalizes (L) hip pain.

b)

Patient found on floor by NAP Smith and verbalizing (L) hip pain.

c)

Patient fell out of bed but is currently in bed.

d)

Patient reminded not to climb OOB after falling.

Answer: ANS: B

Charting must be accurate and succinct. Only chart what you observe. Do not chart what others have observed as your own observation. Avoid judging patients; instead, chart objectively.

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Question: Which set of topics makes up a handoff report given in a recommended format?

a)

Data-action-response (DAR)

b)

Subjective-objective-assessment-plan (SOAP)

c)

Situation-background-assessment-recommendation (SBAR)

d)

Patient-diagnosis-medications-activity

Answer: ANS: C

The SBAR technique is used as a mechanism to give a handoff report by enabling a focused communication between healthcare team members. DAR is used in Focus Charting®, SOAP is a method for documenting nursing care. The nursing admission assessment is completed and documented at the time of admission.

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Question: What is one advantage of problem-intervention-evaluation (PIE) charting?

a)

Focuses on a complete list of client problems

b)

Assesses the client in a comprehensive manner

c)

Documents the planning portion of the client’s care

d)

Establishes an ongoing plan of care for the client

Answer: ANS: D

The PIE charting format organizes information by the client’s problems and requires a daily assessment record and progress notes, thus eliminating the need for a nursing care plan. It documents, in a comprehensive manner, the client information. It does not assess the client.

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Question: A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. This type of charting is a form of:

a)

Narrative charting

b)

Charting by inclusion

c)

Charting by exception

d)

Source oriented charting

Answer: ANS: C

Charting by exception is a system of charting where only exceptions to the normal findings or to the unit standards are charted. These are directed by organizational, professional, and legal guidelines. Narrative charting records all findings, normal and abnormal. Charting by inclusion is not discussed in the text. Source-oriented charting refers to each healthcare practitioner’s charting in a specific section of the chart. For example, nurses would document in the nurses’ notes section and physicians would document in the physician section of the healthcare record.

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Question: At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym “CUBAN,” does which of the following?

a)

Ensures that the nurse is able to finish the shift as quickly as possible

b)

Provides a guide for the nurse’s report to the oncoming nurse

c)

Requires the nurses to engage in walking rounds for the report

d)

Provides a detailed cultural report for Latino patients

Answer: ANS: B

The CUBAN acronym is used in all types of report formats and stands for Confidential, Uninterrupted, Brief, Accurate, Named nurse. Following this format, the nurse giving report has a guide to remember the important data that need to be shared with the oncoming nurse who will care for the patient. Report should not be rushed in order for a nurse to finish the shift as quickly as possible. However, the nurse should try to begin report before the shift is over, early enough to complete report before the next shift begins. The CUBAN approach does not require walking rounds. The CUBAN acronym can be used for report about any patient regardless of race, ethnicity, or religion and does not necessarily provide cultural information. It is not specific to Latino patients.

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Question: The instructor is teaching the nursing students about electronic health records (EHR). Which student statement indicates the need for further instruction?

a)

“I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it.”

b)

“The EHR integrates the patient’s health information documented by the entire healthcare team into one electronic system.”

c)

“The EHR can track problems and errors, which can direct quality improvement efforts in a given institution.”

d)

“I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution.”

Answer: ANS: D

The EHR can vary according to institution and is employed through integrative technology for the entry of data from all healthcare professionals. Although a student knows how to use a computer, this knowledge may not directly translate so that the student is able to accurately document in any particular institution. A person needs to be taught the specifics of each system. A student who understands that even though the system has been taught to him also knows that the instructor will be a resource for EHR questions that may arise. The EHR generally integrates information to be used by the healthcare team. Data can be collected and analyzed multiple ways to evaluate and improve patient care.

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Question: A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. Here bid means:

a)

Once every day

b)

Two times every day

c)

Three times every day

d)

Four times a day

Answer: ANS: B

Bid is the abbreviation for twice a day, which is generally 12 hours between doses. Once a day is written as “daily”: every hour is abbreviated qh, three times a day is tid and four times a day is qid. Abbreviations are used with caution to reduce error(s) by the nurse and the healthcare teams. The abbreviation qd is not used for once a day, but is written as “daily.”

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Question: Why might a healthcare provider choose narrative charting instead of using forms or checklists?

a)

Narrative charting tracks the client’s changing health status as it occurs.

b)

Free form documentation is inconsistent among healthcare providers.

c)

Less charting time by healthcare provider is needed for narrative charting.

d)

Less interdisciplinary discussion occurs with the narrative style of charting.

Answer: ANS: A

A narrative chart entry tells the story of the patient’s experience as it occurs in a chronological format with the goal to track a client’s changing medical and health status. It also documents progress toward goals for the client. Disadvantages to narrative charting include the following: inconsistency among healthcare providers and the manner in which they document using narrative charting; longer time spent in documenting client progress; and a decrease in interdisciplinary discussion of client progress owing to lengthy and redundant documentation by healthcare team members.

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Question: Which statement(s) by the student nurse indicates an understanding of the nursing Kardex? Select all that apply.

a)

“It pulls data from multiple areas of the patient’s chart.”

b)

“It is usually kept at the patient’s bedside.”

c)

“It is used to document patient response to interventions.”

d)

“It summarizes the plan of care and guides nursing care.”

Answer: ANS: A, D

The Kardex is a tool that pulls data from multiple areas of the patient’s health record and helps guide nursing care. Responses to interventions are documented on flowsheets and in nurses’ notes. Kardexes are paper forms that are kept together in a portable file at the nurses’ station to allow all team members access to the summary information. The file is portable, so it could be carried to the bedside briefly; however, it is not stored there as a general rule.

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Question: Which action by the nurse breaches patient confidentiality? Select all that apply.

a)

Leaving patient data displayed on a computer screen where others may view it

b)

Remaining logged on to the computer system after documenting patient care

c)

Faxing a patient report to the nurses’ station where the patient is being transferred

d)

Informing the nurse manager of a change in the patient’s condition

Answer: ANS: A, B

Leaving patient data displayed on a computer screen where others may view them breaches patient confidentiality. The nurse should log off the computer immediately after use. Faxing a report to the nurses’ station receiving a patient does not breach patient confidentiality because it is located at the nurses’ station out of others’ view. Anyone directly involved in the patient’s care has the right to know about the patient’s condition without breaching patient confidentiality.

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Question: Which statement(s) by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply.

a)

“I can wait until the end of the shift to document my care.”

b)

“Charting every 2 hours is the most appropriate way to document nursing care.”

c)

“I find it easier to chart before I go to lunch, and then after my shift report.”

d)

“I should chart as soon as possible after nursing care is given.”

Answer: ANS: A, B, D

Documentation should be performed as soon as possible after the nurse makes an assessment or provides care. The longer the nurse waits, the less accurate the documentation will be. Leaving documentation until the end of the shift may cause important details to be omitted or mistaken. It is not necessary to complete documentation on a strict schedule, such as every 2 to 4 hours. Even waiting until lunch or report after the shift is over is too long a period of time for accurate documentation. In addition, the objectivity of documentation might be influenced by the discussion that occurs during report.

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Question: 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

Answer: ANS: A, B, D

The implementation of electronic health records (EHR) has many advantages for the nurse. These include 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. EHR does not impair interdisciplinary collaboration; rather, EHR fosters communication and collaboration among healthcare team members.

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Question: In performing a handoff report, the nurse should communicate information on which of the following?

Select all that apply.

a)

Teaching performed

b)

Any change in client status

c)

Treatments administered

d)

Hygiene measures performed

Answer: ANS: A, B, C

Handoff reports include any client teaching done, therapies and treatments administered, and changes in the client’s status. Hygiene care is routinely done in inpatient settings and is usually recorded on a flowsheet. Handoff reports should be succinct and not contain routine information.

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Question: Knowing that discharge summary information is integral to the client’s ongoing care, which of the point(s) regarding discharge summaries must the nurse be aware? Select all that apply.

a)

The discharge summary is important because many clients require follow-up care.

b)

A complete discharge summary is a guide for healthcare professionals in the community.

c)

The nurse can give a verbal transfer report, which is the same as a discharge summary.

d)

The discharge summary is the final note in the client’s health record

e)

A complete discharge summary must be handwritten using the narrative note format.

Answer: ANS: A, B, D

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. It is important for every client for ongoing care and documentation while the client is in the community. A verbal transfer report is not a replacement for the comprehensive discharge record; it can be done in the EMR formats, a narrative note, or on a discharge summary form.

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Question: The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient’s laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient’s buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply.

a)

Notify the prescriber before giving the medication.

b)

Give subcutaneous heparin as ordered.

c)

Hold the medication dose at this time.

d)

Chart the reason the medication was not given.

e)

Assess for other significant signs and symptoms.

f)

Record abnormal findings in the patient’s health record.

Answer: ANS: C, D, E, F

Heparin, an anticoagulant, should be given to achieve one and a half to two times the normal clotting times and PTT. Because the findings of the laboratory values are four times the normal range and petechiae are present, this indicates a significant risk for bleeding. Therefore, the heparin should be held; the physician should be notified immediately. The nurse must document why the medication was not given and should assess for other significant findings. Omitted or delayed administration must be charted as soon as possible with an explanation for the delay or omission. The nurse will notify the provider but not give the medication. Heparin is given via a subcutaneous injection; however, because it is being held, it will not be administered or documented as “given.” Because the findings regarding the heparin and its use are abnormal, the nurse would not document normal findings.

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Question: The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply.

a)

Increases the potential for breaches in confidentiality

b)

Decreases the time spent to complete documentation

c)

Minimizes medical errors through use of alert systems

d)

Communicates the client’s plan of care to the healthcare team

Answer: ANS: B, C, D

The EHR streamlines many documentation steps, making written communication concise and standardized. Electronic access to the patient’s health record increases confidentiality and security of information by using customized passwords for each healthcare professional to limit access to the records. Time for documentation is decreased as the nurse becomes more comfortable using electronic documentation. Medical errors are decreased owing to programmed alerts that are automatically displayed when a healthcare provider takes an action that could potentially be harmful to the client. The EHR facilitates communication of client care across the healthcare team because all of the information is in one place and multiple people can access it from different computers at the same time.

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Question: The nurse administered the narcotic Demerol, 50 mg PO at 1400 to a patient with pain rated as 9 on a 0 to 10 scale. At 1430, the patient stated that the medication was not working and requested to have morphine IV, which the provider had prescribed for severe pain. What is the nurse’s best evaluation of this situation?

a)

The patient needs to understand that it takes time for the medication to reduce pain.

b)

Administering Demerol PO was not the best nursing intervention in this situation.

c)

The provider should be notified if the patient’s pain is not relieved in 2 hours.

d)

Demerol PO was the best intervention because morphine IV can cause drug addiction.

Answer: ANS: B

Administering Demerol PO was not the best nursing intervention in this situation because the patient was in severe pain (9/10). The patient needed immediate pain relief, which would not occur with PO pain medication. The nurse should have been administered morphine IV. Waiting 2 hours to notify the physician does not provide patient comfort. The nurse should focus on pain relief and not worry about the patient becoming “addicted” to the morphine.

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Question: An insulin-dependent diabetic patient tells the nurse that she has been giving herself injections in the same location in her right thigh for the past several months because it is easier. What is the nurse’s best action?

a)

Provide patient teaching on rotating injection sites.

b)

Assess the patient for cumulative effects.

c)

Check the type of insulin the patient receives to ensure that it is compatible with the vastus lateralis site.

d)

Document the patient’s comments, as the patient understands the treatment regimen.

Answer: ANS: A

Administering medications in the same site over prolonged periods of time can cause fat deposits and skin lumps, which will interfere with absorption and thus hinder the effectiveness of the medication. Insulin is administered subcutaneously, not intramuscularly. The patient should be taught to rotate injection sites.

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Question: A surgeon prescribes heparin 2,500 mEq IM q 12 hr. What is the nurse’s best action?

a)

Administer the medication as prescribed.

b)

Clarify the medication dose with the surgeon.

c)

Administer the medication subcutaneously.

d)

Clarify the dose and route with the surgeon.

Answer: ANS: D

The nurse should contact the surgeon to clarify the dosage and route of administration. Heparin is measured in units and administered either subcutaneously or intravenously. The nurse should contact the provider who prescribed the medications.

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Question: A patient is having pain and has requested a dose of analgesic medication. The medication administration record indicates that he prescribed the narcotics hydromorphone (Dilaudid) intramuscularly and morphine sulfate intravenously. Where should the nurse first assess to determine which medication to administer?

a)

The patency of the IV site

b)

Which drug the patient prefers

c)

The patient’s pain level

d)

Skin integrity of the dorsogluteal site

Answer: ANS: C

The nurse should check the patient’s pain level. If the pain is severe, the nurse should administer IV morphine to provide the patient immediate relief. The dorsogluteal site for IM injections should be avoided.

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Question: Which term refers to the movement of a drug from the site of administration to the bloodstream?

a)

Absorption

b)

Distribution

c)

Metabolism

d)

Excretion

Answer: ANS: A

Absorption refers to the movement of drug from the site of administration into the bloodstream. Distribution involves the transport of the drug in body fluids, such as blood, to the tissues and organs. Metabolism is the biotransformation of the drug into a more water-soluble form or into metabolites that can be excreted from the body. Excretion, or the removal of drugs from the body, takes place in the kidneys, liver and gastrointestinal tract, lungs, and exocrine glands.

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Question: A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in his medication administration record will offer him the fastest relief?

a)

Liquid acetaminophen with codeine

b)

Intravenous morphine sulfate

c)

Intramuscular meperidine

d)

Oral oxycodone tablets

Answer: ANS: B

Drugs administered by the intravenous route are injected directly into the bloodstream and do not have to be absorbed into it. Therefore, they act more quickly than drugs administered by the oral or intramuscular routes.

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Question: A nurse is being investigated for stealing narcotics from several patients. Which federal agency can become involved in the investigation of this incident?

a)

State Board of Nursing

b)

U.S. Food and Drug Administration

c)

U.S. Drug Compliance Department

d)

U.S. Drug Enforcement Agency

Answer: ANS: D

The U.S. Drug Enforcement Agency (DEA) can investigate diversion and theft of controlled substances. The State Board of Nursing is not a federal agency and is only empowered to discipline a nurse’s license. The U.S. Food and Drug Administration regulates the testing, sale, and manufacture of drugs.

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Question: A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug?

a)

0930

b)

1000

c)

1100

d)

1500

Answer: ANS: D

The nurse should no longer see the effects of furosemide at around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak effect (diuresis) should occur in 1 to 2 hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario.

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Question: Which factor in a patient’s medical history is most likely to prolong the half-life of certain drugs?

a)

Heart disease

b)

Liver disease

c)

Rheumatoid arthritis

d)

Tobacco use

Answer: ANS: B

Metabolism takes place largely in the liver. If there is a decrease in liver function (e.g., because of liver disease), the drug will be eliminated more slowly, prolonging the drug’s half-life. Tobacco use can increase the elimination of some drugs, decreasing their effectiveness.

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Question: The nurse receives a laboratory report that states her patient’s digoxin level is 1.2 mg/mL; therapeutic range for this drug is 0.5 to 2.0 mg/mL. Which action should the nurse take?

a)

Notify the prescriber to reduce the dose.

b)

Withhold the next dose of digoxin.

c)

Administer the next dose as prescribed.

d)

Notify the prescribing healthcare provider to increase the dose.

Answer: ANS: C

Therapeutic range is a range whereby the medication is at a concentration to produce the desired effect. This patient’s level is within the therapeutic range, so the nurse should administer the next dose as prescribed. The dose should not be increased or decreased because the prescribed dose is producing a level within the therapeutic range. The dose should not be withheld; this action could result in detrimental cardiac effects for the patient.

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Question: The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough?

a)

With the morning routine laboratory studies

b)

Approximately 30 minutes before the next dose

c)

Two hours after the next dose infuses

d)

While the drug is infusing

Answer: ANS: B

Trough levels are typically obtained approximately 30 minutes before administering the next dose of the drug. Therefore, the trough cannot be collected with the morning routine laboratory studies. The vancomycin peak should be obtained 2 hours after the next dose infuses. Peak level must be measured when absorption is complete. This depends on all the factors that affect absorption. Trough levels would be inaccurate if the specimen is obtained while the drug infuses.

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Question: Teratogenic drugs should be avoided in which patient population?

a)

Pregnant women

b)

Elderly

c)

Children

d)

Adolescents

Answer: ANS: A

Drugs that are known to cause developmental defects are termed teratogenic. These drugs are contraindicated during pregnancy because of the likelihood of adverse effects in the embryo or fetus.

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Question: A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed?

a)

Supportive

b)

Restorative

c)

Substitutive

d)

Palliative

Answer: ANS: D

Morphine is prescribed for its palliative effects—to relieve pain, a symptom of cancer. Supportive effects support the integrity of body functions until other medications or treatments become effective. Restorative effects return the body to or maintain the body at optimal levels of health. Substitutive effects replace either body fluids or a chemical required by the body for improved functioning.

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Question: After receiving diphenhydramine, a patient complains that his mouth is very dry. This is not uncommon for patients taking this medication. Which drug effect is this patient experiencing?

a)

Side effect

b)

Adverse reaction

c)

Toxic reaction

d)

Supportive effect

Answer: ANS: A

Dry mouth is a side effect of diphenhydramine. Side effects are unintended, often predictable, physiological effects that are well tolerated by patients. Adverse reactions are harmful, unintended, usually unexpected reactions to a drug administered at a normal dosage. They are commonly more severe than are side effects. Toxic reactions are dangerous, damaging effects to an organ or tissue. Supportive effects are intended effects that support the integrity of body functions.

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Question: While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first?

a)

Administer epinephrine IM.

b)

Give bolus dose of intravenous fluids.

c)

Stop the infusion of medication.

d)

Prepare for endotracheal intubation.

Answer: ANS: C

The patient is experiencing an anaphylactic reaction (severe shortness of breath, wheezing, and severe hypotension), a life-threatening allergic reaction. Therefore, the nurse should immediately discontinue the medication. The first priority is to eliminate the cause of the problem. Next, the nurse should notify the physician, give IV fluids, and administer epinephrine, steroids, and diphenhydramine. Respiratory support ranging from oxygen administration to endotracheal intubation and mechanical ventilation may also be necessary.

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Question: A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing?

a)

Mild adverse reaction

b)

Dose-related adverse reaction

c)

Toxic reaction

d)

Anaphylactic reaction

Answer: ANS: A

Urticaria and pruritus are considered minor adverse reactions. Dose-related adverse reactions are undesired effects that result from known pharmacological effects of the medication. Toxic reactions are dangerous, damaging effects to an organ or tissue. Anaphylactic reaction is a life-threatening allergic reaction that occurs during or immediately after administration.

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Question: Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended period of time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect?

a)

Antagonistic drug interaction

b)

Synergistic drug interaction

c)

Idiosyncratic reaction

d)

Drug incompatibility

Answer: ANS: A

In an antagonistic drug interaction, one drug interferes with the actions of another and decreases the resultant drug effect. In a synergistic drug interaction, there is an additive effect; that is, the effects of both drugs combined are greater than the individual effects. An idiosyncratic reaction is an unexpected, abnormal, or peculiar response to a medication. Drug incompatibilities occur when drugs are physically mixed together, causing a chemical deterioration of one or both drugs.

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Question: A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug:

a)

Abuse

b)

Misuse

c)

Tolerance

d)

Dependence

Answer: ANS: C

Patients in the terminal stages of cancer commonly exhibit drug tolerance, a decreasing response to repeated doses of a medication. Therefore, pain management must be carefully planned to promote patient comfort. Drug abuse is the inappropriate intake of a substance continually or periodically. Drug misuse is the nonspecific, indiscriminate, or improper use of drugs, including alcohol, over-the-counter preparations, and prescription drugs. Drug dependence occurs when a person relies on or needs a drug. Dependence leads to lifestyle changes that focus on obtaining and administering the drug.

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Question: Before administering a medication, the nurse must verify the six rights of medication administration, which include:

a)

Right patient, right room, right drug, right route, right dose, and right time

b)

Right drug, right dose, right route, right time, right physician, and right documentation

c)

Right patient, right drug, right route, right time, right documentation, and right equipment

d)

Right patient, right drug, right dose, right route, right time, and right documentation

Answer: ANS: D

The six rights of medication administration are the right patient, right drug, right dose, right route, right time, and right documentation.

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Question: Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen?

a)

After an explanation and written materials, describes the expected actions and adverse reactions of his medication

b)

In 1 week after instructional session, describes the expected actions and adverse reactions of his medications

c)

Follows the treatment plan as prescribed

d)

Experiences no adverse effect from his prescribed treatment plan

Answer: ANS: B

The best phrasing for the expected outcome is the one with a specific, measurable time frame (1 week) and details for how to resolve the patient’s knowledge deficit. The other options provide no time line for achieving the goal and, therefore, are not measurable. Expected outcome statements must be measureable.

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Question: When the nurse enters a patient’s room to administer a medication, he calls out from the bathroom, telling her to leave his medication on the bedside table. He reassures her that he will take the medication as soon as he is finished. How should the nurse proceed?

a)

Inform the patient that she will return when he is finished in the bathroom.

b)

Wait outside the bathroom door until the patient is ready for the dose.

c)

Withhold the dose until the next administration time later in the day.

d)

Document that the dose was omitted in the medication administration record.

Answer: ANS: A

The nurse should inform the patient that she will return with the medication when he is finished in the bathroom. The nurse likely would not have time to stand outside the door and wait for the patient to finish in the bathroom. If the medication is left at the bedside for the patient, the nurse cannot be sure that the patient actually took the medication. Withholding the dose until the next administration time may compromise the patient’s condition and is not appropriate nursing action. The drug should not be omitted; therefore, the nurse should not document a missed dose in the medication administration record.

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Question: Which documentation entry related to prn medication administration is complete?

a)

6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN

b)

0600 famotidine 20 mg IV given in right hand, S. Abraham RN

c)

9/2/14 0900 levothyroxine 50 mcg PO given

d)

1/16/14 furosemide 40 mg PO given, J. Smith RN

Answer: ANS: A

The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, the route of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a prn order, the nurse also included the reason the medication was administered. Other options are incomplete.

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Question: A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications?

a)

Request that the physician change the order to the IV route.

b)

Administer the medication by the IM route.

c)

Use a needleless syringe to place the medication in the side of the mouth.

d)

Add the dose to a small amount of food or beverage to facilitate swallowing.

Answer: ANS: C

When a patient has difficulty taking liquid medications from a cup, the nurse should use a syringe without a needle to place the medication in the side of the patient’s mouth. After placing the syringe between the gum and cheek, the nurse should push the plunger to administer the medication slowly. It is not necessary to ask the prescriber to change the order to the IV route; it is preferable to use the least invasive route. The nurse cannot administer a drug by another route without a prescription to do so. Dosing might not necessarily be the same in the oral versus the IM route; thus, a prescription is needed to change the route. Some drugs are not compatible with various food or liquid substances and should be taken on an empty stomach. Consult a pharmacist, prescriber, or drug formulary.

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Question: The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug?

a)

Place the drug in the cheek and allow it to dissolve.

b)

Place the drug under the tongue and allow it to dissolve.

c)

Inject the drug superficially into the subcutaneous tissue.

d)

Give the pill and water to the patient for him to swallow the tablet.

Answer: ANS: B

Drugs administered by the sublingual (SL) route should be placed under the patient’s tongue and allowed to dissolve. Drugs administered by the buccal route are placed in the cheek and allowed to dissolve. A subcutaneous injection is administered into the subcutaneous tissue. Placing the drug into the patient’s mouth, giving him water, and instructing him to swallow the tablet describe oral administration.

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Question: Which action should the nurse take immediately after administering a medication through a nasogastric tube?

a)

Verify correct nasogastric tube placement in the stomach.

b)

Auscultate the abdomen for presence of bowel sounds.

c)

Immediately administer the next prescribed medication.

d)

Flush the tube with water using a needleless syringe.

Answer: ANS: D

The nurse should flush the nasogastric tube with water using a needleless syringe after administering each medication. Some medications are less effective when given in combination with others. The nurse should verify nasogastric tube placement and auscultate the abdomen for bowel sounds before administering the medication.

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Question: How should the nurse dispose of a contaminated needle after administering an injection?

a)

Place the needle in a specially marked, puncture-proof container.

b)

Recap the needle, and carefully place it in the trashcan.

c)

Recap the needle, and place it in a puncture-proof container.

d)

Place the needle in a biohazard bag with other contaminated supplies.

Answer: ANS: A

To avoid needlestick injuries, the nurse should place the uncapped needle, pointing downward, directly into a specially marked, puncture-proof container. Recapping the needle should only be done when no other feasible alternative is available. When recapping is necessary, use an acceptable technique such as the one-handed scoop technique in which the nurse places the needle cap on a sterile surface and, using one hand, scoops up the cap with the needle. Placing the needle in an improper container (biohazard bag) that could be punctured by the contaminated needle places other staff members at risk.

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Question: The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant born to an HB Ag-positive mother. Which injection site should the nurse choose to administer this injection?

a)

Ventrogluteal

b)

Vastus lateralis

c)

Deltoid

d)

Dorsogluteal

Answer: ANS: B

The preferred site for IM injections for infants who are not yet walking is the vastus lateralis muscle because there are no major blood vessels or nerves in the area and the gluteal muscles have not been developed by walking. For children who are walking, the site of choice is the ventrogluteal muscle. The dorsogluteal site is not recommended for children or adults. The deltoid muscle can be used for small volumes in older children and adults.

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Question: Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site?

a)

Apply a warm compress.

b)

Massage the site in a circular motion.

c)

Apply a soothing lotion.

d)

Have the client assume a sitting position.

Answer: ANS: D

To relax the vastus lateralis for injection, the nurse should have the patient assume a sitting position or lie flat with his knee slightly flexed. Applying a warm compress, massaging the site, and applying soothing lotion are inappropriate interventions before administering an IM injection. After injection, massaging the site can enhance the absorption of medication into the muscle. Applying a warm compress increases circulation to the site, which can also enhance absorption. This action would be performed after the injection and not before.

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Question: The physician prescribes warfarin 5 mg orally at 1800 for a patient. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?

a)

No action is necessary because an extra 5 mg of warfarin is not harmful.

b)

Call the prescriber and ask her to change the order to 10 mg.

c)

Document on the chart that the drug was given and indicate the drug was given in error.

d)

Complete an incident report according to the facility’s policy.

Answer: ANS: D

When a medication error is made, the nurse should first check the patient to assess for negative effects. If she is unfamiliar with the side effects of the medication, she should consult a drug reference, the licensed pharmacist at the institution, or the prescriber. Next, she should verify that she made an error and identify the type. Notify the nurse in charge and the physician. Follow any orders the physician prescribes. Document the drug, the dose, site, route, date, and time in the patient’s healthcare record but do not document that the drug was given in error. Complete an incident report according to the facility’s policy; submit the signed report to the nurse manager. Finally, critically review the error, and identify ways to improve your practice.

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Question: The nurse must administer ear drops to an infant. How should she proceed?

a)

Pull the pinna down and back before instilling the drops.

b)

Pull the pinna upward and outward before instilling the drops.

c)

Instill the drops directly; no special positioning is necessary.

d)

Position the patient supine with the head of the bed elevated 30°.

Answer: ANS: A

For a child younger than 3 years old, the nurse should pull the pinna down and back. For older children and adults, the nurse should pull the pinna upward and outward. Doing each straightens the ear canal for proper channeling of the medication. The patient should be assisted into a side-lying position with appropriate ear facing up before instillation.

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Question: The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance?

a)

Crush time-release capsules to put in his favorite food.

b)

Give medication quickly before he knows what is happening.

c)

Allow the child to eat a frozen pop before receiving the medication.

d)

Mask the flavor of medication in a toddler cup with orange juice.

Answer: ANS: C

The parent can give the child a frozen fruit bar or frozen flavored ice pop just before the medication. This helps to numb the taste buds to weaken the taste of the medication.

To mask bad-tasting medicines, parents can crush pills or empty the contents of a capsule as long as it is not a time-release dose and mix with soft foods, such as applesauce, hot cereal, or pudding. This is helpful for patients who might aspirate liquids, as well.

If the child is old enough to understand, warn him when a medication has an objectionable taste. Otherwise, his trust might be compromised if he is surprised with a bad taste.

Do not use essential foods in the child’s diet (e.g., milk or orange juice) to mask the taste of medications. The child may later refuse a food that he associates with the medicine.

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Question: An adult patient admitted with lower gastrointestinal bleeding is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product?

a)

18 gauge

b)

22 gauge

c)

24 gauge

d)

26 gauge

Answer: ANS: A

Large-gauge needles, 14 to 18 gauge, are used for blood products in adults because the bore is large enough to allow transfusion without cell damage (lysis). Smaller-gauge bores can cause clumping and breakage of the cell, thus leading to reduced effectiveness of the transfusion as well as contributing to fragmented by-product of red blood cell waste.

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Question: What is the most essential action by the nurse prior to delegating the administration of an intravenous (IV) medication to a licensed practical nurse (LPN)?

a)

Review the state’s nurse practice act for LPN scope of practice.

b)

Review the unit policy and procedure for IV medication administration.

c)

Determine whether the LPN has previously performed this procedure.

d)

Demonstrate the procedure; then allow the LPN to administer the IV medication.

Answer: ANS: A

The State Board of Nursing regulates the types and routes of medications that can be administered by the various levels of nurses. For example, LPNs in some states cannot administer IV medications, whereas other states require additional education and experience before LPNs can perform this action. The nurse must refer to her state’s nurse practice act for the scope of practice. Once scope of practice is identified, the nurse can proceed with reviewing the unit policies and assessing the experience level of the LPN. If state regulations do not allow LPNs to administer IV medications, there is no reason for the nurse to proceed with the other actions.

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Question: Which body organ is mostly responsible for the metabolism of medications?

a)

Kidney

b)

Skin

c)

Liver

d)

Large intestine

Answer: ANS: C

Drug metabolism takes place mainly in the liver, but medications can also be detoxified in the kidneys, blood plasma, intestinal mucosa, and lungs. If liver function is impaired due to liver disease, medications will be eliminated more slowly, and toxic levels may accumulate.

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Question: Which body organ is mostly responsible for medication excretion?

a)

Liver

b)

Kidney

c)

Lungs

d)

Exocrine glands

Answer: ANS: B

The kidneys are the primary site of excretion. Adequate fluid intake facilitates renal excretion. If the patient has decreased renal function, the nurse should closely monitor for medication toxicity.

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Question: The nursing student is preparing to administer an intramuscular (IM) injection to her patient. She states to her instructor, “I’m going to administer this medication in my patient’s buttocks at the dorsogluteal site.” What is the most appropriate response by the instructor?

a)

“Okay. Explain the procedure to me and you are good to go.”

b)

“This may not be the best site owing to proximity of the sciatic nerve.”

c)

“I agree, this is a good site for thin patients such as this one.”

d)

“Okay, but first be sure to locate the bony landmarks carefully.”

Answer: ANS: B

The dorsogluteal site consists of the gluteal muscles of the buttocks. Avoid using the dorsogluteal site for IM injections because its close proximity to the sciatic nerve and superior gluteal artery increases the risk of injection into a major blood vessel and damage to the sciatic nerve. Furthermore, the site is difficult to identify accurately in older adults or people with flabby skin. The instructor should advise the student that this is not the appropriate site and elicit another site from the student. Once this is identified, the student can proceed with patient identifiers.

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Question: The nursing student is preparing to administer lisinopril to her patient but does not know what lisinopril is used for. What is the most appropriate action by the student to obtain the information?

a)

Consult the pharmacist.

b)

Ask the primary nurse.

c)

Ask her nursing instructor.

d)

Look up lisinopril in a medication reference text.

Answer: ANS: D

Look it up! As a nurse, one is professionally, ethically, legally, and personally responsible for every dose of medication administered to a patient. Always use current information when researching a medication.

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Question: The nurse mixes two medications together in one syringe and is preparing to administer them to her patient. On entering the patient’s room, the nurse notices that the medication looks cloudy and there are some particles floating in the mixture. What is the most appropriate action by the nurse?

a)

Notify the pharmacist before proceeding.

b)

Check for medication compatibility.

c)

Discard the medications and syringe.

d)

Remix the medications in a different syringe.

Answer: ANS: C

Drug incompatibilities occur when multiple drugs are mixed together, causing a chemical deterioration of one or more of the drugs. The result is an incompatible solution that should not be administered. You can usually recognize an incompatibility when the mixed solution takes on a changed appearance. If the contents of the syringe become discolored or there are particles in the solution, do not administer the medication. The nurse should always consult a medication resource and compatibility chart before mixing medications. Remixing the medications using a different syringe is inappropriate, as this will only elicit the same result.

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Question: The nursing student has registered for a class on pharmacokinetics. Which of the following reflects the student’s accurate understanding of what he can expect to focus on in this class?

a)

The study of drug actions and their various side effects

b)

A classification system for organizing brand names and generic names of drugs

c)

The absorption, distribution, metabolism, and excretion of drugs

d)

The study of how medications achieve their effects at various sites in the body

Answer: ANS: C

Pharmacokinetics refers to the absorption, distribution, metabolism, and exertion of a drug. These four processes determine the intensity and duration of a drug’s action. Each drug has unique pharmacokinetics characteristics. Pharmacology is the science of drug effects. It deals with all drugs used in society, legal and illegal, prescription and nonprescription. Pharmacodynamics, another subconcept of pharmacology, is the study of how medications achieve their effects at various sites in the body, how specific drug molecules interact with target cells, and how biological responses occur.

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Question: What is/are the primary roles of the Food and Drug Administration (FDA)? Select all that apply.

a)

Regulate the testing, manufacture, and sale of all medications

b)

Monitor safety and effectiveness of medications available to consumers

c)

Manage the storage and handling of controlled substances

d)

Manage the sale and regulation of all herbal remedies

Answer: ANS: A, B

The FDA of the U.S. Department of Health and Human Services regulates the testing, manufacturing, and sale of all medications. This agency also monitors the safety and effectiveness of medications available to consumers. This process helps to ensure that ineffective or unsafe drugs are not marketed or are recalled, if later found unsafe. However, many medicinal products are not regulated by the FDA. For example, herbal remedies and some naturopathic supplements are considered “food products” and are not regulated, even though they are advertised as having health benefits. The management of controlled substances is under the auspices of the Drug Enforcement Agency (DEA)

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Question: The new nurse is beginning her orientation on a medical-surgical unit. What is most important for the nurse to know regarding hospital policies concerning controlled substances? Select all that apply.

a)

Controlled substances are usually stored in a double-locked area.

b)

A count of all controlled substances is performed at specific times, usually monthly.

c)

The facility must keep a record of every dose of a controlled substance that is administered.

d)

Handling and storage of controlled substances is regulated by the U.S. Drug Enforcement Agency (DEA).

Answer: ANS: A, C, D

Controlled substances must be stored, handled, disposed of, and administered according to regulations established by the U.S. Drug Enforcement Agency (DEA). Controlled substances must be stored in locked drawers with a second locked area. This process is known as double-locking. The facility must also keep a record of every dose administered. A count of all controlled substances is performed at specified times, usually at change of shift (not monthly).

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Question: The nurse is preparing to administer a subcutaneous does of insulin to a patient with diabetes. Which two sites might the nurse use that would provide the best absorption of the injection? Select all that apply.

a)

Upper arm

b)

Abdomen

c)

Thigh

d)

Upper buttocks

Answer: ANS: A, B

Subcutaneous injections are given into the subcutaneous tissue, the layer of fat located below the dermis and above the muscle tissue. Absorption is slower than through the intramuscular route because subcutaneous tissue does not have as rich a blood supple as does muscle. However, the speed of absorption varies with the subcutaneous site selected. Absorption is fastest in sites on the abdomen and arms; it is slower on the thigh and upper buttocks. Medication is absorbed more evenly from the abdomen than from the thighs and buttocks because it is affected less by activity.

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Question: The nurse is preparing to administer ophthalmic eye drops to her patient. What are the most appropriate actions for administering eye drops? Select all that apply.

a)

Place the patient in a high-Fowler’s position.

b)

Administer the eye drops from the inner to the outer canthus of the eye.

c)

Position the eyedropper 1 to 2 inches above the eye.

d)

Apply the medication into the conjunctival sac.

Answer: ANS: A, B, D

When administering ophthalmic medications, use a high-Fowler’s position, work from the inner canthus to the outer canthus, and apply the medication into the conjunctival sac. Position the eyedropper about 1.5 to 2.0 cm ( to in.) above the eye; 1 to 2 inches is too high. Do not apply the medication to the cornea and do not allow the dropper to touch the eye.

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Question: The nurse is preparing to administer otic medications to her 35-year-old patient. What are the most appropriate actions by the nurse? Select all that apply.

a)

Pull the pinna up and back.

b)

Pull the pinna down and back.

c)

Place patient in side-lying position with appropriate ear up.

d)

Instruct the patient to remain on his side for at least 30 minutes.

Answer: ANS: A, C

When administering otic medications, warm the solution to be instilled to body temperature, assist the patient to a side-lying position with the appropriate ear facing up, straighten the ear and pull the pinna up and back (adult patient), and instill the prescribed number of drops into the ear canal. Instruct the patient to remain on his side for 5 to 10 minutes after the procedure.

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Question: The home health nurse is caring for a 75-year-old patient with severe arthritis of her hands and fingers. The patient states, “I can’t use these childproof safety lock caps because I can’t open them.” What is the most appropriate response(s) by the nurse? Select all that apply.

a)

“I see this is difficult for you. Do you have any family members or friends who can help you?”

b)

“We can ask the pharmacist not to put childproof caps on your medications; you may need to sign a form.”

c)

“You can transfer your medications to different containers that are easier for you to open.”

d)

“All medications come in childproof containers, so there isn’t much we can do about this.”

Answer: ANS: A, B

If a patient has difficulty opening containers and administering medications owing to pain or stiffness in the hands and fingers, family members and friends can be asked to help. Additionally, the nurse or patient can ask the pharmacy and the primary care provider not to put childproof safety lids on containers for easier handling. Older adults are allowed to sign a release with their pharmacy to be able to do this. Do not store a drug in a container that is different from the one it came in. The medication may lose its strength or the patient may take the wrong medication.

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Question: The nurse educator in the local hospital is preparing a teaching plan for staff nurses on using medication abbreviations in nursing documentation. What is most important for the nurse to include in the teaching plan concerning acceptable abbreviations? Select all that apply.

a)

They are based on Joint Commission recommendations.

b)

They are commonly used by the pharmacy department.

c)

They are most commonly used by nurses.

d)

They are based on policies of the facility.

Answer: ANS: A, D

The nurse should write out drug names and dosages in full. Abbreviations can be easily confused and many are not universally understood. However, you will see and use some abbreviations when administering and documenting medications. Always do so carefully because some may be similar and confusing. Consult The Joint Commission’s official Do Not Use list and know the acceptable abbreviations used in your facility.

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Question: Which commonly accepted practice came out of the Framingham study? Use of:

a)

Mammography in breast cancer screening

b)

Colonoscopy in colon cancer screening

c)

Pap testing in cervical cancer screening

d)

Digital rectal examination in prostate cancer screening

Answer: ANS: A

One commonly accepted practice that came out of the Framingham study is the link between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening.

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Question: Which theorist developed the nursing theory known as the Science of Human Caring?

a)

Florence Nightingale

b)

Patricia Benner

c)

Jean Watson

d)

Nola Pender

Answer: ANS: C

Dr. Jean Watson developed the nursing theory known as the Science of Human Caring. Her theory describes caring from a nursing perspective. Florence Nightingale developed the theory that stated that a clean environment would improve the health of patients. By changing the care environment, she dramatically reduced the death rate of soldiers. Dr. Patricia Benner’s theory described the progression of a beginning nurse who learns to be an expert nurse. Nola Pender’s theory on health promotion became the basis for most health promotion teaching done by nurses.

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Question: A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n):

a)

Phenomenon

b)

Concept

c)

Assumption

d)

Definition

Answer: ANS: B

A concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience. In the scenario above, the nurse forms a mental image of pain because of her past experiences with pain. Phenomena are the subject matter of a discipline. They mark the boundaries of a discipline. An assumption is an idea that is taken for granted. In a theory, the assumption is the idea that the researcher presumes to be true and does not intend to test with research. A definition is a statement of meaning of a term or concept that sets forth the concept’s characteristics or indicators.

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Question: The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist?

a)

Virginia Henderson

b)

Imogene Rigdon

c)

Katherine Kolcaba

d)

Florence Nightingale

Answer: ANS: D

Florence Nightingale was instrumental in identifying the importance of a clean patient care environment. During the Crimean War, Nightingale dramatically reduced the death rate of soldiers by changing the healthcare environment. Virginia Henderson identified 14 basic needs that are addressed by nursing care. Imogene Rigdon developed a theory about bereavement in older women after noticing that older women handle grief differently than do men and younger women. Katherine Kolcaba developed a theory of holistic comfort in nursing.

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Question: A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse whether her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is using the theory developed by which nurse theorist?

a)

Betty Neuman

b)

Dorothea Orem

c)

Callista Roy

d)

Madeline Leininger

Answer: ANS: D

The nurse is using the theory developed by Madeline Leininger. Leininger’s theory focuses on the values of cultural diversity. According to her theory, the nurse must make cultural accommodations for the health benefit of the patient.

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Question: A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next?

a)

Perform a literature review

b)

Develop a conceptual framework

c)

Formulate the hypothesis

d)

Define the study variables

Answer: ANS: A

After identifying and stating the problem, the nurse researcher should clarify the purpose of the study. Next, the researcher should perform a literature search to find out what is already known about the problem. After the literature search, the researcher should choose a conceptual framework to guide the research, formulate the hypothesis or research question, and define the study variables.

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Question: The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still does not change her mind. By withdrawing from the study, the mother is exercising which right? The right

a)

Not to be harmed

b)

To self-determination

c)

To full disclosure

d)

Of confidentiality

Answer: ANS: B

The mother is exercising the right to self-determination. This refers to the right of the participant (or parent, in the case of a minor) to withdraw from a research study at any time and for any reason. The right not to be harmed outlines the safety protocols of the study. All research participants also have the right to full disclosure. This guarantees the participants answers to questions, such as the purpose of the research study, the risks and benefits, and what happens if the patient feels worse as a result of the study. Moreover, participants also have the right to confidentiality. Typically that right is preserved by giving participants an identification code rather than associating them by name.

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Question: fter suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow’s Hierarchy of Needs, cardiac rehabilitation most directly addresses which need?

a)

Safety and security

b)

Physiological

c)

Self-actualization

d)

Self-esteem

Answer: ANS: B

Cardiac rehabilitation most directly addresses the patient’s physiological need for physical activity as well as for health and healing. Indirectly, of course, better physical condition might enable the patient to perform activities that would lead to higher self-esteem and even self-actualization.

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Question: In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include:

a)

Cognitive and aesthetic needs

b)

Love and belonging needs

c)

Safety and security needs

d)

Physiological and self-esteem needs

Answer: ANS: A

In his later work, Maslow identified two growth needs that must be met before reaching self-actualization. They include cognitive (to know, understand, and explore) and aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified in his earlier work were physiological, safety and security, love and belonging, esteem, and self-actualization.

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Question: The PICO question reads, “Is TENS effective in the management of chronic low-back pain in adults?” Which part of this question comes from the “I” in PICO?

a)

Adults

b)

Management

c)

Pain

d)

TENS

Answer: ANS: D

“TENS” is the intervention (I) in the PICO system. “Adults” comes from patient (P). “Management” comes from the outcome (O). There is no comparison intervention (C) in this PICO question.

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Question: While reading a journal article, the nurse asks herself these questions: “What is this about overall? Is it true in whole or in part? Does it matter to my practice?” What is this nurse doing?

a)

Reading the article analytically

b)

Performing a literature review

c)

Formulating a searchable question

d)

Determining the soundness of the article

Answer: ANS: A

Analytical reading involves questioning the article to be sure you understand it and to determine whether it is applicable to your practice. Such reading asks these questions: “What is this about as a whole? Is it true in whole or in part? Does it matter to my practice?” A literature review is performed by searching indexes and databases, and reading more than one article. Formulating a searchable question involves creating a PICO-type statement to guide a search of the literature. The nurse would determine whether the article is a research report by looking for the individual parts of the article to see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions).

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Question: A participant in a research study informs the nurse researcher that he has decided to withdraw from the study citing personal reasons. The most appropriate action by the researcher is to:

a)

Inform the participant that the signed consent form requires him to remain in the study

b)

Review the purpose of the study with the participant and encourage him to remain

c)

Support the participant in his withdrawal from the study

d)

Discuss with the research team strategies to keep the participant in the study

Answer: ANS: C

At any time in a study, the participant has the right to stop participating, for any reason. As the nurse or researcher, you are responsible to support a participant during the process of withdrawing from a study. Do not allow anyone to coerce the participant into remaining in the study.

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Question: The nurse researcher is conducting a study. In preparation for the study, she will be developing a method for participants’ identification while securing their privacy and confidentiality. What is the best method the researcher can use for participant identification and securing privacy and confidentiality?

a)

Use a code number for each participant

b)

Use participant initials only

c)

Use gender and age only

d)

Use participant surname only

Answer: ANS: A

All participants have the right to have their identification protected. Generally, they are given a code number rather than being identified by name. Once the study is completed and the data are analyzed, the researcher is responsible for protecting the raw data (such as questionnaires and taped interviews).

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Question: The new nursing student is working on a surgical unit and observes some patients developing a low-grade fever of 99°F a few hours after their surgery. The most appropriate action for the student to take to gain some insight into her observation is to:

a)

Ask an experienced nursing instructor why this might be occurring

b)

Talk to someone about starting a research study

c)

Formulate a searchable question and research the literature

d)

Speak with a surgeon from the unit

Answer: ANS: C

When you have found a topic of interest, the first step is to state it in the form of question to help narrow a search. A question stated too broadly may yield overwhelming and irrelevant results. A question stated too narrowly may yield no results. Once the question is formed the next step is to look for research articles related to your inquiry. Asking an instructor or surgeon for an answer may yield an immediate and narrow response. Talking to someone about starting a research study is most likely beyond the level of a new nursing student.

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Question: The nurse enters a patient’s room and notes he is nauseous, vomiting, and experiencing abdominal pain, and has no bowel sounds. She concludes that the patient’s symptoms may be associated with a paralytic ileus. In arriving at this conclusion, the nurse has used:

a)

Inductive reasoning

b)

Deductive reasoning

c)

Guesswork

d)

Diagnostics

Answer: ANS: A

Inductive reasoning is often used in the nursing process. Induction moves from the specific to the general. One gathers separate pieces of information, recognizes a pattern, and forms a generalization or conclusion. In this item, the nurse uses inductive reasoning based on her observations and assessment of this patient and concludes his symptoms are associated with a paralytic ileus. This is not guesswork, as the nurse is using her observation, assessment skills, and knowledge to draw a conclusion. Deductive reasoning starts with a general premise and moves to a specific deduction. The nurse is not diagnosing this patient, as this is the scope of practice for the medical doctor. She is, however, making an association between S+S and a disease process.

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Question: The nurse researcher decides to conduct a research study on the association between aging male populations and their development of prostate cancer. She uses a sample size from her community of 50 males aged more than 80 years, a quantitative research design, and finds that many of these participants developed cancer after the age of 80. She reports in her findings: All male patients over the age of 80 years old will most likely develop prostate cancer. Based on the information given above, what is flawed in this research?

a)

The problem statement does not provide enough information.

b)

Sample size is too small to make a generalization.

c)

The research is only valuable to those working with aging males.

d)

A quantitative research design is most likely inappropriate for this type of study.

Answer: ANS: B

The sample size of 50 males in the local community is too small to make the generalization that all males over the age of 80 will develop prostate cancer. The problem statement provides enough information to form an idea of what this study is about. The quantitative research design is appropriate for this type of study as it is the design for gathering data from enough subjects to be able to generalize the results to a similar population. This research is valuable to nurses working with these patients and is valuable to the medical community and healthcare consumers.

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Question: he nurse educator in the local hospital is developing a plan to implement research into nursing care practices. What are some of the barriers she may encounter in this implementation process? Select all that apply.

a)

Not enough nursing research has been published.

b)

There is a negative attitude toward research.

c)

There is a lack of support from the employing hospital.

d)

Most nursing research is not relevant to hospital practice.

Answer: ANS: B, C

Barriers to using nursing research include a lack of knowledge of nursing research, negative attitudes toward research, inadequate forums for disseminating research, lack of support from the employing institutions, and study findings that are not ready for the clinical environment. There is an abundance of nursing research and evidence-based nursing research providing sound evidence on which to base nursing care. Many times, this is in the form of clinical practice guidelines.

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Question: Which of the following statement(s) best describe(s) nursing research? Select all that apply.

a)

Nursing research is a systematic, objective process of analyzing phenomena important to nursing.

b)

The purpose of nursing research is to develop knowledge about issues important to nursing.

c)

Nursing research is an organized set of related ideas and concepts that build principles and theories.

d)

All data in the research process are reported in numbers to make generalizations about specific populations.

Answer: ANS: A, B

Nursing research is the systematic, objective process of analyzing phenomena of importance to nursing. Its purpose is to develop knowledge about issues that are important in nursing. An organized set of related ideas and concepts is a theory. Data reported in numbers is a quantitative research design used in nursing research however not all nursing research is quantitative research. Much of nursing research can be qualitative as well.

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Question: The American Nurses Association (ANA) has set standards for registered nurses in utilizing evidence-based interventions and treatments in practice. According to the ANA, which of the following statement(s) best describes these standards? Select all that apply. The registered nurse:

a)

Uses current evidence-based nursing knowledge to guide practice decisions

b)

Critically analyzes evidence-based practice and research findings for application to practice

c)

Shares research activities and findings with peers and others

d)

Uses specific competencies in conducting and integrating research

Answer: ANS: A, B, C

According to the ANA Standards of Professional Performance (standard 9) concerning evidence-based practice, there are two main criteria: The registered nurse uses current evidence-based nursing knowledge, including research findings, to guide practice decisions, critically analyzes evidence-based practice and research findings for application to practice, participates in the development of evidence-based practice through research activities, and shares research activities and/or findings with peers and others. Competencies related to research are stated by QSEN under its educational competencies and are not part of the ANA standards.

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Question: The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, “I’ve gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now.” After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?

a)

“The baby’s lungs are well developed now, but he will be at increased risk for SIDS if I deliver early.”

b)

“We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.”

c)

“If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening.”

d)

“Thanks for reassuring me; I was pretty sure there isn’t much risk to the baby this far along in my pregnancy.”

Answer: ANS: C

Premature infants (younger than 33 weeks’ gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open.

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Question: While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?

a)

Clamp the chest tube close to the insertion site.

b)

Set up a new drainage system, and connect it to the chest tube.

c)

Have the patient take and then hold a deep breath while the nurse reconnects the tube to the CDU.

d)

Place the disconnected end nearest the patient into a bottle of sterile water.

Answer: ANS: D

Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water.

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Question: The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

a)

The amount of sputum the patient expectorates decreases with each dose administered.

b)

Cough is completely suppressed, and she is able to sleep through the night.

c)

Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

d)

Involuntary coughing produces large amounts of thick yellow sputum.

Answer: ANS: C

Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

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Question: The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

a)

Review and implement the primary care provider’s prescriptions for treatments.

b)

Perform a quick physical examination of breathing, circulation, and oxygenation.

c)

Gather a thorough medical history, including current symptoms, from the family.

d)

Administer oxygen to the patient through a nasal cannula.

Answer: ANS: B

The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation to determine the type of immediate intervention required. The nurse’s assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patient’s oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physician’s orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.

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Question: You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

a)

Biot’s breathing

b)

Kussmaul’s respirations

c)

Sleep apnea

d)

Cheyne-Stokes respirations

Answer: ANS: D

This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

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Question: You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113 beats/min, and respiratory rate is 30 breaths/min. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

a)

Call the respiratory therapist to check the ventilator settings.

b)

Provide endotracheal suctioning.

c)

Provide tracheostomy care.

d)

Notify the physician of the patient’s signs of fluid overload.

Answer: ANS: B

Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient’s symptoms should subside once the airway is cleared.

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Question: Which of the following blood levels normally provides the primary stimulus for breathing?

a)

pH

b)

Oxygen

c)

Bicarbonate

d)

Carbon dioxide

Answer: ANS: D

Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs.

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Question: A 62-year-old man with emphysema says, “My doctor wants me to quit smoking. It’s too late now, though; I already have lung problems.” Which of the following would be the best response to his statement?

a)

“You should quit so your family does not get sick from exposure to secondhand smoke.”

b)

“You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home.”

c)

“Once you stop smoking, your body will begin to repair some of the damage to your lungs.”

d)

“You should ask your primary care provider for a prescription for a nicotine patch to help you quit.”

Answer: ANS: C

The nurse’s response should focus on correcting the patient’s misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patient’s family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is “too late” for him to do so.

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Question: The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects?

a)

Decreased heart rate

b)

Muscle weakness

c)

Decreased urine output

d)

Respiratory depression

Answer: ANS: D

Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations.

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Question: When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?

a)

You will need a single pair of sterile gloves.

b)

Place the patient in semi-Fowler’s position, if possible.

c)

Clean the stoma under the faceplate with hydrogen peroxide.

d)

Cut a slit in sterile 4 in. × 4 in. gauze halfway through to make a dressing.

Answer: ANS: B

Semi-Fowler’s position promotes lung expansion and prevents back strain for the nurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma under the faceplate with sterile saline. Never cut a 4 in. × 4 in. gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress.

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Question: A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance?

a)

Keep the head of the bed flat for 6 hours.

b)

Avoid using mouth rinses or mouthwashes.

c)

Provide the patient with a paper and pencil or letter board.

d)

Drain condensation into the humidifier when it collects in the tubing.

Answer: ANS: C

The patient being mechanically ventilated is unable to speak. This can produce extreme anxiety. An alternative method of communication must be used so the patient can express her needs and concerns. Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees). This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP). Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes. You should check the ventilator tubing frequently for condensation. Drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patient’s secretions may have contaminated it.

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Question: The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

a)

A positive reaction indicates that the client has active tuberculosis (TB).

b)

A positive reaction indicates that the client has been exposed to the disease.

c)

A negative reaction always excludes the diagnosis of TB.

d)

The PPD can be read within 12 hours after the injection.

Answer: ANS: B

A positive reaction means the client has been exposed to TB; it isn’t conclusive of the presence of active disease. A positive reaction consists of palpable swelling and induration of 5 to 15 mm. It can be read 48 to 72 hours after the injection. In clients with positive reactions, further studies are usually done to rule out active disease. In immunosuppressed clients, a negative reaction doesn’t exclude the presence of active disease.

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Question: A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

a)

Limiting fluid

b)

Having the client take deep breaths

c)

Asking the client to spit into the collection container

d)

Asking the client to obtain the specimen after eating

Answer: ANS: B

To obtain a sputum specimen, the client should rinse his mouth to reduce contamination, breathe deeply for three or four breaths, hold his breath, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit in order to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. A specimen should be obtained 1 to 2 hours after eating to prevent vomiting and aspiration risk.

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Question: A nurse is suctioning a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

a)

1 minute

b)

5 seconds

c)

15 seconds

d)

30 seconds

Answer: ANS: C

Hypoxemia and tissue trauma can be caused by prolonged suctioning. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to no longer than 15 seconds.

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Question: The nurse is caring for a 6-month-old infant diagnosed with RSV, a viral infection causing copious airway secretions. What consideration will influence the nurse’s plan of care most?

a)

Infants breathe more rapidly than adults.

b)

Infants’ airways are narrower and more easily obstructed.

c)

Infants have lower hemoglobin levels reducing oxygenation.

d)

Infants have larger tonsils and adenoids.

Answer: ANS: B

Although infants do breathe more rapidly than adults, this consideration will not influence the plan of care for this patient. The narrower airways mean that the copious secretions caused by the infection could result in airway obstruction, so the plan of care must include mobilizing secretions to maintain a clear airway to allow for adequate oxygenation. Infants’ hemoglobin levels are not lower than those of adults, so this is an untrue statement. Toddlers, not infants, have enlarged tonsils and adenoids.

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Question: The nurse is caring for a patient admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this patient?

a)

Ineffective Breathing Pattern

b)

Ineffective Airway Clearance

c)

Impaired Gas Exchange

d)

Impaired Spontaneous Ventilation

Answer: ANS: D

This patient’s breathing is altered but does not fit this diagnosis because respiratory rate is unknown, so it is impossible to know what pattern of breathing is occurring based on the information given. There is no indication of an obstructed airway or increased secretions that would measure ability to clear airway. There is no indication in the question regarding the patient’s gas exchange, so this is not the best choice, even though it would be easy to read into the question and suspect hypoxia. The best diagnosis for this patient is Impaired Spontaneous Ventilation because without external support, this patient’s muscle strength is inadequate to maintain breathing adequate to support life.

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Question: The nurse is planning care for a 70-year-old patient newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance. Which is the nurse’s priority intervention?

a)

Teach the importance of pneumonia immunization.

b)

Teach coughing and deep breathing exercises.

c)

Position to optimize maximum ventilation.

d)

Encourage use of incentive spirometer to increase deep breathing.

Answer: ANS: C

Although teaching the patient the importance of receiving immunizations is important, it is not the priority with a newly admitted patient. Teaching coughing and deep breathing exercises is high on the priority list, but it is not the top priority. The highest priority is to optimize ventilation as soon as the patient is admitted. Only when the patient is adequately oxygenating can other interventions be addressed. Use of an incentive spirometer will promote deep breathing, which will help to mobilize secretions, but is not the top priority intervention at this time.

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Question: For which patient could the nurse collect a sputum specimen without using a suction catheter?

a)

The patient with a newly placed tracheostomy

b)

The patient with an endotracheal tube

c)

The patient with late-stage amyotrophic lateral sclerosis

d)

The patient admitted with chronic bronchitis

Answer: ANS: D

The patient with a newly placed tracheostomy will need help clearing the airway and can provide a sputum specimen only by having the airway suctioned. A client with an endotracheal tube in place can contribute a sputum specimen only with the assistance of suctioning. A patient in the later stages of a muscle-wasting disease would not have the strength to expectorate a sputum specimen and would require suctioning. The patient with a chronic cough, if there are no other considerations, would be able to expectorate a sputum specimen and would not require suctioning.

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Question: The patient was admitted to the ICU in respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28, PaO2 = 85, PaCO2 = 60. What changes to care does the nurse anticipate?

a)

Wean the patient from the ventilator.

b)

Increase the concentration of oxygen delivered.

c)

Decrease the concentration of oxygen delivered.

d)

Increase the number of breaths per minute on the ventilator.

Answer: ANS: D

The patient is still in a state of respiratory acidosis and is not ready for extubation and weaning from the ventilator. The PaO2 is adequate, so there is no need to increase the delivered oxygen concentration. The PaO2 is adequate so there is no need to decrease the delivered oxygen concentration. Increasing the number of breaths per minute provided by the mechanical ventilator will help the patient to blow off more carbon dioxide, which will result in an improved pH.

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Question: The nurse is caring for a patient diagnosed with pneumonia, teaching him or her how to cough and deep-breathe. The patient asks, “Why is drinking fluids so important?” What is the nurse’s best response?

a)

“The doctor ordered increased fluid intake.”

b)

“Fluids prevent pathogens from growing in your lungs.”

c)

“Fluids help to flush infection away so it doesn’t grow in your lungs.”

d)

“Fluids make secretions thin, making them easier to cough up.”

Answer: ANS: D

Although the doctor may have prescribed increased fluid intake, this does not explain why it is important. Fluids do not prevent the growth of pathogens. Fluids do not flush out the lungs because they do not, normally, enter the lungs. Fluids help to thin secretions and keep them from becoming thick and gluelike, which would be much harder to mobilize. Thin secretions will reduce the effort required by the patient to cough mucus into the larger airways and expectorate it.

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Question: The nurse admits a patient to the surgical unit from the postanesthesia care unit. The patient has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?

a)

Remove the oral airway and elevate the head of the bed.

b)

Position the patient with the head turned to the side.

c)

Measure vital signs and check surgical dressing.

d)

Call the surgeon and obtain postoperative prescriptions.

Answer: ANS: B

The oral airway should not be removed until the patient is more awake, and elevating the head of the bed is not appropriate until the patient is more responsive. The most important priority is to position the patient with the head turned to the side to prevent aspiration of secretions or emesis if the patient should vomit. Vital signs and dressing checks are important but not the highest priority. Postsurgical prescriptions are written when the patient is in postanesthesia care and come to the floor with the patient.

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Question: Which procedure can the nurse safely delegate to the certified nursing assistant who is knowledgeable and experienced in the procedure?

a)

Suctioning the newly placed tracheostomy tube

b)

Suctioning the endotracheal tube

c)

Suctioning the laryngopharynx

d)

Suctioning the oropharynx

Answer: ANS: D

Suctioning a new tracheostomy requires sterile technique, which cannot be delegated to a certified nursing assistant (CNA). Suctioning an endotracheal tube requires sterile technique, which cannot be delegated to a CNA. Deep (laryngopharyngeal) suctioning requires a nurse, owing to the risk of the procedure and complexity of care. The CNA would be capable of performing oral suctioning or assisting a patient to suction his own mouth.

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Question: The nurse, working in the postanesthesia care unit inserts an oral airway into the semiconscious patient to prevent airway obstruction. When should the airway be removed?

a)

When the patient can be aroused

b)

When the patient is 24 hours postoperative

c)

When the patient removes it

d)

When the provider prescribes that it be removed

Answer: ANS: C

A semiconscious patient can be aroused but is not awake enough to have the airway removed. Maintaining an airway in place for 24 hours would cause trauma to the airway and is longer than the patient will need this to be in place. When the patient is awake enough to find the airway annoying, the patient will remove it and that will be the safest time. If the provider were to write a prescription specifying when to remove the airway, it would be based on the patient’s level of alertness.

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Question: The nurse is caring for a patient requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable?

a)

78°F

b)

96°F

c)

105°F

d)

84°F

Answer: ANS: B

A temperature of 78°F would be too cold and could result in hypothermia. The temperature should be near body temperature, so 96°F would be acceptable. A temperature of 105°F is too high and could cause damage to the respiratory tract. A temperature of 84°F is too cold and could result in hypothermia.

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Question: 25. The student nurse observes the staff nurse providing care to a patient with a chest tube. Which of the nurse’s actions should the student recognize as incorrect and report to the nursing instructor?

a)

Recording drainage from chest tube as output

b)

Securing the chest tube to the chest tube dressing

c)

Checking the water seal chamber for bubbling

d)

Milking the chest tube to promote drainage

Answer: ANS: D

Recording drainage from the chest tube as output would be an appropriate nursing action. Securing the chest tube to the chest tube dressing helps to prevent dislocation or removal of the chest tube and is an appropriate nursing action. A lack of bubbling in the water seal chamber indicates air is no longer being evacuated, so it is an appropriate nursing assessment. Milking the chest tube, or squeezing it from the patient to the drainage collection device, is not an evidence-based practice and should not be done. Seeing a nurse doing this would indicate the need for corrective action, which should not be provided by a student.

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Question: The nurse is caring for a patient with a chest tube. What outcome would indicate the chest tube can be discontinued?

a)

No further bubbling is seen in the water seal chamber.

b)

No further drainage is measured from the chest tube.

c)

Chest x-ray shows the lungs are fully inflated.

d)

The patient’s respirations are regular and unlabored.

Answer: ANS: A

When the pleural space is free of air, and there is no longer air leaking into the pleural space, bubbling in the water seal chamber will stop, indicating the chest tube can be discontinued. It is expected that the largest quantity of drainage will occur when the chest tube is first placed. Although reduced drainage is a positive sign, this is not an adequate sign to discontinue the chest tube. Chest x-rays will often reflect a fully inflated lung shortly after the chest tube is placed, indicating the chest tube is doing its job. Premature discontinuation will cause the affected lung to collapse again. Respirations should ease as soon as the chest tube is placed, and this is not an indication the chest tube can be removed.

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Question: The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply.

a)

“Keep healthy snacks or gum available to chew instead of smoking a cigarette.”

b)

“Don’t tell your friends and family you are trying to quit, until you feel confident that you’ll be successful.”

c)

“Plan a time to quit when you will not have many other demands or stressors in your life.”

d)

“Reward yourself with an activity you enjoy when you quit smoking.”

Answer: ANS: A, C, D

People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement.

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Question: A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply.

a)

Normal urine output

b)

Strong peripheral pulses

c)

Clear breath sounds bilaterally

d)

Normal muscle strength

Answer: ANS: A, B, D

To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed.

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Question: The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Select all that apply.

a)

Perform frequent coughing and deep-breathing exercises.

b)

Sit up in a chair but do not walk while the drainage system is in place.

c)

Get out of bed without assistance as often as possible.

d)

Immediately notify the nurse if she experiences increased shortness of breath.

Answer: ANS: A, D

Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. The nurse should also encourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so that the nurse can check for occlusion of the system, which can result in a tension pneumothorax.

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Question: When providing safety education to the mother of a toddler, you would inform the mother that, based on the child’s developmental stage, he is at high risk for which of the following factors that influence oxygenation? Select all that apply.

a)

Frequent, serious respiratory infections

b)

Airway obstruction from aspiration of small objects

c)

Drowning in small amounts of water around the home

d)

Development of asthma

Answer: ANS: B, C

As a toddler’s respiratory and immune systems mature, the risk for frequent and serious infections is less than it is in infancy. Most children recover from upper respiratory infections without difficulty. Toddlers’ airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the child’s developmental stage.

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Question: Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply.

a)

Reduced alveolar-capillary gas exchange

b)

Lower respiratory tract infections

c)

Sleep apnea

d)

Hypertension

Answer: ANS: B, C, D

Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolar-capillary gas exchange.

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Question: Which of the following is/are accurate about nasotracheal suctioning? Select all that apply.

a)

Apply suction for no longer than 15 sec during a single pass.

b)

Apply suction while inserting and removing the catheter.

c)

Reapply oxygen between suctioning passes for ventilator patients.

d)

Gently rotate the suction catheter as you remove it.

Answer: ANS: A, D

Limiting suctioning to 15 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent trauma to the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen.

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Question: Which of the following factors influence normal lung volumes and capacities? Select all that apply.

a)

Age

b)

Race

c)

Body size

d)

Activity level

Answer: ANS: A, C, D

Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes. Race does not influence normal lung volumes and capacities.

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Question: Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Select all that apply.

a)

Administer bronchodilators.

b)

Apply low-flow oxygen.

c)

Encourage coughing and deep breathing.

d)

Administer pain medication.

Answer: ANS: C, D

Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patients for pain. Once you have medicated the patient, reassess breath sounds and encourage the patient to cough and breathe deeply. This will help to open air sacs and mobilize secretions in the airways.

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Question: he nurse admits a patient diagnosed with pneumonia. Which data findings indicate that the patient is not oxygenating adequately? Select all that apply.

a)

Oxygen saturation 87%

b)

Arterial blood gas pH 7.33

c)

Respiratory rate 52 breaths/min

d)

Fine rales in the left lower lobe

e)

Cyanosis of the nailbeds and lips

Answer: ANS: A, C, E

An oxygen saturation of 87% is below the accepted range and indicates inadequate oxygenation. A pH of 7.33 indicates acidosis, but further information is needed to determine whether the cause is respiratory or metabolic. A respiratory acidosis indicates poor gas exchange, but oxygenation may be adequate with inadequate carbon dioxide exchange. A respiratory rate of 52 breaths/min does not allow adequate time for gas exchange and would contribute to a finding of inadequate oxygenation. Fine rales indicates an altered airway, but alone is not adequate for indicating lack of oxygenation. Cyanosis is caused by lack of oxygen to the tissues and is a good indicator of inadequate oxygenation.

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Question: The nurse is caring for a patient with an acute asthma event. What classification of medications would the nurse anticipate administering to this patient? Select all that apply.

a)

Expectorant

b)

Corticosteroid

c)

Bronchodilator

d)

Cough suppressant

e)

Antibiotic

Answer: ANS: B, C

Expectorants help to mobilize secretions and would not be an anticipated classification of medication to be administered to this patient. Corticosteroids reduce inflammation of tissues in the airway and are often administered during acute asthma events. Bronchodilators help to expand airways and are usually a primary classification of medication administered to patients experiencing an acute asthma event. Cough suppressants help to reduce the cough reflex and would not be appropriate to administer to a patient experiencing an acute asthma event because it does not treat the cause of the problem. Antibiotics would not be anticipated unless the event was triggered by a bacterial event. Because most asthma attacks are not the result of bacterial infections, this would be an unlikely medication classification to be administered.

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