PRN1178/ PRN 1178 Exam 2 (2026/ 2027 Updated) Client-Centered Care II Review| Comprehensive Q&A| 100% Correct| A Grade - Rasmussen

PRN1178/ PRN 1178 Exam 2 (2026/ 2027 Updated) Client-Centered Care II Review| Comprehensive Q&A| 100% Correct| A Grade - Rasmussen Q. The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours ANSWER B Rationale: The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. Q. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours. ANSWER D Rationale: Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation. Q. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise. ANSWER D Rationale: Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well." Q. When evaluating the response to treatment for a patient with a fluid imbalance, the most important assessment to include is a. skin turgor. b. presence of edema. c. hourly urine output. d. daily weight. ANSWER D Rationale: Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds. Q. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake a. when the patient feels thirsty. b. in the late evening hours. c. as soon as changes in LOC occur. d. if the oral mucosa feels dry. ANSWER D Rationale: An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur. Q. A patient is taking hydrochlorothiazide, a potassium-wasting diuretic, for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as a. generalized weakness. b. facial muscle spasms. c. frequent loose stools. d. personality changes. ANSWER A Rationale: Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with hyperkalemia. Personality changes are not associated with electrolyte disturbances, although changes in mental status are common manifestations with sodium excess or deficit. Q. The long-term-care nurse is evaluating the effectiveness of protein supplements on a patient who has low serum total protein level. Which of these data indicate that the patient's condition has improved? a. Absence of peripheral edema b. Good skin turgor c. Hematocrit 28% d. Blood pressure 110/72 mm Hg ANSWER A Rationale: Edema is caused by low oncotic pressure in individuals with low serum protein levels; the absence of edema indicates an improvement in the patient's protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status Q. A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary Refill Capillary refill ANSWER C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema. Q. After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b.Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c.Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d.Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates ANSWER C Rational: The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications. Q. The nurse notes several angiomas on the legs of a 73-year-old patient. Which action should the nurse take next? a. Assess the patient for evidence of liver disease. b. Discuss the adverse effects of sun exposure on the skin. c. Educate the patient about possible skin changes with aging. d. Suggest that the patient make an appointment with a dermatologist ANSWER A Rational: Angiomas are a common occurrence as patients age, but they may occur with systemic problems such as liver disease. The patient may want to see a dermatologist to have the angiomas removed, but this is not the initial action by the nurse. The nurse may need to educate the patient about the effects of aging on the skin and about the effects of sun exposure, but the initial action should be further assessment Q. During assessment of the patient's skin, the nurse observes a ring of small, raised, discrete lesions filled with serous fluid on the patient's right temple. When documenting the lesions, the nurse will describe the lesions as a. grouped. b. confluent. c. zosteriform. d. generalized. ANSWER A The description of the lesions indicates that they are grouped. The other terms are inconsistent with the description of the lesions. Q. Lichenification is likely to occur in areas where the patient scratches the skin frequently. Thickening of the skin with accentuated normal skin markings. ANSWER Yellowish brown skin indicates Jaundice. Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities. Vitiligo-complete absence of melanin (pigment) resulting in chalky white patch. Keloids-hypertrophied scar beyond wound margins Understand these conditions: Lichenification, Vitiligo, Keloids, Yellowish-brown skin indicates? Q. You are in a position to provide patient education regarding the management of pruritus, topical application of medications, and proper skin care. ANSWER Factors affecting the outcome of long-term dermatological problems include skin type, history of previous exacerbation, family history, complications, intolerance to therapy, environmental factors, and lack of adherence to the prescribed regimen. It is important for the nurse to assist with the emotional stress that can occur for persons who suffer from certain chronic skin problems or have undergone some surgical procedures. C Careful hand washing and the safe disposal of soiled dressings are the best means of preventing the spread of skin problems. Q. The most common symptoms of poor circulation include: ANSWER tingling, numbness, throbbing or stinging pain in limbs, pain, muscle cramps Each potential condition that might lead to poor circulation can also cause unique symptoms. For example, people with PAD may experience erectile dysfunction in addition to typical pain, numbness, and tingling. Raynaud's disease can cause a prickly sensation or stinging in the affected extremities when they are warmed. Signs of decrease in circulation Q. A patient who has severe refractory psoriasis on the face, neck, and extremities has quit working and withdrawn from social activities because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of enrolling in a worker-retraining program. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life. ANSWER D Assess the impact of the disease on the patient's life and to allow the patient to verbalize feelings and allow the patient to verbalize feelings about the psoriasis. Depending on the assessment findings, other actions may be appropriate Q. The nurse uses auscultation during assessment of the urinary system to A. check for ureteral peristalsis. B. assess for bladder distention. Incorrect C. identify renal artery or aortic bruits. D. determine the position of the kidneys. ANSWER C The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information. Q. A patient with a possible renal cell tumor who is scheduled for an intravenous pyelogram (IVP) and computed tomography (CT) scanning of the abdomen gives the nurse all the following data. Which information has the most immediate implications for the patient's care? a. The patient has not had anything to eat or drink for 8 hours. b. The patient used a bisacodyl (Dulcolax) tablet the previous night. c. The patient describes allergies to shellfish and penicillin. d. The patient complains of costovertebral angle (CVA) tenderness. ANSWER C Iodine-based contrast dye is used during IVP and for many CT scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information is also important to note and document but does not have immediate implications for the patient's care during the procedures. The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to a. teach the patient to clean the urethral area, void a small amount into the toilet, then void into a sterile specimen cup. b. insert a short, small "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. c. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container. d. have the patient empty the bladder completely, and then obtain the next urine specimen that the patient is able to void. Answer: A Rationale: This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, "insert a short, small, 'mini' catheter attached to a collecting container" describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. And the technique described in the answer beginning "have the patient empty the bladder completely" would not result in a sterile specimen. A patient with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine specimen that is a red-orange color. Which action should the nurse take first? A. Notify the patient's health care provider. B. Ask the patient about use of any medications. C. Question the patient about any UTI risk factors. D. Teach about the correct procedure for midstream urine collection. Answer: B Rationale: A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, & does not need to be communicated to the health care provider until further assessment is done. Before planning any interventions, the nurse should complete the assessment and determine the patients normal state. Following an intravenous pyelogram (IVP), all of the following assessment data are obtained. Which one requires immediate action by the nurse? A. The heart rate is 58 beats/minute. B. The respiratory rate is 38 breaths/minute. D. The patient complains of a dry mouth. D. The urine output is 400 mL in the first 2 hours. Answer: B Rationale: The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patient's oxygen saturation & breath sounds. The other data are not unusual findings following an IVP. A patient with nephrotic syndrome develops flank pain. The nurse will anticipate treatment with a. antibiotics. b. antihypertensives. c. anticoagulants. d. corticosteroids. Answer: C Rationale: Flank pain in a patient with nephrosis suggests a renal vein thrombosis, and anticoagulation is needed. Antibiotics are used to treat a patient with flank pain caused by pyelonephritis. Antihypertensives are used if the patient has high blood pressure. Corticosteroids may be used to treat nephrotic syndrome but will not resolve a thrombosis. The patient with nephrotic syndrome will show signs of the following: A patient is admitted to the hospital with nephrotic syndrome after taking an OTC nonsteroidal antiinflammatory drug (NSAID) a week earlier. Which assessment data will the nurse expect to find related to this illness? a. Low blood pressure b. Recent weight gain c. Poor skin turgor d. High urine ketones Peripheral edema, massive proteinuria, hypertension, hyperlipidemia, and hypoalbuminemia. Focus on the management of edema, assess the edema by weighing the patient daily, record the intake and output, and measuring abdominal girth or extremity size, patients are usually anorexic and have potential to malnourished from excessive loss of protein in the urine. Patient is also susceptible to infection. Answer: B Rationale: The patient with a rapid-onset nephrotic syndrome will have rapid weight gain associated with edema. Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal because of the edema. Urine protein is high. The composition of a patient's renal calculus is identified as uric acid. To prevent recurrence of stones, the nurse teaches the patient to avoid a. spinach, chocolate, and tomatoes. b. organ meats and fish with fine bones. c. milk and dairy products. d. legumes and dried fruits. B Rationale: Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones. When obtaining the health history for a 30-year-old patient who smokes two packs of cigarettes daily, the nurse will plan to do teaching about the increased risk for a. interstitial cystitis. b. UTI. c. kidney stones. d. bladder cancer. Answer: D Rationale: Cigarette smoking is a risk factor for bladder cancer. The patient's risk for developing interstitial cystitis, UTI, or kidney stones will not be reduced by quitting smoking. Following rectal surgery, a patient voids about 50 ml of urine every 30 to 60 minutes. Which nursing action is most appropriate? a. Use an ultrasound scanner to check for residual urine after voiding. b. Have the patient take small amounts of fluid frequently throughout the day. c. Reassure the patient that this is normal after rectal surgery due to anesthesia. d. Monitor the patient's intake and output over the next few hours Answer: A Rationale: An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours. A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? a. Place a bedside commode near the patient's bed. b. Demonstrate the use of the Credé maneuver to the patient. c. Use an ultrasound scanner to check postvoiding residuals. d. Teach the use of Kegel exercises to strengthen the pelvic floor. Answer: A Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence. While the nurse is assessing a 62-year-old man, the patient says that he does not respond to sexual stimulation the way he did when he was younger. The nurse's best response to the patient's comment is, a. "Many men need more sexual stimulation with aging." b. "Interest in sex frequently decreases as men get older." c. "Erectile dysfunction is a common problem with older men." d. "Tell me more about how your sexual response has changed." Answer: D The initial response by the nurse should be further assessment of the problem. The other statements by the nurse are accurate but might not respond to the patient's concerns. An 18-year-old visits the health clinic for a routine check-up. To determine whether a Pap test is needed, which question should the nurse ask? a. "Do you use any illegal substances?" b. "Have you ever had sexual intercourse?" c. "How old were you when your menstrual periods started?" d. "Do you have any cramping with your menstrual periods?" Answer: B Rationale: The current American Cancer Society recommendation is that a Pap test be done every 3 years, starting 3 years after the first sexual intercourse and no later than age 21. The information about menstrual periods and substance abuse will not help to determine whether the patient requires a Pap test. Instruct sexually active women to have pap test according to american cancer society guidelines. Interact patient not to douche for at least 24 hours before examination. Collect careful menstrual and gynecologic history. A 19-year-old patient who is being assessed for amenorrhea at the clinic makes all of these statements to the nurse. Which one indicates a need for patient teaching? a. "I drink at least 3 glasses of non-fat milk every day." b. "I am not sexually active currently but I have an IUD." c. "I run 10 to 12 miles every day to keep in shape." d. "I had a bladder infection once about 3 years ago." Answer: C Rationale: Excessive exercise can cause amenorrhea. The other statements by the patient do not suggest any urgent teaching needs. Average tampon absorbs how much blood? 20-30ml All these data are obtained by the nurse while performing a physical assessment of a male patient's reproductive system. Which one should be reported to the health care provider? a. The foreskin is absent. b. Clear penile discharge is present. c. One testes hangs lower than the other. d. Inguinal lymph nodes are nonpalpable. Answer: B Rationale: Clear penile discharge may be indicative of a sexually transmitted disease (STD). The other findings are normal and do not need to be reported. A 38-year-old man is treated for hypertension with amiloride/hydrochlorothiazide (Maxide) and metaprolol (Lopressor). Four months after his last clinic visit, his BP returns to pretreatment levels and he admits he has not been taking his medication regularly. The best response by the nurse is, a. "Try always to take your medication when you carry out another daily routine so you do not forget to take it." b. "If you would exercise more and stop smoking, you probably would not need to be taking medications for hypertension." c. "The drugs you are taking cause sexual dysfunction in many patients. Are you experiencing any problems in this area?" d. "You need to remember that hypertension can be only controlled with medication, not cured, and you must always take your medication." Sexual dysfunction, which can occur with many of the antihypertensive drugs, including thiazide and potassium-sparing diuretics and B-blockers, can be a major reason that a male patient does not adhere to his treatment regimen. It is helpful for the nurse to raise the subject because sexual problems may be easier for the patient to discuss and handle once it has been explained that the drug might be the source of the problem Intimate partner history is important. Why? To know what they could have been exposed to. Chlamydia Chlamydia infections in men and women can be diagnosed by testing urine or collecting swab specimens from the endocervix or vagina (women) or urethra (men). Rectal swab specimens are tested in persons engaging in anal sex. Cell culture can be used to detect chlamydia organisms. The most common diagnostic test include the NAAT, DFA test and enzyme immunoassay, EIA. These test do not require special handling of specimens and are easier to perform than cell cultures. Amplification tests are the most sensitive diagnostic methods available and require fewer organisms. In addition, these tests can be used with urine samples rather than urethral and cervical swabs. A patient in the sexually transmitted disease clinic has a positive Venereal Disease Research Laboratory (VDRL) test, but no chancre is noted. The nurse will plan to send specimens for a. gram stain. b. cytologic studies. c. rapid plasma reagin (RPR) agglutination. d. fluorescent treponemal antibody absorption (FTA-ABS). ANS: D Since false positives are common with VDRL and RPR testing, FTA-ABS testing is recommended to confirm a diagnosis of SYPHILIS. Gram staining is used for other sexually transmitted diseases (STDs) such as gonorrhea and chlamydia and cytologic studies are used to detect abnormal cells (such as neoplastic cells). A patient in the STD clinic tells the nurse about a recent exposure to syphilis through sexual intercourse. The nurse teaches the patient that the fastest information about syphilis infection will be obtained from a. Venereal Disease Research Laboratory (VDRL) testing. b. rapid plasma reagent (RPR) agglutination. c. examination of a specimen obtained from an active chancre. d. fluorescent treponemal antibody absorption (FTA-Abs) testing. Rationale: If the patient has an active chancre, the Treponema pallidum bacteria can be visualized. The VDRL, RPR, and FTA Abs tests all will take longer. Cognitive Level: Comprehension Text Reference: p. 1339 Nursing Process: Implementation NCLEX: Physiological Integrity Know about syphilis. caused by Treponema palladium occurs through skin abrasions not all exposed get it Treatment for sexually transmitted infections along with patient teaching. seek treatment right away, abstain from sex for 7 days and until all partners have completed treatment as well Patient psychosocial assessment regarding sexually transmitted infections. shame, guilt, anger, frustrations, encourage them to share feelings, couples have to deal with cheating, herpes keep coming back, frequent office visits, costs Intimate partners and sexually transmitted infections. inform both, get tested, both get treated, use condoms, (EPT) allows pt to take prescriptions to their partner The usual technique in the physical assessment is to begin with inspection. inspect: starting at head or neck, to upper extremities, to lower extremities, to trunk: inspect for color, scars, previous injury/ surgery, note pts general build, muscle configuration and symmetry of joints,observe for swelling, deformity, nodule or masses, and discrepancies in limb or muscle size palpate, move When assessing the musculoskeletal system, the nurse's initial action will usually be to a. have the patient move the extremities against resistance. b. feel for the presence of crepitus during joint movement. c. observe the patient's body build and muscle configuration. d. check active and passive range of motion for the extremities. Answer: C Rationale: The usual technique in the physical assessment is to begin with inspection. Abnormalities in muscle mass or configuration will allow the nurse to perform a more focused assessment of abnormal areas. The other assessments are also included in the assessment but are usually done after inspection. Which nursing action is correct when the nurse is assessing the straight-leg raising test for a patient with back pain? a. Raise the patient's legs to a 60-degree angle from the bed. b. Have the patient dangle the legs over the edge of the exam table. c. Place the patient initially in the prone position on the bed or exam table. d. Instruct the patient to elevate the legs while tightening the abdominal muscles. ANS: A When performing the straight leg-raising test, the patient is in the supine position and the nurse passively lifts the patient's legs to a 60-degree angle. The other actions would not be correct for this test. Straight Leg Raise (SLR) * A nerve tension test used to rule out sciatica or L4-S1 nerve root irritation How to Perform: -Supine -You place one hand under the patient's heel and the other over the knee to keep the leg straight -You passively raise the patient's leg from the table, holding the knee straight (extended) until the onset of pain -You note the angle at which the onset of pain occurs as well as the location, quality, & magnitude of the pain Positive Test: 1. sharp, burning, electrical pain radiating past the knee with hip flexion between 35 and 70 degrees (hard positive) 2. pain radiating into lower extremity but not past knee (soft positive) 3. no pain at all or only pain in back or to buttocks 4. focal point of pain in the leg or pelvis Positive Test Indicates: 1. A "hard" positive test suggests + sciatic nerve irritation + L4-S1 nerve root radiculitis -Other causes: + lumbar disc herniation + tumor + spinal canal stenosis + encroachment by spurring or osteophytes 2. A "soft" or "equivocal" positive suggests: -considered meaningful if any other evidence suggests that nerve root or sciatic nerve is inflamed or compressed -considered insignificant if no other evidence supports radicular syndrome 3. no pain at all or only pain in back or to buttocks suggests: -NEGATIVE for nerve root involvement -if pain, it is most likely sacroiliac or lumbar 4. focal point of pain in the leg or pelvis -ALARM sign suggesting a tumor (soft tissue or bony) in location of pain * pain between 0-35 degrees: lumbar strain, piriformis spasm, or sacroiliac * pain between 35-70 degrees: disc and or nerve root involvement * pain over 70 degrees: sacroiliac or lumbar joint pain MRI Safety no metal, remain still, inform claustrophobic pt they will experience symptoms, administer anti anxiety med if necessary, open MRI can be preformed for obese, large chested and large abdominal girth, or severe claustrophobic Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. The nurse is caring for a patient in Buck's traction. Which task is best to delegate to the UAP (with supervision)? a. Turning and repositioning b. Inspecting heels and sacral area c. Asking the patient about muscle spasms d. Adjusting the weights on the apparatus a. Turning and repositioning A patient with a long leg cast that was applied in the ED is being admitted to the Orthopedic unit. Which task is best for the nurse to delegate to the UAP? a. Obtain a fracture bedpan and use caution to prevent spillage on the cast b. Obtain several plastic covered pillows for elevation of the leg c. Check flexion/extension and color of the toes d. Turn the patient every 4 to 6 hours to allow the cast to dry a. Obtain a fracture pan and use caution to prevent spillage on the cast The unlicensed assistive personnel (UAP) is assisting the orthopedic physician to cut a window in a patient's cast. What does the nurse instruct the UAP to do? a. Check the pulse that is accessed after the window is cut b. Clean up and dispose of all casting debris c. Inform the patient that the procedure is painless d. Save the plaster piece that was cut so it can be taped in place d. Save the plaster piece that was cut so it can be taped in place Delegating care of the orthopedic patients to the UAP. can: position casted extremity above heart level apply ice to cast as directed by RN maintain body position and integrity of traction (after being trained and evaluated in the procedure) assist patient with passive and active ROM exercises Notify RN about pt complaints of pain, tingling, or decreased sensation in the affected extremity Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg. ANS: C The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment. Testing for Tinel's sign. tapping over the median nerve as it passes through the carpal tunnel in the wrist + a sensation of tingling in the distribution of the median nerve on the hand Tinel's sign: TESTS FOR CARPAL TUNNEL Percuss lightly over the median nerve in the carpal tunnel Tingling=positive Tinel's signs which suggests carpal tunnel 3. Which person is most likely to qualify for Program of All Inclusive Care for the Elderly (PACE)? (1178) 60-year-old woman with mild dementia who needs adult daycare when her daughter is at work 4. The LPN/LVN staffing coordinator receives an incomplete report about an older person (Mr. X) who is requesting home care. Which question is the most important to ensure appropriate scheduling and assignment? (1178) 3. "Does Mr. X need assistance with activities of daily living or skilled nursing care?" 5. Which outcome statement indicates that the primary goal of hospice care has been met? (1178) 4. Patient is clean, dry, comfortable, and pain-free. 6. Which patient is most likely to benefit from palliative care? 2. Patient with a feeding tube and oxygen therapy shows slow but steady deterioration. The nurse is giving anticipatory guidance to a woman who provides around-the-clock care for an older grandmother with early stage Alzheimer's disease. Which action would the nurse suggest to avoid a "precipitating event" that would lead to sudden long-term care placement for the grandmother? (1181) 1. Check home for safety hazards. The LPN/LVN is caring for 60 residents at a long-term care facility with a team of four certified nursing assistants (CNAs) and two certified medication aides (CMAs). What role/ responsibilities related to medication administration is the LPN/LVN most likely to assume? 2. LPN/LVN will administer opioids, non-opioids, enteral tube, and as-needed (PRN) medications. 9. What is an example of a person who requires assistance with instrumental activities of daily living? 4. Owns a car, but vision and psychomotor coordination are poor Before a clinical rotation at a long-term care center, the nursing instructor advises a group of first-year nursing students to do some reading about health problems that are likely to be found among the older adult residents. Which list represents the most common disorders that the students will see? (1181) 1. Cardiovascular disease, hypertension, depression, dementia, and type 2 diabetes The nurse is training a new CNA at a long-term care facility. Which topics would the nurse include in the CNA's training regarding activities of daily living? Select all that apply. 1. Equipment needed for bathing or showering 2. Ways to maintain independence in brushing teeth 4. Safety measures to use during ambulation 6. Ways to maintain privacy during toileting 12. A patient requires extensive wound care and intravenous antibiotics due to an infection of a surgical wound. Which type of care will best meet his needs? (1180) 2. Subacute unit 13. Which nursing action reflects the positive influence of the Omnibus Budget Reconciliation Act (OBRA) on long-term care? (1182) 3. Reviews the qualifications of a CNA who applied for a job An older couple needs assistance with bathing, dressing, and taking their medication. Both are always alert and oriented. They are mobile but suffer from arthritis. Which setting would be the most beneficial for this couple? (1179) 1. 4. Assisted-living community 15. The interdisciplinary team at a long-term care facility is meeting to discuss the care plan of one of the residents. Who should attend this meeting?Select all that apply. (1181) 1. Physical therapist 2. Activities director 3. CNA 4. Nursing unit manager 6. Resident The nurse is talking to a nursing student who is doing a clinical rotation in a nursing home facility. What is the priority concept that the nurse will emphasize during the student's orientation to the facility? 3. Residents' safety and security What is the purpose of a resident assessment instrument? (1184) 1. Facilitates assessment of functional, medical, mental, and psychosocial status How does documentation in a long-term care facility differ from that in a hospital setting? (1184) 3. Summaries of resident status over a longer time, usually monthly, are recorded. An older patient is alert, ambulatory, and can independently perform activities of daily living. Recently, he has started wandering and today the police had to bring him back home. Which question would the nurse use first to help the family determine if long-term care is needed? 3. "What kinds of options have you considered for your dad?" An interdisciplinary team meeting is planned to discuss the needs and goals of a resident who is very hostile about being in the long-term care facility. The CNA who has the best relationship with the resident is not invited to attend. What should the nurse do? 2. Advocate for the CNA to attend. An older patient who had a stroke has multiple residual symptoms. The spouse wants more therapy for her husband so he can "be like himself." What should nurse do first? 3. Assess what spouse means by "be like himself" and her expectations of additional therapy. 4. Which patient action is the best demonstration of a functional outcome? 4. Patient independently ambulates around the house Which outcome statement best indicates that the goal of rehabilitation has been successfully met? (1190) Patient telecommutes for work, regularly attends church, and joins a chess club. 6. The physiatrist tells the nurse that the patient with a spinal cord injury may be developing heterotopic ossification in the right knee. How would the nurse use this information in planning care for this patient? 2. Ask the physical therapist about type and frequency of range-of-motion exercises. Which patient needs interventions that are based on the habilitative approach? (1200) 4. Child who was born with spina bifida The nurse is assisting a patient with a spinal cord injury to move into a wheelchair. What should the nurse do first to prevent postural hypotension? (1197, Raise the head of the bed 15-20 minutes before moving him. The nurse works at a rehabilitation unit and is assigned four patients with the following medical conditions: arthritis, spinal cord injury, stroke, and multiple sclerosis. What basic nursing measure is common to the care of these four patients? (1192) 1. Maintaining body alignment and position changes 10. Which patient is most likely to need cues and reminders to accomplish activities of daily living? (1199) Has traumatic brain injury (TBI) The patient experienced a spinal cord injury at the T1-T5 level. What should the patient be able to do? 1. Assist with activities of daily living. A construction worker sustained an injury to C3 after a fall at a work site. What does the nurse anticipate that this patient will demonstrate? Potential for respiratory failure and infections The spouse reports that her husband tripped and bumped his head. He never lost consciousness but seemed confused for a few minutes after the accident. Which assessment finding does the nurse expect? (1199) 1. Headache and vertigo The patient has a spinal cord injury above the level of T5. While assisting with hygienic care, the nurse notices that the patient is diaphoretic and shivering, and he states that he has a headache. Upon assessment, it is found that his blood pressure is elevated. What should the nurse do first Check for bladder distention. The older patient with a hip fracture has a self-care deficit related to bathing due to problems with ambulation and balance. Which action would the nurse use to foster independence, while ensuring safety? 4. Assist the patient to sit in a stable chair in the shower stall and adjust the water temperature of the handheld shower spray. 18. Which patient is most likely to need minimization of distractions that would prevent participation in therapy? (1199 3. Patient who had a traumatic brain injury 19. A patient had cardiac surgery. His condition is much improved, but it seems unlikely that he will be able to return to his job. The spouse expresses fears that her husband will die if she doesn't quit her job and stay home to take care of him. In this case, what would be considered the best outcome 2. Spouse acknowledges patient's ability to independently stay at home. 20. A patient was involved in an explosion at a chemical factory and sustained polytrauma/ blast-related injury. What types of injuries would the health care team expect to find? Select all that apply 1. Burns 2. Fractures of extremities 3. Chemical pneumonitis 4. Brain injury 6. Hearing loss The nurse is assessing a patient who had a stroke and was recently admitted to the rehabilitation unit. What is the best method to determine how much assistance is required for hygienic care? (1193) 2. Passive and active range-of-motion exercises 4. Administration of anticoagulants 5. Application of elastic stockings 6. Assessment for swelling, redness, and heat in extremities The nurse anticipates that the patient with a spinal cord injury is at risk for venous thrombosis. Which interventions will be used for prevention? Select all that apply. (1199 4. Observe the patient as he performs tasks such as eating.