Answers 2024/2025
.0 to 10 pain scale - ANSWER-The nurse has the child rate the level of pain on a 0
to 10 pain scale.
.ABC Principles - ANSWER-Continuous monitoring and a systematic approach
following ABC (Airway, Breathing, Circulation) principles are essential for
providing timely and appropriate care.
.Abdominal assessment for teen female - ANSWER-Assess the area that is most
tender first.
.Abdominal assessment steps - ANSWER-Inspection, auscultation, percussion,
palpation, and special maneuvers while ensuring patient comfort and privacy.
.Abdominal Pain Patient - ANSWER-A patient writhing and moaning from
abdominal pain after abdominal surgery.
.Abnormal Finding Reporting - ANSWER-If another health care provider reports
an abnormal finding, the RN is responsible to assess the patient.
.Absent bowel sounds - ANSWER-Not hearing bowel sounds after 5 minutes may
indicate an obstruction and requires further evaluation.
,.Action for patient in emergency holding - ANSWER-Expedite the process of
obtaining a medical-surgical room for the patient.
.Actions for wound dehiscence - ANSWER-Apply sterile saline-moistened
dressings, position the patient to minimize tension, notify the surgeon, and
prepare for possible return to the operating room.
.Actions for wound evisceration - ANSWER-Do not push contents back, cover
with sterile dressings, position the patient on their back with knees flexed,
notify the surgeon, and prepare for immediate transfer to the operating room.
.Adaptation to sensory deficit - ANSWER-The patient turns one ear toward the
nurse during conversation.
.Additional Medications - ANSWER-Medications like methylnaltrexone,
naldemedine, and naloxegol can be added if laxatives are insufficient.
.Adequate suction in drainage devices - ANSWER-Ensures proper function when
connected to low continuous suction.
.Adverse effects of morphine - ANSWER-Respiratory rate, depth, and effort;
level of sedation; pain control; constipation; nausea/vomiting; pruritus; urinary
retention.
.Analgesic Medication Need - ANSWER-The patient's need for analgesic
medication decreases during the dressing changes.
,.Analgesic medications - ANSWER-Pain relief medications that may be provided
before changing a dressing.
.Anomic aphasia - ANSWER-Causes word-finding difficulties. Patients can
understand and produce grammatically correct sentences but frequently pause,
unable to retrieve specific words.
.Anticipating Constipation - ANSWER-Anticipate constipation in all opioid
patients and implement preventive measures promptly.
.Applying petrolatum or hydrogel dressing - ANSWER-A thin layer is applied to
the wound bed before covering it with a sterile dressing.
.Appropriate Task for UAP - ANSWER-Obtaining vital signs for Patient A (stable
post-op).
.Ascites - ANSWER-Ascites (fluid accumulation in the abdomen).
.Assess Neurovascular Status - ANSWER-Assess neurovascular status distal to
the fracture by checking pulses, capillary refill, sensation, and movement.
.Assessing bony prominences - ANSWER-Part of the skin integrity assessment to
identify areas at risk for breakdown.
.Assessing pain in oriented patients - ANSWER-The nurse asks the patient to
rate the level of pain.
, .Assessment findings for adaptation to presbycusis - ANSWER-Findings include
turning up volumes, leaning in closer, and using visual cues.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Anxiety,
irritability, and restlessness.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Changes in
physiological function such as temperature.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Decreased
appetite and weight loss.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Impaired
judgment.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Nausea,
vomiting, and diarrhea.
.Assessment findings for disrupted sleep-wake cycle - ANSWER-Shortness of
breath and chest pain.
.Assessment findings for presbycusis - ANSWER-Indicators include turning up
volumes, leaning in closer during conversations, frequently asking for repetition,
avoiding social situations, using visual cues, obtaining hearing aids, and
rearranging living spaces.
.Assessment of abdominal protrusions - ANSWER-Visible protrusions.