Which action by the student nurse performing a cardiovascular assessment requires correction quizlet?

Ans: B,C Assess for activity intolerance and shortness of breath. Note increase in systolic, diastolic, and pulse pressures.

Rationale: Changes that occur in the older patient's heart include systemic vascular resistance that increases as a result of the less distensible arteries; therefore, the left ventricle (LV) pumps against greater resistance, contributing left ventricular hypertrophy. The nurse should assess for activity intolerance and shortness of breath, and note any increase in systolic, diastolic, and pulse pressures and while caring for the patient. Heart sounds for murmurs should be assessed if the patient has changes in cardiac valves. Dizziness, when the patient changes positions, should be possessed when baroreceptors become insensitive. Assessment of electrocardiogram (ECG) for widening QRS complex and a longer QT interval should be carried out when the patient has increase in size of the LV.

Patient 4

The normal values of serum lipids are total cholesterol value less than 200 mg/dL, triglycerides between 40 and 160 mg/dL, high-density lipoproteins (HDLs) more than 45 mg/dL, and low-density lipoproteins (LDLs) less than 130 mg/dL. Patient 4 has elevated total cholesterol, triglycerides and LDLs along with lower than recommended HDLs, which indicate a risk for CAD.While performing a cardiovascular assessment of a patient, the nurse detects a very loud heart murmur accompanied by a palpable thrill. This is audible even if the stethoscope is partially off the patient's chest. What grade of heart murmur does this describe?

The nurse supervises a student nurse performing the initial assessment of a patient. Which action by the student nurse needs correction?

1. The nurse offers a glass of water to the patient.
2. The nurse avoids direct eye contact with the patient.
3. The nurse checks the name on the patient's wristband.
4. The nurse performs hand washing in front of the patient.

2

Rationale:
During the assessment, the student nurse should maintain direct eye contact with the patient. This helps establish nonverbal communication with the patient. Failing to maintain eye contact with the patient, the student nurse may become distracted during the assessment. The nurse should offer water to the patient as a courtesy. This also helps assess the patient's hearing ability and swallowing reflex. The student nurse should check the name on the patient's wristband to avoid confusion and to provide appropriate treatment. The student nurse should wash hands in the front of the patient to assure good hygiene.

While examining a patient, the nurse checks the patient's weight, determines body mass index, and hydration status. What is the rationale behind these interventions?

1. To identify neurologic disorders in the patient
2. To establish the nutritional status of the patient
3. To identify gastrointestinal disorders in the patient
4. To determine the endocrine functioning in the patient

2

Rationale:
The assessment data with regard to the patient's weight, hydration status, and the body mass index help determine the nutritional status of the patient. This helps identify whether the patient is obese or underweight due to malnourishment. The nurse should check the levels of consciousness, alertness, and cognitive ability of the patient to identify the neurologic disorders in the patient. The nurse should check the levels of the endocrine hormones to determine the endocrine functioning. The nurse should monitor the patient's bowel movements and appetite to identify whether the patient has gastrointestinal disorders.

During the assessment of the patient, the nurse asks the patient to push both the feet against the nurse's palm. What is the nurse assessing by doing this?

1. The sensation of the lower limb
2. The balance of the lower limbs
3. The skin turgor in the lower limbs
4. The strength of the lower limb muscles

4

Rationale:
By asking the patient to push his feet against the nurse's palm, the nurse is trying to assess the strength of the lower limb muscles, such as the plantar flexors. Skin sensation in the lower limb can be assessed by asking the patient to tell where the nurse is touching. Balance of the lower limbs can be assessed by asking the patient to stand and walk. Skin turgor is assessed by pinching a skin fold.

By asking the patient to push his feet against the nurse's palm, the nurse is trying to assess the strength of the lower limb muscles, such as the plantar flexors. Skin sensation in the lower limb can be assessed by asking the patient to tell where the nurse is touching. Balance of the lower limbs can be assessed by asking the patient to stand and walk. Skin turgor is assessed by pinching a skin fold.

1. The patient is postoperative.
2. The patient's blood pressure is low and may be caused by internal hemorrhage.
3. The patient may need a blood transfusion and surgical exploration.
4. The patient underwent abdominal surgery a day ago.

2

Rationale:
The SBAR framework helps in verbal reporting. It consists of four elements: situation, background, assessment, and recommendation. "A" stands for "assessment" and includes information about the patient's vital signs and the probable cause. The assessment findings include that the patient's blood pressure is low possibly owing to internal hemorrhage. The situation is that the patient is postoperative. The recommendation is that the patient may need a blood transfusion and surgical exploration. The background is that the patient underwent abdominal surgery a day ago.

The nurse is assessing the skin of the patient. How would the nurse assess the skin turgor of the patient?

1. By pinching the skin of the forearm
2. By palpating the skin on the forearm
3. By palpating the skin on the forehead
4. By pinching the skin over the forehead

1

What is Doppler imaging used for?

1. It helps to determine muscle strength.
2. It helps to determine the pupillary reflex.
3. It helps to determine bladder functioning.
4. It helps to assess pulses in the lower extremities.

4

Rationale:
Doppler imaging is an ultrasonographic technique that helps to assess pulses in the lower extremities. It does not measure grip strength and does not help to determine muscle strength. It does not measure the diameter of the pupil in response to light. Thus, it does not determine the pupillary reflex. Doppler imaging does not measure urine volume and does not determine bladder functioning.
p. 802

What question should the nurse ask during the pain assessment of a hospitalized cancer patient?

1. "When did you last take pain medication?"
2. "Which pain medications are you taking?"
3. "Have you been given any epidural analgesia?"
4. "Do you currently have any pain or discomfort?"

4

Rationale:
A patient with cancer may have severe pain and would be given analgesic therapy. While doing the pain assessment of such patients, the nurse should ask the patient about any pain or discomfort. This would help the nurse determine the efficacy of the pain medications. The nurse should gather the information from the medical records about the time of the administration of the last pain medication, the type of medications prescribed, and whether the patient has been given any epidural analgesia. Therefore, before doing the actual pain assessment, the nurse should gather all the information about the pain therapy from the patient's reports.

While assessing a patient, the nurse finds that the patient's respiratory rate is 26 breaths/minute, urinary output is 40 mL/hour, body temperature is 98 o F (36.6 o C), and heart rate is 120 beats/minute. What does the nurse interpret from these findings?

1. The patent has bradypnea.
2. The patient has tachycardia.
3. The patient has hyperthermia.
4. The patient has urinary retention.

2

Rationale;
An increase in the heart rate is known as tachycardia. A heart rate above 90 beats/minute indicates that the patient has tachycardia. A respiratory rate of 12 to 28 breaths/minute is a normal finding. Therefore, a respiratory rate of 26 breaths/minute does not indicate that the patient has bradypnea, or low respiratory rate. An increase in body temperature indicates that the patient has hyperthermia. A body temperature of 98 o F (36.6 o C) is normal. A urinary output of 800 to 2000 mL/24 hours is a normal finding. Therefore, the urinary output of 40mL/hour does not indicate that the patient has urinary retention.

While examining a patient with peripheral artery disease, the nurse was unable to palpate the dorsalis pedis pulse. Which intervention should the nurse complete immediately?

1. Elevate the patient's bed to a 45° angle
2. Perform Doppler imaging on the patient
3. Obtain an order for an electrocardiogram
4. Administer cardiac glycosides to the patient

2

Rationale:
Doppler imaging is a diagnostic test that helps to evaluate blood flow in the arteries; when the nurse is unable to palpate the patient's dorsalis pedis pulse, then the nurse should perform Doppler imaging. Elevating the patient's bed to an angle of 45° does not help to determine the patient's dorsalis pedis pulse. An electrocardiogram helps to determine the heart rate and rhythm. It does not help to determine the presence of the dorsalis pedis pulse. Cardiac glycosides help to treat heart failure but are not helpful in the treatment of peripheral artery disease.

The nurse is assessing the peripheral circulation of a patient. The patient has lower limb edema, and the nurse is not able to palpate the posterior tibial and dorsalis pedis pulsations. What action should the nurse take?

1. Assess the pulsations through Doppler imaging.
2. Assess the pulsation using magnetic resonance imaging.
3. Assess the pulsations after elevating the patient's limbs.
4. Assess the pulsations after the swelling has subsided.

1

Rationale:
Peripheral circulation assessment is an important part of the cardiovascular assessment. The nurse is not able to palpate the posterior tibial and dorsalis pedis pulsations due to lower limb edema. Thus, to assess the integrity of the peripheral vessels, the nurse should assess these pulsations via Doppler imaging. Magnetic resonance imaging is not useful in assessing circulation in the peripheral vessels. Elevating the patient's limb would reduce the swelling. However, reduction of swelling would not be immediate, and the nurse would have to wait to assess the peripheral pulsations. The nurse cannot determine the time required for the swelling to subside. Thus, the nurse should not wait for the swelling to subside to assess for the peripheral pulsations.

The student nurse is caring for a patient with a urinary catheter. The nurse instructed the student nurse to monitor the patient's blood pressure, pulse rate, and rate of respiration every hour. Which additional parameter would the student nurse monitor in the patient every time while determining these parameters?

1. Skin integrity
2. Blood glucose level
3. Red blood cell count
4. Color and quantity of urine

4

Rationale:
A urinary catheter drains urine and empties the bladder. However, a patient with a urinary catheter has an increased risk of urinary tract infection (UTI). Therefore, the nurse should monitor the color, quantity, and clarity of urine while monitoring the vital signs. A urinary catheter does not increase the risk of skin infection. Hence, the nurse would not monitor the patient's skin integrity. Blood glucose levels help to diagnose diabetes mellitus, not UTI. UTI is not associated with a change in the number of red blood cells. Therefore, the nurse would not monitor the patient's red blood cell count.

While assessing a patient, the nurse finds that the patient has ptosis. What does the nurse conclude from this finding?

1. The patient has a risk of hearing impairment.
2. The patient has a risk of genitourinary disorders.
3. The patient has impaired cardiovascular functioning.
4. The patient has impaired neuromuscular development.

4

Rationale:
Ptosis is a condition characterized by the presence of drooping eyelids. It is caused by impaired neurologic and muscle development. Therefore, the nurse suspects that the patient has impaired neuromuscular development. Ptosis is not a hearing disorder. A patient with ptosis may not have clear vision because of the drooping eyelids. Ptosis is not caused by impaired renal or cardiovascular functioning, so the nurse would not assume the patient has a genitourinary or cardiovascular disorder.

The nurse reports to the health care provider that a 1-year-old child admitted to the hospital 3 days ago with high fever has had a seizure. The child is safe and has no physical injuries. The fever is high, and the child may need injectable antipyretics. The nurse requests that the health care provider see and assess the child and plan further interventions. Which of the nurse's statements reflects the "R" element of the Situation, Background, Assessment, and Recommendation (SBAR) framework?

1. The child is safe and has no physical injury.
2. A 1-year-old child admitted with fever has had a seizure.
3. The child has a high fever and may need injectable antipyretics.
4. The health care provider should see the child and plan further treatment.

4

Rationale:
"R" stands for "recommendation" and includes the nurse's suggestions. The nurse requesting that the health care provider see and assess the child and plan further intervention is included in the recommendation element of SBAR. The child being admitted with fever and having a seizure is included in the "S" element. Information such as the child being safe and having no physical injury and the child maybe needing injectable antipyretics for a high fever is included in the "A" element.

While assessing a patient with peripheral vascular disorder, the nurse finds that the patient has lower limb edema and lesions on the legs. What would the nurse do in order to provide effective treatment for the patient?

1. Check hemoglobin levels
2. Recommend a bladder scan
3. Palpate the posterior tibial pulse
4. Determine blood glucose levels

3

Rationale:
Rationale
Lower limb edema and lesions indicate that the patient may have pretibial edema. The posterior tibial artery is located in the lower limb. Varicosity of this vein may cause edema by impairing blood supply. Therefore, the nurse would palpate the posterior tibial pulse to diagnose the patient's illness. If the patient has reduced urinary output, then the nurse would recommend a bladder scan for the patient. Peripheral vascular disorder is not associated with alteration in the blood glucose and hemoglobin levels.

While examining the patient, the nurse finds that the patient's respiratory rate is 10 breaths/minute, urinary output is 50 mL/ hour, and body temperature is 98 o F (36.6 o C). Which intervention does the nurse expects to be beneficial for the patient?

1. Providing excess oral fluids
2. Teaching deep breathing exercises
3. Reducing the room temperature
4. Placing the patient in a prone position

2

Rationale:
A respiratory rate of 10 breaths/minute indicates that the patient has difficulty in breathing. Therefore, the nurse would teach deep breathing exercises to the patient to prevent breathlessness. A urine output of 50 mL/hour is a normal finding. It does not indicate that the patient has a risk of dehydration. Therefore, the nurse would not provide excess fluid to the patient. A body temperature of 98 o F (36.6 o C) is a normal finding. It does not indicate that the patient has hyperthermia, so the nurse would not reduce the room temperature. The nurse should avoid placing the patient in the prone position, because it can cause breathlessness in the patient.

The nurse supervises a student nurse who is performing the cardiovascular assessment of a patient. Which step taken by the student nurse needs correction?

1.Checking the capillary refill for prompt return

2. Comparing the apical pulse with the radial pulse

3. Auscultating the apical pulse after removing the patient's gown

4. Assessing the heart sounds by first using the bell of the stethoscope

4

Rationale:
The student nurse should assess the normal heart sounds using the diaphragm of the stethoscope and should then use the bell to listen to the abnormal cardiac murmurs. The student nurse should assess the capillary refill and compare the apical pulse with the radial pulse to assess the integrity of the peripheral circulation. The student nurse should remove the patient's gown before auscultating the apical pulse to prevent muffling of heart sounds.

The nurse is completing an electronic health record (EHR) for a new patient. Which patient data should the nurse include?

1. Scheduled visits
2. Clinical findings
3. Medical history
4. Expenses incurred
5. Laboratory results

2, 3, 5

Rationale:
An EHR contains all information related to the patient's health. Information such as laboratory results, clinical findings, and medical history are directly related to the patient's health and are therefore included in the EHR. Information such as expenses incurred and scheduled visits are not included in the EHR.

When the nurse is organizing patient data for verbal communication, which of the nurse's questions would reflect element "B" of the Situation, Background, Assessment, and Recommendation (SBAR) framework?

1. "What interventions may help the patient?"
2. "What is happening to the patient right now?"
3. "What are the patient's current medications?"
4. "Which body system is affected in the patient?"

3

Rationale:
Background includes information about the patient's data related to present problems, including current medications. It helps the health care provider to understand the patient's condition. The "S" element includes information about what is happening to the patient at that time. The "A" element of SBAR includes information about which system is affected in the patient. The "R" element of SBAR includes information about the interventions that may help the patient.

The nurse instructs a student nurse to monitor the pulse rate every 30 minutes, blood pressure every 1 hour, and temperature every 4 hours in a cancer patient. While recording the pulse rate, the student nurse gets distracted by the sound of a bell ring by a 2-year-old child in the adjacent room. What should the student nurse do in this situation?

1. Ask the child to stop ringing the bells
2. Inform the nurse about the child's action
3. Continue recording the patient's pulse rate
4. Determine the patient's pulse rate after 2 hours

3

Rationale:
Sounds such as ringing of the bells in the adjacent room may distract the student nurse, which would cause the student nurse to not be able to record the patient data accurately. However, the student nurse is responsible for delivering effective care to the patient. Therefore, despite distractions, the student nurse should continue recording the vitals of the patient on time. The child is young and is playing with the bells. Therefore, the student nurse should not ask the child to stop ringing the bells nor complain about the child to the nurse. It is important to measure the vitals at specified intervals. The patient with cancer may have an abnormal heartbeat. Therefore, determining the pulse rate after 2 hours may result in serious complications.

In which situations should the nurse use the Situation, Background, Assessment, and Recommendation (SBAR) framework for communication?

1. When recording vital signs in the patient's chart
2. When organizing assessment findings on the admission form
3. When informing a nurse in another unit about the patient's transfer
4. When calling the health care provider to report the patient's condition
5. When giving nursing shift reports to other nurses working the next shift

3, 4, 5

Rationale;
The SBAR framework is used to organize the patient's data for providing verbal reports. These reports include calling the health care provider to report the patient's condition. In this situation, SBAR helps to communicate the essential information quickly to obtain the orders for the intervention required. SBAR is also used when the nurse provides a shift report to other nurses; it helps to avoid duplications of interventions. A nurse also uses the SBAR framework to inform nurses in other units when a patient is transferred. It helps in maintaining continuity of care. Information about the patient's vital signs and organizing the assessment findings in the patient's admission form are not a part of the SBAR framework.

The nurse is caring for a patient with a peripheral vascular disorder. What should the nurse monitor in this patient frequently?

1. Intensity of abdominal pain
2. Blood pressure and pulse rate
3. Presence of gangrene in the legs
4. Thyroid stimulating hormone levels
5. Presence of canker sores in the mouth

2, 3,

Rationale;
When caring for the patient, the nurse should be aware of the parameters that require continuous monitoring in order to prevent severe complications in the patient. Peripheral vascular disorder (PVD) is associated with narrowing of the arteries and impaired blood supply. This may increase blood pressure and result in hypertension. Therefore, the nurse should frequently monitor the patient's blood pressure. The patient with PVD has impaired blood supply to the lower limbs, resulting in tissue death. This may cause necrosis and may result in gangrene in the legs. Therefore, the nurse should check for the presence of gangrene in the legs. PVD may result in leg pain, but not abdominal pain. PVD may be caused by deposition of fat in the blood vessels, but not by an increase in thyroid stimulating hormone levels. PVD may cause painful sores on the foot because of impaired blood supply. It is not associated with canker sores in the mouth. Therefore, the nurse would not monitor these conditions in the patient frequently.

The nurse is caring for a patient who has undergone abdominal surgery the previous day. The patient has a stable oxygen saturation of 96%. The health care provider has prescribed an incentive spirometer for the patient. What instruction should the nurse give to the patient regarding using the incentive spirometer?

1. "Take 10 deep inspirations every hour using this device."
2. "Take 3 deep inspirations every hour using this device."
3. "Take 10 deep inspirations every 15 minutes using this device."
4. "Take 3 deep inspirations every 30 minutes using this device."

1

Rationale;
An incentive spirometer helps to improve the patient's inspiratory volume. Because the patient has a stable oxygen saturation, the nurse should instruct the patient to take 10 deep inspirations every hour using this device. The patient whose respiratory rate or oxygen saturation has dropped should be encouraged to take 10 deep inspirations every 15 minutes using this device. Taking 3 inspirations every hour or every 30 minutes would not be helpful to improve the inspiratory volume of a patient who has undergone abdominal surgery.

The nurse is planning to assess a hospitalized patient with active tuberculosis. Which assessment should the nurse complete first?

1. Whether the patient has any breathing difficulty

2. Whether the patient has had a recent chest x-ray

3. Whether the patient's room has a marker for isolation

4. Whether the patient received the prescribed doses of antibiotics

3

Rationale:
Tuberculosis is an airborne infection and is contagious. A patient with active tuberculosis should be kept in an isolation room. Therefore, even before entering the patient's room, the nurse should ensure that the patient's room has a marker for isolation. This helps the health care professionals and the visitors take proper measures to prevent the spread of infection. The nurse should assess whether the patient has breathing difficulty, whether the patient has had a recent x-ray, and whether the patient is being administered proper doses of the medications after entering the patient's room.

The nurse is supervising a student nurse who is assessing a patient in the cardiac unit. Which step taken by the student nurse needs correction?

1. Introducing him- or herself after entering the patient's room

2. Documenting the patient's vital signs after talking to the patient

3. Repeating the questions asked by the nurse in the previous shift

4. Maintaining direct eye contact with the patient during the assessment

3

Rationale:
The student nurse should first refer to the notes documented by the nurse in the previous shift and find out the questions asked by the nurse. The student nurse should not repeat the same questions asked by the nurse in the previous shift, because answering the same questions again and again might increase distress in the patient. The student nurse should first introduce him- or herself after entering the patient's room. This would help the patient become acquainted with the student nurse. The student nurse should document the vital signs after talking to the patient and not during the history collection, because this may make the patient feel that the student nurse is not interested in the history given by the patient. The student nurse should maintain direct eye contact with the patient. This would indicate that the student nurse is paying attention to what the patient is saying.

The nurse is caring for a pregnant patient who has been administered epidural anesthesia during labor. Which intervention would the nurse follow to ensure the patient's safety?

1. Monitor patient's vitals every 4 hours.
2. Administer intravenous analgesics to the patient.
3. Ensure that the patient has 92% oxygen saturation.
4. Place the patient in the prone position after the procedure.

3

Rationale:
The epidural anesthesia causes central nervous system depression and may result in respiratory depression and breathlessness in the patient. Therefore, to prevent hypoxia and breathlessness, the nurse should ensure that the patient has an oxygen saturation level of 92%. The patient receiving epidural anesthesia has a risk of cardiac failure and respiratory depression. Therefore, the nurse should monitor the vital signs frequently to ensure safety. Epidural anesthesia and intravenous analgesics may interact and cause severe vasodilatation. This would worsen the patient's condition. The nurse should avoid placing the patient in the prone position because it causes breathlessness.

The nurse is caring for a patient who has hypovolemia caused by severe bleeding. The health care provider has prescribed a blood transfusion and intravenous (IV) lactated Ringer solution. Which action would the nurse follow to provide effective care to the patient?

1. The nurse would cross-check the label on the IV solution with the written prescription.

2. The nurse would flush the IV tubing with dextrose before transfusing the blood.

3. The nurse would raise the patient's bed at an angle of 45° while administering blood.

4. The nurse would administer blood and lactated Ringer solution simultaneously.

1

Rationale:
The nurse should cross-check the label on the IV solution with the written prescription before administering the medication. This action helps the nurse to confirm the rate and type of solution prescribed and to prevent a medication error such as administering the wrong medication to the patient. Dextrose interacts with the blood and causes hemolysis, so the nurse would not flush the IV tubing with dextrose solution. Raising the bed to a 45° angle would increase signs and symptoms of hypovolemia; therefore, the nurse would not raise the bed to a 45° angle. The nurse would not administer blood and lactated Ringer solution simultaneously, because they may interact and cause adverse effects.

While assessing a patient, the nurse finds urine output to be 20 mL/hour. Which intervention should the nurse perform first?

1. Administering a diuretic to the patient
2. Performing a bladder scan on the patient
3. Inserting a urinary catheter in the patient
4. Administering intravenous fluids to the patient

2

Rationale:
Normal urine output should be 30 mL/hour or more. In this case, the patient has a urine output of 20 mL/hour, which indicates that the patient has decreased urine output. The nurse should first determine the possible reason for this abnormality. This can be done by performing a bladder scan. Diuretic or intravenous fluids should be administered only if the patient has decreased urine output because of decreased urine production by the kidneys. A urinary catheter should be inserted only if the decreased urine output is caused by urine retention in the bladder.

What should the nurse determine while assessing a patient's personal hygiene?

1. Whether the patient is able to shave
2. Whether the patient has normal body weight
3. Whether the patient is able to apply makeup
4. Whether the patient is able to comb hair properly
5. Whether the patient has a normal urine voiding frequency

1, 3, 4

Rationale:
While assessing a patient's personal hygiene, the nurse should assess whether the patient is able to shave, apply makeup, and comb hair properly. The inability to perform these activities indicates that the patient has a poor sense of personal hygiene. The nurse should assess the patient's body weight while assessing the nutritional status. The frequency of voiding urine does not determine personal hygiene; it is dependent on the patient's renal function.

A new nurse is caring for a bedridden patient. Which measure, if taken by the nurse, would be inappropriate?

1. Ensuring that there are no areas of skin breakdown

2. Checking if the patient can tolerate the change in position

3. Confirming that the head of the patient's bed is not elevated

4. Applying thromboembolic disease hose for at least 22 hours a day

3

Rationale:
When the patient is bedridden, the nurse should ensure that the head of the patient's bed is elevated to 15 degrees or more. This would help prevent respiratory complications of prolonged supine position. The nurse should check for the areas of skin breakdown to determine the risk of pressure sores. The nurse should check if the patient is able to tolerate the changes in the positions to assess the functional ability of the patient. The nurse should ensure that the patient wears thromboembolic disease hose for at least 22 hours a day to prevent venous thromboembolism.

The nurse is preparing to examine a geriatric patient. Which interventions would the nurse plan to obtain data about the patient's neurologic functioning?

1. The nurse would offer a glass of water to the patient.

2. The nurse would check the changes in the pupil in response to light.

3. The nurse would check the patient's fat distribution and hydration status.

4. The nurse would check the patient's apical pulse against the radial pulse.

5. The nurse would ask the patient to push his or her feet against the nurse's palm.

1, 2, 5

Rationale:
In order to determine the patient's neurologic functioning, the nurse should check whether the patient has proper swallowing reflex, muscle strength, and pupillary reflex. Thus, to determine the swallowing reflex and hearing ability, the nurse would offer a glass of water to the patient. In order to check the pupillary reflex, the nurse would assess the changes in the pupil in response to light. To check the muscle strength of the lower limbs, the nurse would ask the patient to push his or her feet against the nurse's palm. Checking the apical pulse against the radial pulse helps to assess cardiovascular functioning. The nurse would check fat distribution and hydration in a patient in order to assess the patient's nutritional status.

The nurse administers an oral analgesic to a patient. When should the nurse assess pain reduction after administration of the medication to determine the efficacy of the treatment?

1. After 15 minutes
2. After 30 minutes
3. After 60 minutes
4. After 120 minutes

3

Rationale:
Oral analgesics require at least 60 minutes to exhibit their action. Therefore, in order to assess pain, the nurse should monitor pain reduction 60 minutes after oral analgesic administration. Oral analgesics do not exhibit their action 15 minutes or 30 minutes after administration. The nurse should assess pain reduction minutes after administering intravenous analgesics to a patient. The nurse need not wait 120 minutes to check the efficacy of the pain treatment in the patient.

While reviewing the medical record of a patient with a renal disorder, the nurse finds that the patient has been administered an analgesic for relieving lower limb pain. Which question asked by the nurse may cause frustration in the patient?

1. "How was your lower limb pain last night?"

2. "Do you currently have pain in the lower limbs?"

3. "How are you feeling after taking the painkiller?"

4. "Did you get any relief after taking the painkiller?"

2

Rationale:
The patient may feel frustrated if the nurse asks the same questions that had been asked before. The medical record clearly states that the patient had lower limb pain. Therefore, the nurse should avoid asking the patient whether he or she has lower limb pain. However, to assess the status of pain and effectiveness of the treatment, the nurse has to ask different questions referring to the content found in the patient's medical record. The nurse can ask the patient how he or she felt after taking the medication to determine the effectiveness of the treatment and perception of the patient. The nurse can ask the patient whether he or she had relief after taking the medications. This helps the nurse evaluate the effectiveness of the treatment.

A patient who has undergone nephrectomy is lethargic and reports severe pain in the abdomen. The health care provider instructed the nurse to administer an intravenous analgesic through the left brachial artery. Which intervention would the nurse follow while caring for this patient?

1. Ambulate the patient every 20 minutes.
2. Determine the right brachial blood pressure.
3. Evaluate the intensity of pain every 6 hours.
4. Monitor the rate of respirations every 4 hours.

2

Rationale:
While administering the intravenous medications through the left brachial artery, the nurse should avoid taking the blood pressure on the same arm because it may cause bleeding from the intravenous site. Therefore, the nurse would determine the right brachial blood pressure. If a patient is lethargic, the nurse should continuously monitor the patient's respiratory rate to assess whether the patient has respiratory depression. Intravenous medications show their action immediately. Therefore, the nurse should check pain reduction in the patient every 15 minutes. Frequently ambulating the patient may cause discomfort so the nurse would not ambulate the patient every 20 minutes.

The nurse plans to administer intravenous analgesics to a patient who had cardiac surgery the previous day. Currently, the patient is on intravenous fluids, which is administered through the left brachial vein. What measure should the nurse take to provide effective care to the patient?

1. The nurse should assess the patient's pain using the facial grimace scale.

2. The nurse should ensure that the patient's oxygen saturation is more than 92%.

3. The nurse should regularly assess the blood pressure in the left arm of the patient.

4. The nurse should monitor the patient's pain 60 minutes after administering the analgesic.

2

Rationale:
The nurse should regularly monitor the oxygen saturation of the patient. If the patient is receiving supplemental oxygen, the nurse should ensure that the oxygen supplied is adequate to keep the oxygen saturation to more than 92%. The nurse should assess the patient's pain using a 1 to 10 pain scale. The patient has intravenous fluids administered via the left arm. Therefore, the nurse should not check the blood pressure on the left arm, because this might lead to bleeding through the intravenous site. The patient has been administered intravenous analgesics. Thus, the reduction of the pain would be evident within 15 minutes of medication administration. Therefore, the nurse should assess the reduction of pain 15 minutes after medication administration.

A health care provider is working on patient data using an electronic health record (EHR). On entering a medication, the health care provider receives a drug allergy alert. Which statement best describes the health care provider's action?

1. The health care provider is using CPOE.
2. The health care provider is using SOAP.
3. The health care provider is using SBAR.
4. The health care provider is using a checklist.

1

Rationale:
CPOE, or computerized physician order entry, helps to decrease prescription errors by giving an alert if a patient is sensitive to any drug or if any dose adjustments are needed. "SOAP" stands for "subjective, objective, assessment, and plan" and is used for organizing patient data in a written format. "SBAR" stands for "situation, background, assessment, and recommendation" and is used for organizing patient data in verbal communication. Checklists may help in screening the patient for infections.

The nurse is caring for a patient who has undergone abdominal surgery on the previous day. The nurse finds that the patient's oxygen saturation has dipped from 98% to 95% in 30 minutes. What measure should the nurse take to improve the gas exchange in the patient?

1. Ask the patient cough 10 times every 15 minutes.
2. Encourage the patient to walk around the corridor for 30 minutes.
3. Administer supplemental oxygen through a low flow device to the patient.
4. Ask the patient to take 10 breaths through an incentive spirometer every 15 minutes.

4

Rationale:
The patient's oxygen saturation has dipped down from 98% to 95%. An incentive spirometer helps increase the volume of the air inspired. Thus, the nurse should ask the patient to take 10 breaths through the incentive spirometer every 15 minutes. The patient has undergone abdominal surgery and would not be able to cough as frequently as 10 times every 15 minutes, because this would put pressure on the surgical sutures. The patient has just undergone surgery the day before; therefore, the patient may not be able to walk for 30 minutes continuously. The patient's oxygen saturation is within normal range; the nurse should encourage use of the incentive spirometer before initiating supplemental oxygen.

While examining a patient, the nurse finds that the patient's blood pressure is 110/80 mm Hg, the heart rate is 70 beats/minute, the urine output is 180 mL/8 hours, and the respiratory rate is 28 breaths/minute. Which finding indicates that the patient requires immediate attention?

1. Heart rate
2. Urine output
3. Blood pressure
4. Respiratory rate

2

Rationale:
While caring for the patient, the nurse should monitor the vital signs and analyze which parameter requires immediate attention by comparing it with the normal value. A normal urine volume is 800 to 2000 mL/24 hours. This indicates that the urine output of 180 mL/8 hours is an abnormal finding and requires immediate attention. If the systolic blood pressure is less than 90 mm Hg or greater than 160 mm Hg, then it indicates that the patient has a risk of cardiovascular disorder. A blood pressure of 110/80 mm Hg is a normal finding. A heart rate of 60 to 90 beats/minute is a normal finding. If the patient's respiratory rate is in the range of 12 to 28 breaths/minute, it is a normal finding.
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