Answers

CHAPTER 1
The Vista of Nursing
1. c 42. Be very organized; make notes (do not trust your
2. e memory); prioritize care
3. a 43. You have many other choices to make and goals
4. b to set for yourself after you become a nurse. For
5. d example, you will decide on a practice setting, perhaps
6. g a specialization, and how you will continue your
7. f education.
8. NCLEX-RN 44. The licensed practical/vocational nurse (LPN/LVN)
9. Diploma program education programs last from 9 months to 1 year
10. NCLEX-PN full-time; the associate degree nurse (ADN) education
11. National Association of Licensed Practical Nurses program lasts for a minimum of 2 years and includes
12. Baccalaureate degree basic general education courses. The licensure
13. b, c, d examination for the LPN/LVN is the NCLEX-PN, and
14. b the licensure examination for the ADN is NCLEX-RN.
15. b, c 45. You will expect to rotate through many areas of nursing
16. c, d care, but you will not specialize in obstetrics until you
17. a, c, d, e are out of school and licensed as a nurse.
18. b, c 46. To stay current in nursing; many aspects of nursing care
19. d change frequently
20. b 47. Nursing is an art because it requires caring, creativity,
21. The desire to learn and to care for people communication, and compassion to connect with
22. To help evaluate the clinical experience of caring for patients in a meaningful way. Nursing is a science
the patient in the Critical Thinking Connection because of the necessity of analyzing and integrating
23. c data, making decisions, and monitoring patients with
24. a, b, d technology.
25. d 48. Able to communicate clearly and well; takes
26. a responsibility for own behavior, including errors; sees
27. c self as a professional and acts in a professional manner
28. d 49. Although other health-care professionals come in and
29. a out of patients’ lives with short-term contact, nurses
30. c are the 24/7 caregivers, giving them opportunities to
31. a, b, c, e develop relationships with patients. These relationships
33. a, b, c, d allow nurses to teach healthier lifestyles, when and how
33. a, b, d to take medications, negative side effects to watch for,
34. a, b, c, d and when to notify the physician.
35. c 50. Answers will vary but should include information about
36. d the nurse not just simply doing things the way they
37. b have always been done, but instead keeping up with
38. c research that shows the most effective way to provide
39. d care. It should include the concept that nurses should
40. a think about procedures and care, and question them if
41. The theorist’s views regarding the person, environment, they do not follow best practices, going through the
health, and nursing itself proper channels at their facilities.

1
2 Answers

51. d Documentation Exercise Answer

52. b, c 54. Each student’s answers will be unique, according to
53. a their own educational plans. Here is an example:

NURSING EDUCATION PLAN FOR

Jeri Lynn Woods

DATE August 4, 2028

I plan to complete my LPN program in July 2028. After that, I plan to go to work in a multiple-physician clinic for 3 or 4 years. While I am

working days at the clinic, I plan to get my prerequisites for my ADN at Oklahoma City Community College in the evenings.

Three years from now, I plan to be ready to start college full-time to obtain my Associate’s Degree in Nursing. Five years from now, I plan to

have finished my associate’s degree and be working in a hospital as an RN. I think I want to work in the emergency room or in a critical care unit.
CHAPTER 2
Health Care Delivery, Settings,
and Economics
1. c 29. a, d, e
2. e 30. e
3. a 31. f
4. b 32. a
5. d 33. c
6. h 34. d
7. i 35. b
8. j 36. Occupational therapists or certified occupational
9. f therapy assistants
10. g 37. Speech and language therapists
11. Inpatient 38. b
12. Home health care 39. d
13. Hospice 40. a
14. Patient-centered care 41. b
15. Team nursing 42. b
16. Primary care nursing 43. Physical and drug and alcohol rehabilitation units
17. Referral 44. c
18. Outpatient 45. a
19. Rehabilitation 46. a, b, c, d
20. d 47. a, b, d
21. a, c 48. a, c
22. d 49. a, b, c, d
23. b 50. a
24. c 51. b
25. c 52. a, b, c
26. Answers will vary but should include these points: 53. T
The team leader needs good communication skills so 54. F
that they can get the best patient care out of the team 55. F
while also keeping team morale high. The team leader 56. T
expresses respect for all team members and the patient. 57. T
Comments about caring, concern, competence, or 58. F
dedication would also be acceptable. 59. F
27. Answers will vary but should include these points: 60. T
Patients should know the details of their insurance 61. F
plans so that they avoid incurring any expenses that 62. F
they must pay on their own. Another acceptable 63. T
response would be so that the individual can shop for a 64. F
better policy, if possible. 65. T
28. Answers will vary but should include these points: 66. T
Each practitioner brings a unique skill set, which helps 67. T
to provide the patient with holistic care. 68. Medicare

3
4 Answers

69. Medicaid briefly to discuss report activities from the previous

70. Private hour. Another example is that the team leader takes it
71. Health maintenance organization (HMO) upon himself or herself to contact other team members
72. d or read progress notes. Finally, the team leader could
73. c outline assessment findings or patient complaints that
74. Answers will vary but should include these points: would trigger an immediate need to contact the team
This is probably not a good plan because it segregates leader. This approach would also serve to educate team
patients according to their ability to pay and may members as to reportable signs and symptoms and
contribute to those patients receiving less than those factors that suggest risk.
the standard of care. Although the facility may 77. Answers will vary but should include these points:
not consciously encourage such behaviors, it may Patients receiving Medicaid coverage may receive
unconsciously but perceptibly encourage putting costs fewer invasive procedures or surgeries than the patient
ahead of quality. with private insurance because private insurance will
75. Answers will vary but should include these points: pay more than Medicaid. This means that the patient
One example of fragmentation of care would be when receiving Medicaid will receive conservative care,
a member of the team takes vital signs and documents whereas the patient with better insurance will receive
them but does not immediately report significant newer, possibly riskier care. The cost/benefit analysis
variations. The physician may see the documentation is difficult because newer treatments may be more
several hours to 1 day later. Also, an intern, physician effective, but more conservative treatments may be
assistant, or nurse practitioner may fail to include the safer. It results in a trial-and-error approach to health
patient’s current medications when transferred into care that few people would choose if they were aware
a unit, meaning that another assessment, which the of all the details.
patient undoubtedly has already answered, must be 78. Answers will vary but should include thoughtful
performed again. reflection regarding a specific nursing model, its
76. Answers will vary but could include these points: advantages and disadvantages, and specific thoughts
One possibility is to have timed, brief meetings (for about how the model would provide better nursing care
example, on the hour) allowing the team to get together and job satisfaction.
CHAPTER 3
Ethics, Law, and Delegation in Nursing
1. f 29. Respect, dignity, honesty, compassion
2. i 30. d
3. h 31. a, b
4. g 32. b
5. a 33. c
6. j 34. a, b, d, e
7. c 35. b, c, d
8. k 36. The injuries do not match the explanation given for
9. l how they happened, and there are other unexplained
10. b bruises. The child is not dressed appropriately for the
11. d weather. The mother calls the child names, such as
12. e clumsy and stupid. The child is hungry and gulps her
13. m food. The child flinches when around her mother’s
14. Centers for Disease Control and Prevention (CDC) raised hand.
15. Emancipated minor 37. The child is exhibiting signs of physical and emotional
16. HIPAA abuse as well as neglect.
17. Incident report 38. To report suspected abuse to your supervisor so it can
18. Good Samaritan be reported to the proper authorities or agencies
19. c 39. She does not seem to know that there is a risk of losing
20. a, b, c, e her reproductive organs.
21. c, d 40. No. The patient has legal rights to know the possible
22. Absolutely outcomes and risks of this surgery before its
23. Government hospital performance. She needs further education before she
24. The nurse can give informed consent.
25. “If it is not documented, it was not done.” A nurse 41. Document this information in the patient’s medical
will not be able to prove that specific nursing care was record and notify the physician immediately of the
provided for a patient if it was not charted. situation.
26. Fraud 42. Failure to obtain informed consent can be considered
27. Under the right circumstances assault and battery.
28. The patient is no longer stable.

5
6 Answers

Documentation Exercise Answer

43. The incident report form should include the following
information:
A correctly filled-out incident report will be similar
to this:

INCIDENT REPORT EXAMPLE

Incident Date: 8/8/2028 Incident Time: 2230 Department: Nursing

Injured Person’s Name: Jamey Jacob
Injured Person is a:
6 Patient
Visitor
Employee
Physician’s Name if a Patient: Dr Percy White
Name of Employee Reporting the Incident Your Name
Details of the Incident:
Patient found in bathroom wedged between the wall and toilet; had not called for help to go BR, said he forgot. VS:
100.8-98-28 186/94 pulse ox 92%
Details of Injury:
Red, abrased areas on left torso and on back; dark red area on top of left thigh; C/o pain in left hip and leg
Physician Notified? Yes New Orders? Yes; X-ray Left hip and leg
Contributing Factors to the Event:
Unsafe environment
6 Failure to follow policies and procedures
Incomplete or inaccurate documentation, including MAR
Problem with equipment
Other (Explain below)
___________________________________________________________________________________________________
___________________________________________________________________________________________________

SIGNATURE: YOUR SIGNATURE AND TITLE DATE: 8/8/2028 DEPARTMENT: NRSG

CHAPTER 4
The Nursing Process: Critical Thinking,
Decision Making, and Clinical
Judgment
1. c 39. F
2. d 40. T
3. b 41. F
4. a 42. T
5. Care plan 43. T
6. Critical thinking 44. T
7. Validate 45. T
8. Nursing process 46. T
9. Rapport 47. F
10. Nursing diagnosis 48. T
11. Defining characteristics 49. T
12. Expected outcome 50. a, b, c, d, e, f
13. Nursing goals 51. a, c, e, f
14. Direct patient care 52. Assessment—Gathering data is important because it is
15. Indirect patient care not possible to make a good decision if you do not have
16. Independent interventions all the information you need. Making decisions with
17. Dependent interventions insufficient data could result in misdiagnosis, which
18. Collaborative interventions would lead to applying incorrect and possibly harmful
19. Clinical judgment treatments.
20. a, b, c, d Diagnosis—Diagnosis is important in decision making
21. d about patient care because failing to accurately
22. c describe the problem can result in choosing the wrong
23. c interventions.
24. d Planning—Setting goals and outcomes is important in
25. a decision making because it is what drives the activities.
26. e Goals and outcomes provide direction.
27. c Implementation—Implementation is important in decision
28. b making because only implementation can provide
29. d feedback about the effectiveness of all the other
30. a, b, c, d, e decisions.
31. c Evaluation—Evaluation is important to decision making
32. c because one must find out what is working and what
33. a is not.
34. c 53. The LPN/LVN can help develop a care plan in many
35. b different ways. He or she can gather data, offer input,
36. d implement nursing interventions, and evaluate patient
37. c progress toward goal achievement.
38. F

7
8 Answers

54. Answers will vary, but here is one example: As I see 56. Self-transcendence
the patient in distress, I would immediately begin Readiness for enhanced spiritual well-being
taking in information (assessment) through my Spiritual distress
senses, particularly sight and hearing. At the same Self-actualization
time, especially because this is an emergency, I’d be Readiness for enhanced power
making some plans, such as notifying the physician Esteem needs
as soon as I’m able. I would unconsciously diagnose Chronic low self-esteem
the patient as having impaired gas exchange, as Belongingness and love needs
evidenced by his ashen skin color and shortness of Risk for loneliness
breath, and acute pain, based on his report. I would Safety needs
also be thinking of interventions. I would immediately Risk for injury
go to the patient and check his heart rate, blood Physiological (survival) needs
pressure, respiratory rate, and pulse oximetry while Ineffective breathing pattern
simultaneously interviewing him about his status. If Decreased cardiac output
he required oxygen, I would put the delivery device Ineffective airway clearance
on, probably nasal cannula, and set the flow rate. I 57. Answers will vary but should include this information:
would administer the nitroglycerin and reassess his There is a huge gap in new nurses’ abilities to pass the
chest pain after 1 to 3 minutes. I would be rechecking NCLEX tests and their abilities to perform their jobs
his vital signs and, if his blood pressure dropped too safely. Research showed that 50% of new nurses were
much from the nitroglycerin (a potential side effect), I involved in nursing errors, and 65% of those errors
would recognize that as a new problem (diagnosis). I were due to poor clinical judgment, so the NCLEX was
would call his physician to report the situation and the not testing what it really needed to test.
patient’s ongoing status, and then I would plan other
interventions until he stabilized or was transferred to a
higher level of care. By this example, you can see that
the steps of the nursing process overlap and that you
will, especially in urgent situations, perform the steps
almost simultaneously.
55. Answers will vary; however, the following signs and
symptoms are examples of objective and subjective
data for a gastrointestinal infection:
Subjective Objective
Nausea Vomiting
Cramping Hyperactive bowel sounds, diarrhea
Weakness Dehydration
Hypokalemia
 Chapter 4 The Nursing Process: Critical Thinking, Decision Making, and Clinical Judgment 9

58.

Cough
• Has frequent moist cough
• Is expectorating green sputum
• Complains of headache from frequent
coughing
Severe rhinorrhea
• Blows nose frequently
• Has red, sore nose
• Complains of postnasal drip

Administered cough
suppressant at 0600
Obtained sputum
Provided tissues sample for culture
and medicated Provided water to help
cream for sore skin thin secretions

Patient with
upper respiratory
tract infection

Fever Body aches

• Has oral temperature of 101°F • Complains of muscle aches
• Complains of waking up previous and weakness
night drenched in sweat

Administered
Acetaminophen acetaminophen
administered at 0900 500 mg at 0900
Provided fluids Encouraged rest

Nursing Diagnosis: Severe body aches r/t viral infection and fever
Outcome: Patient will state increased comfort level within 2 hours of receiving medication.

Interventions Evaluation

Administer acetaminophen 500 mg every 4 Pt stated feeling better after medication.

to 6 hours per physician order.

Monitor severity of body aches.

CHAPTER 5
Documentation
1. PIE (problem, intervention, evaluation) charting 35. b, f
2. Narrative charting 36. d
3. SOAPIER (subjective, objective, assessment, plan, 37. e
implementation, evaluation, revision) charting 38. a, b, c, d, e, f
4. Documentation 39. c. Procedure tolerated well.
5. Charting by exception d. ADA diet—ate 75%, tolerated poorly.
6. Focus charting f. Got mad while ambulating in the hall.
7. Kardex g. Has a bad attitude.
8. b, d 40. c, e
9. d 41. (a) You are working 7 a.m. to 7 p.m., and it is now
10. a, b, c 8:30 a.m. Millie Norris has insulin-dependent diabetes
11. a and is hospitalized because her blood sugar has been
12. a, c, d, f, g out of control. She is acting differently than she did
13. a yesterday; she is awake but confused, and her skin
14. d is flushed, hot, and dry. She slept normally on the
15. a, b, g previous shift, according to the report. Results of a
16. b, c, d, e, f fasting blood sugar test show a serum glucose level of
17. a, b, d, e, f, g, i, j 475 mg/dL. You find regular insulin, 8 units, charted on
18. b, c, d, f the medication administration record for the previous
19. a, d evening at 9:15 p.m.
20. T (b) Charting should be similar to the following:
21. F 0830 Confused X 4 spheres. Skin flushed, hot, dry.
22. T FSBS 475 mg/dL.__________________ ___________
23. T ____________________________________________
24. T Student’s name and credentials
25. T 42. (a) You are working the 7 p.m. to 7 a.m. shift. It is now
26. F 8:10 p.m. The patient is Mike Gibson, who has been
27. T admitted with pneumonia. In the report, you were told
28. F that an antitussive (cough syrup) was administered to
29. Call the intended recipient to let that person know that Mr. Gibson for frequent, nonproductive coughing at
the document’s arrival is imminent. 2:45 p.m. and acetaminophen for a headache at
30. d 6:55 p.m. During your initial shift assessment, he
31. b tells you that his headache is completely gone but that
32. a, b, c, d he is feeling slightly short of breath and cannot stop
33. a, b, c, d, e coughing. You empty and clean his emesis basin, which
34. At least 9 of these categories should be included: contains a large amount of thick, yellowish sputum
physical assessment findings, nutrition, hygiene that he tells you just started to “come up” in the last
provided, activity level, physician visits, elimination hour or so. You find that he took his evening shower
(both bowel and bladder), nursing care provided, right after taking the acetaminophen. He tells you that
patient’s responses to nursing care, safety issues, it was a “hotter-than-usual shower,” and it felt so good
laboratory, x-ray, and other diagnostic tests that were that he stayed in the shower for 20 to 25 minutes, when
prepped and done, all patient complaints. normally he jumps in, showers quickly, and gets out,
staying 7 to 8 minutes at the most.

10
 Chapter 5 Documentation 11

(b) Charting should be similar to the following: now. You assess his abdomen and find that it is flat and
2010 Reports headache is gone. C/O shortness of not distended; he guards when you palpate the RLQ
breath & coughing frequently. Cough productive of and right upper quadrant (RUQ) and he flinches and
large amount yellow sputum since taking hot shower. moans when you palpate and then release hand pressure
____________________________________________ applied over the RLQ area, where he states he hurts the
____________________________________________ most.
Student’s signature and credentials (b) Charting should be similar to the following:
43. (a) The patient is Marvin Bishop, who was admitted 1305 Now complaining of nausea and RLQ abd. pain
on November 28, 2028, for abdominal pain to rule out increased to a 10 on scale 0–10. Guarding during
appendicitis. You are working from 7 a.m. to 7 p.m. It palpation of RLQ & RUQ. Flinches and moans when
is now 1:05 p.m., and Mr. Bishop rings to tell you that palpation pressure on RLQ is released. Reports
he is nauseated, a new development, and that his right that pain is worst in RLQ.—Student’s signature and
lower quadrant (RLQ) pain just escalated suddenly to a credentials
10. He tells you that he must have something for pain 44.

Patient Elliott, Mary

ID# 021481 RM 333
BD 2-14-82 Mission Regional Hospital
Admit 6-21-28
Physician Steve Holsted

Date and Nurse’s Notes

time

6-23-28
0815 C/O shortness of breath and any movement makes it get worse, even turning over in bed and getting up to

bathroom. P–92 reg 2+, R–33 reg, even, slightly labored, SpO2–90% on room air. Color pale, skin warm & dry,

continues to have frequent cough, productive of lg. amt. greenish yellow sputum.------------------------L. Phillips, LPN

0820 O2 applied at 3 L/min per NC per orders.------------------------------------------------------------------------------L. Phillips, LPN

0825 Guaifenesin syrup w/ Codeine 2 tsp given orally. BSC provided. Instructed to avoid getting up alone, to call for

help with toileting. Will use BSC until dyspnea improves.--------------------------------------------------------L. Phillips, LPN

0830 10 min. after application of O2, SpO2–96%. R–29, reg, even, P–87, 2+ reg. Color less pale. Mucous membranes

pink. States breathing eased.-----------------------------------------------------------------------------------------------L. Phillips, LPN

12 Answers

45. The Create Your Own Pocket Brains for Sample Patient
may be similar to this template, or you may create your
own format. Ensure that all components are included.

Rm 417–Julie James, 69 y/o/f Dr. Taylor Adm. MM/DD/YY Dx: COPD

Allergy: NKDA Ordered tests: CXR and UA today Meds due at 9, 12, 2, 5

IV lt. forearm, 22 g, D 1/2 NS at 30 mL/hr per pump.

Convert to SL today__________________SS enema X1 ___________
BSC____________Up in room ad lib ______________________________ UA to lab __________
Up in chair meals B _______ L _______
VS q2hr. 8 ____________________________________________10 ____________________________________________.
12 ____________________________________________ 2 ____________________________________________.
O2 at 2 L/M per NC con’t ___________.
SpO2 at 8 _____________ 10 ____________ 12 ____________ 2 ____________
Low NA diet: B ________________________% L ________________________%
Shower at _____________. mouth care q4hr 9 ____________ 1 ____________
I – ____________ mL O – ____________ mL BMs ____________
CHAPTER 6
Communication and Relationships
1. f 41. Answers will vary but should mention the following:
2. a When talking with a health-care provider, receiving
3. g orders, and then reading the orders back to be sure that
4. b you have heard it all correctly.
5. c 42. Answers will vary but should mention the following:
6. d State what the problem is and what you think is causing
7. h it to occur.
8. e 43. Answers will vary but should mention the following:
9. Active listening When communicating with other nurses, such as a
10. Therapeutic communication nurse supervisor or IV team nurse, or when questions
11. Denotative meaning, connotative meaning are anticipated and answered.
12. Rapport 44. So that you can look at the patient and make eye
13. Empathy contact as they answer
14. Aphasia 45. To prevent depersonalizing the patient and focusing
15. Incivility on the computer, not on the patient, allowing you to
16. b promote trust and project caring
17. d 46. i
18. b 47. f
19. a 48. j
20. b 49. b
21. a, b, c, d 50. c
22. c 51. h
23. F 52. a
24. F 53. e
25. F 54. d
26. T 55. g
27. F 56. a, b, c, d
28. c 57. a, c
29. c 58. b
30. a 59. b
31. c 60. a, d
32. d 61. a
33. b, c, d 62. T
34. c 63. T
35. c 64. T
36. c 65. T
37. c 66. T
38. a 67. F
39. b 68. T
40. Answers will vary somewhat but should include the 69. T
following: Clear information about who is involved 70. c
(patient name and room number) and a brief overview 71. a
of the problem. 72. a, c, d

13
14 Answers

73. a, c, e others if a change is requested. People in authority

74. Answers may vary somewhat but should include: expect communication to come through the chain of
Placing the patient in a comfortable position to command.
communicate, making sure the patient has their 77. Some cultural barriers to communication include
eyeglasses or hearing aid (or both, if applicable), and language differences, differences in nonverbal
determining which communication method works communication messages, and differences in perceptions
best for the patient (e.g., a portable text-to-speech of authority. Language barriers may be the easiest to
communication device, a communication board, or just overcome by obtaining an interpreter who is acceptable
a pad for writing). If a formal conversation is planned, to the patient. Body language, such as whether to make
make sure all the patient’s needs have been addressed eye contact, how close to get to the patient, or whether
and that they are as comfortable as possible. For to sit or stand during communication, can all send the
everyday patient care interactions, try communicating wrong message when people from different cultures
with the patient by asking yes-or-no questions and interact. The best way to avoid this is to ask the patient
asking them to blink their eyes or shake their head for a about their preferences and any cultural considerations
response. Remember, being intubated is highly stressful that might be needed. It is also true that different cultures
for the responsive patient. Try to alleviate the stress by have differing mores regarding authority figures. A nurse
developing effective communication strategies. must find out who the family views as the authority
75. Answers will vary but should include the following when family teaching is required.
concepts: Provide information and conversational 78. Ask the patient what she would like to be called, and
communication to the patient who is unresponsive. use that name. Refer to her using the pronoun of her
By doing so, you address both the psychological gender identity. Be kind and courteous while speaking
and physiological needs of the patient. Use simple, to her about her health needs, remembering that the
conversational language and explain what you are LGBTQ+ community has higher rates of sexually
doing. Use therapeutic touch and stroke the patient transmitted diseases, HIV, AIDS, and depression.
to convey a sense of security. Remember not to Find out if she has kept up with screenings for her
discuss other patients in front of the patient who is sex assigned at birth, such as prostate examination, if
unresponsive, who may be able to hear and misinterpret appropriate. Encourage your fellow nursing staff to use
the information. the pronouns of her gender identity and to call her by
76. Upward communication can be improved by stating the name she wishes to use. Do not encourage ridicule
the issues very clearly, explaining the reason for the of any kind. Help them see her as a patient with specific
communication (whether it is a complaint, comment, needs and help them deliver nursing care in a kind,
or request), and explaining the benefits to yourself and caring, and thoughtful way.
 Chapter 6 Communication and Relationships 15

79.

Patient Jefferson, Charlene

ID# 364190 RM 112
BD 2-29-96 Mission Regional Hospital
Admit 8-22-28
Physician Steve Holsted

Date Time Nurse’s Notes

8-22-28 0800 Refuses food. States she feels “like a freak” due to her illness and dislikes feeling different from her friends.

Encouraged to express feelings.--------------------------------------------------------------------------------------------------------------K, Dean LPN

8-22-28 1100 Discussed fears of becoming sicker and anger that she has these health issues. Offered written info about kidney failure

and dialysis. Discussed people who remain on dialysis for many years and do very well. Offered information on transplants

as well, which pt was eager to hear about. Referral to transplant team for information session.-------------------K, Dean LPN
CHAPTER 7
Promoting Health and Wellness
1. d patient to a substance use treatment center, discussing
2. c various medications used to assist with substance
3. e withdrawal, reviewing the health hazards of the
4. b substance use in general and specifically to the patient’s
5. a current health conditions, and discussing the effects of
6. Stress the substance on anyone who lives with the patient.
7. Adaptation 29. Consequences of having poor health literacy include
8. Fight-or-flight response the complications that can occur when a patient does
9. Coping strategies not understand instructions to prepare for a test or
10. Continuum surgery. For example, a colonoscopy would have
11. Health literacy to be rescheduled if a patient had not followed the
12. Chronic illness instructions correctly the day before to cleanse the
13. Acute illness bowel before the procedure. In addition, patients can
14. Healthy People 2030 have adverse effects from medications or treatments
15. Remission, exacerbation if they do not understand how to correctly take the
16. Risk factors medication or perform the treatment, which could lead
17. Answers will vary but could include: The fight-or-flight to hospitalizations and, worse, illness or disease. Poor
response is the body’s mechanism for dealing with a health literacy has been shown to correlate with poor
threat. The body slows down unneeded body processes, health, even if a person is young or well-educated.
like peristalsis, and directs blood flow to the muscles 30. a, b, c, d
and heart. It also initiates the release of adrenaline. If a 31. a
person is approached by a masked man with a gun, the 32. Any three of the following:
adrenaline will increase the person’s chances of running Obesity—diabetes, heart disease, breast and colon
away from him by temporarily increasing strength. cancer
Shunting blood to the larger muscles such as the leg Diet high in fats—diabetes, stroke, heart disease
muscles would also help a person flee. Increasing Hypertension—stroke, heart disease, kidney disease
the respiratory rate will help the person take in more Smoking—heart disease, chronic obstructive pulmo-
oxygen, which is needed by the muscles to prevent nary disease, stroke, lung and other cancers
them from fatiguing too quickly. 33. F
18. b 34. F
19. b 35. T
20. c 36. T
21. b 37. F
22. d 38. T
23. d 39. T
24. c 40. c
25. d 41. b
26. a 42. c
27. a 43. a, b, d
28. Answers will vary according to which two focus areas 44. a, c, d
are chosen. One example of a correct answer would be 45. b
to choose reducing drug overdose deaths and to explain 46. Emergent high-level wellness
which interventions would be helpful. With reducing 47. Answers will vary but should include examples of
drug overdose deaths, this would include referring the denial, regression, and conversion reaction. An example

16
 Chapter 7 Promoting Health and Wellness 17

of denial could be a person who has chest pain but says be able to work as hard as she normally does, which
it is probably just heartburn, or a person with diabetes will make day-to-day life harder for her husband.
who does not manage their blood sugar and thinks there She decides to work even harder at home and in the
will not be any complications. Examples of regression business (compensation). She blames the stress of
could include a toilet-trained child who reverts to having her in-laws living with her for getting this
bedwetting, or a formerly independent elder needing illness (projection) and wishes they would move
a lot of help and reassurance. Conversion reaction away. She feels guilty for having these feelings, and
examples could include a person who is unable to see when she is home, she lavishes praise on her mother-
or speak after a severely traumatic experience. in-law (sublimation). Mrs. Chan begins to realize that
48. Your patient, Mrs. Chan, is a 55-year-old woman who some days are worse than others and she attributes that
has just been diagnosed with multiple sclerosis (MS) to her husband’s mood swings due to stress (denial,
(stressor). Her symptoms are mild, and the doctor displacement, projection). She decides to go back
cannot be sure if they will progress or at what rate to yoga, which she did in the past and found relaxing
they will progress. Mrs. Chan works with her husband (coping strategy). She has also realized that she is
in their business (stressor). She has four children, more relaxed in the evenings if she drinks two or three
three of whom have left the home and one who is still glasses of wine (a coping strategy but not necessarily
in college. Her husband’s parents, whom Mrs. Chan a good coping strategy). Another way she feels more
does not like, live with them, and Mrs. Chan does in control is by searching Internet sites to find more
all the housework and food preparation (stressor). information about MS (a coping strategy); she feels
Mrs. Chan, immediately after hearing the diagnosis, better when she realizes that she is not as sick as many
thinks to herself that the doctors are probably wrong of the other people in online forums and support sites.
(denial). Subconsciously, she is afraid she will not 49.

Patient Lombardi, Anita

ID# 111353 RM 133
BD 5-20-55 Mission Regional Hospital
Admit 7-12-28
Physician Steve Holsted

Date Time Nurse’s Notes

7-15-28 0815 C/O feeling “sick all the time” and relates that she seems to be feel fine but then gets very sick suddenly and has to be

hospitalized. Almost crying as she talks about this. Explained there are ways she can help take care of herself and set up

time for pt. tchg. at 1000.----------------------------------------------------------------------------------------------------------------------L. Brown, RN

7-15-28 1000 Instructed on strategies to reduce anxiety and manage fears. Emphasized need to balance activity with rest periods.

Demonstrated breathing exercises to improve her strength and stamina. Return demonstration of breathing exercises

correctly. States she will do them daily.--------------------------------------------------------------------------------------------------L. Brown, RN

7-15-28 1400 Discussed ways to avoid infection: frequent hand washing, avoiding people with respiratory infections, performing good

oral hygiene. Reviewed early s and sx of infec. and worsening respiratory status. Instructed to call her doctor before her

condition gets serious. Encouraged to get pneumonia and flu vaccinations. Restated major teaching points. States she will

get her vaccinations at her next office visit, scheduled for next week.--------------------------------------------------------L. Brown RN
CHAPTER 8
Ethnic, Cultural, and Spiritual Aspects
of Care
1. g 28. Answer may include discussion of any of the following
2. h types of barriers: economics, education, geography,
3. f language, stereotyping, prejudice, discrimination, and
4. a misunderstanding.
5. b 29. Rural areas may have more limited access to health-
6. c care providers and facilities. Residents in low-income
7. i areas of larger cities may have difficulty accessing
8. e health-care providers and facilities.
9. d 30. The narrative note should be written as succinctly as
10. j possible but should include dietary preferences and
11. k foods he will not or should not eat. One example of an
12. a acceptable narrative nurse’s note is as follows:
13. b, c, d 3/9/28 8:25 pm States that due to religious convic-
14. a, d tions of Buddhism, maintains vegetarian diet with dairy
15. a, b, c products. All meats, coffee, and alcohol strictly forbid-
16. a, b, d, e den. Allergies: walnuts and tomatoes. Prefers 5-6 small
17. a, c, e meals per day, with chocolate milk and a sweet at HS.
18. c, d States favorite foods include vegetarian pizza, egg rolls,
19. T baked potatoes, eggs cooked in every way possible,
20. F peanut butter, yogurt, dry cereal, peaches, oranges, and
21. F bananas. Dietary consult ordered for tomorrow. States
22. T hasn’t eaten since noon and is “starving.”——————
23. T —————————————————————————
24. F Nurse’s signature and credentials
25. T 3/9/28 8:55 pm Provided 2 cartons chocolate milk,
26. Student answers will vary. cheese sandwich, bowl of Cheerios, yogurt, and banana.
27. Student answers will vary. —————————————————————————
Nurse’s signature and credentials

18
CHAPTER 9
Growth and Development Throughout
the Life Span
1. c 42. h
2. e 43. e
3. h 44. a
4. g 45. c
5. a 46. a
6. d 47. c
7. i 48. b
8. j 49. c
9. b 50. b
10. k 51. b
11. f 52. c
12. Cognitive development 53. b
13. Moral development 54. c
14. Spiritual development 55. c
15. Physical development 56. b, c, d
16. Psychosocial development 57. b
17. b 58. c
18. d 59. b
19. b 60. d
20. d 61. e
21. c 62. a
22. b 63. c
23. d 64. T
24. a 65. T
25. c 66. F
26. a 67. T
27. c 68. T
28. b 69. T
29. b 70. F
30. d 71. F
31. h 72. F
32. e 73. c
33. f 74. f
34. c 75. a
35. a 76. d
36. g 77. b
37. b 78. e
38. f 79. 1 to 9 or 10
39. d 80. Avoiding punishment and gaining rewards
40. g 81. Early adolescence
41. b

19
20 Answers

82. Conforming to avoid disapproval with respect for law being a teenager. A teen who is chronically ill may
and order feel very different from their peers, which is difficult
83. Post adolescence psychologically because teens want to fit in. Adults in
84. Behaving according to internal codes and beliefs their mid-30s enter the generativity versus stagnation
85. Answers will vary, but possibilities include: developmental stage and may feel that chronic illness
• Teens: sexually transmitted diseases, Internet safety represents a threat to their ability to be a productive
• Young adults: parenting skills, health maintenance member of society, an adequate worker, or a fully
• Older adults: fall prevention engaged parent.
86. Answers will vary but may include not giving toddlers 88. Answers will vary but may include references to the
food that can be choking hazards, such as slices of declining stamina and reserve people begin to feel in
hot dog or unsliced grapes; teaching school-aged and their 50s, the somewhat slowed abilities to learn new
preschool-aged children about strangers and obtaining information or skills they may need to successfully
safety gear for sports; and teaching teenagers about adapt to the demands of a chronic illness, or the need
drugs and alcohol. to continue to be a productive wage earner. People in
87. The developmental stage that teenagers encounter their 50s may still have dependent children at home
is identity versus role confusion. The teenager who and may also be caring for aging parents, doubling the
is trying to develop their identity may have a great caretaking they do. Chronic or serious illness represents
deal of trouble reconciling a serious illness with the a threat to family stability for the person in their 50s.
usual image of health and vitality associated with 89.

Patient Sanchez, Juanita

ID# 364972 RM 302
BD 4-19-72 Mission Regional Hospital
Admit
Physician Steve Holsted

Date Time Nurse’s Notes

1-17-28 1015 Discharge teaching performed. Home medications Diovan 160 mg daily and HCTZ 25 mg daily. Instructed on

importance of healthy lifestyle, including walking for 30 min 5 days/wk. Verbalized understanding of meds, lifestyle

changes, and heart-healthy diet to lower B/P and cholesterol.----------------------------------------------------------------------K. Ross, RN

1-17-28 1050 Discussed pt’s concern over 12-year-old daughter and effect of grandmother’s terminal illness on the daughter’s behavior.

Also discussed the burden on pt. and her husband of caring for terminally ill mother. Hospice is currently seeing the

mother. Crying, states ↑B/P is partly due to caring for mother. Discussed possibility of more help (private pay) to

relieve pt. at times. Pt. agreeable to consultation with agency.--------------------------------------------------------------------K. Ross, RN

1-17-28 1110 Referral made to Heartland Hospice for consultation regarding additional help in home.--------------------------------K. Ross, RN
CHAPTER 10
Loss, Grief, and Dying
1. f 34. Answer should reflect an understanding of the fact that
2. d caring for the dying is not so much about the technical
3. k aspects of nursing, curing the disease, diagnostics, or
4. a assessment of vital signs. The student should relate
5. e the importance of observation skills to detection of not
6. j only physical needs but also emotional and spiritual
7. h needs, including anxieties and fears of the patient
8. b and his family, and the fundamentals of nursing that
9. g attracted the student to the field of nursing.
10. i 35. The explanation for the importance of giving presence
11. Respite or respite care should reflect the student’s understanding of the
12. Grief significance of death and the dying process in a
13. Do-not-attempt-to-resuscitate order person’s life, and the anxieties and fears that sometimes
14. Durable power of attorney cannot be relieved by family members but may be
15. Hospice or hospice care within the realm of being relieved by the nurse who
16. a willing to give of his or her time to simply be with the
17. c patient and family members. There should be some
18. a, c, d reference to the honor of being present as a patient
19. b, c makes the most important transition in their life, or
20. a, b, c, d, e maybe to the fearlessness the nurse may exhibit for the
21. d patient or family to use as their strength. The student
22. a may also refer to a nurse’s sense of self-satisfaction that
23. a may be garnered by just being there, helping to make
24. F the dying process more meaningful, less frightening,
25. F and more comfortable for the patient and loved ones.
26. c 36. The answer should reflect the student’s feelings about
27. c do-not-attempt-resuscitation (DNAR) orders and may
28. a, c, e include their religious or individual perspective. The
29. d student may express ambivalence about DNAR orders,
30. b but that is okay. The purpose of this chapter is to teach
31. b, c students how to help patients cope with the dying process.
32. c For this to be possible, the student must begin to identify
33. Answer should reflect that the student identifies the their own personal feelings about death and dying.
patient’s need to talk about her death and leaving her 37. The answer should include at least one or two
young children. It should include reference to giving statements supporting the student’s personal belief
presence, or sitting down beside the bed to listen to either for or against the idea that one can “die well.”
the patient, or having a talk with the patient about her 38. The student’s answer should reflect support for each
feelings and fears related to dying (listening with a life is significant, only certain lives are significant, or
sensitive ear). no life is significant.

21
22 Answers

39.

Patient May, Polie

ID# 42736 RM 302
BD 1-12-39 Mission Regional Hospital
Admit 7-2-28
Physician Chris Wilson

Date Time Nurse’s Notes

7-9-28 0840 Verbalized his desire to stop chemotherapy and that he discussed this at length with Dr. Wilson two weeks ago.

Stated he wants to “enjoy a higher quality of life, even if it is shorter,” instead of feeling “constantly sick, weak, and

nauseated from the chemotherapy that might buy [him] only a few extra weeks of time.” DNAR consent form signed &

signature witnessed. Copy provided to pt. Encouraged to call if he has further questions or wants to talk. --------------------

-----------------------------------------------------------------------------------------------------------------------------------------------------T. Stephens, LVN

7-9-28 0930 Dr. Wilson here, informed of DNAR. To visit pt.----------------------------------------------------------------------------------T. Stephens, LVN
CHAPTER 11
Complementary and Alternative
Medicine
1. d 42. k
2. a 43. j
3. e 44. b
4. b 45. g
5. c 46. f
6. Integrative health care 47. The patient may feel that complementary and
7. Chiropractic alternative medicine (CAM) practitioners encourage
8. Massage therapy him to make health-care decisions and participate in
9. Acupuncture his care, as opposed to a medical practitioner, who tells
10. Yoga him what care will be provided. In addition, he can
11. Acupressure make choices about what types of CAM to use and can
12. d, e obtain them himself.
13. b 48. The idea that the body is designed to function optimally
14. a, b and heal itself is part of chiropractic beliefs. If the body
15. b is given the correct nutrition, a healthy lifestyle, and
16. a, b, c correct biomechanics, it will remain healthy and repair
17. a itself as it was designed to do.
18. c, d, e 49. One effect of massage is that it stimulates your body to
19. c release chemicals called endorphins. These chemicals
20. b, d are made by your body to help relieve pain and promote
21. d a sense of well-being, so it is not your imagination that
22. b, d massage improves your pain.
23. d 50. Any two of the following:
24. a, d • Herbs often have fewer and less severe adverse effects
25. a, c than prescription medicines.
26. c, d • People feel a certain amount of control over their own
27. b, c, d health care when they can try herbs to treat conditions
28. b, c that may have been unsuccessfully treated by Western
29. d medical practitioners.
30. c • Herbs can be used as a preventative for potential health
31. b, c problems, so people feel like they are being proactive
32. c in avoiding illness.
33. b 51. It has been proven that consistent, mindful changes
34. a, c to diet and exercise can reverse or improve disease.
35. d However, some people may be unwilling to make those
36. c kind of strict lifestyle changes. They may prefer to use
37. e medications or surgery so they do not have to live with
38. i such a strict diet and exercise program. It is possible,
39. c but perhaps few people are willing to commit to such
40. a restrictions.
41. d

23
24 Answers

52. Symptoms in Western medicine are seen as something symptoms and otherwise consider themselves “well.”
to be eliminated or suppressed with medications and In Eastern medicine, prevention is very important.
surgery. In Eastern medicine, they are warning signs that The focus is to keep the mind and body functioning in
the body is imbalanced and needs help to heal itself. harmony and balance to prevent symptoms and illness.
53. In Western medicine, prevention is not normally a big 54.
focus of care. People go to the doctor when they have

Briggs, Kelsea
ID# 664990 RM 1112
BD 4-19-86 Mission Regional Hospital
Admit 3-13-28
Physician Steve Holsted

Date Time Nurse’s Notes

3-14-28 1215 Ate 0% of clear liquid lunch. C/O of nausea unrelieved by Phenergan. Refuses any additional meds, concerned that “it could

be bad for my baby.” Requests acupuncture treatment from her chiropractor.-------------------Student’s name and credentials

3-14-28 1230 PA for Dr. Moody notified of request for acupuncture tx. Will discuss with Dr. Moody--------Student’s name and credentials

3-14-28 1315 PA for Dr. Moody gave telephone order for acupuncture by chiropractor.--------------------------Student’s name and credentials

3-14-28 1420 Acupuncture performed. States nausea is “much better.” Requests apple juice and Jell-O.----------------------------------------------

-----------------------------------------------------------------------------------------------------------------------------------Student’s name and credentials

3-14-28 1445 Drank all of apple juice and ate all of Jell-O. Denies any nausea.---------------------------------------Student’s name and credentials
CHAPTER 12
Patient Teaching
1. c 27. d
2. a 28. b
3. b 29. c
4. Health promotion 30. b, d, e
5. Wellness strategies 31. Answers may vary slightly. An example is: “Use a
6. Teachable moment condom (or make sure your partner uses a condom)
7. Reinforce when having sex.”
8. Interpreter 32. Answers may vary slightly. An example is: “Do not eat
9. Learning fatty cuts of meat or full-fat butter.”
10. c 33. Answers may vary slightly. An example is: “Always
11. b wear sunscreen when you leave the house.”
12. c 34. Answers may vary but can include discussions of
13. a culture, sex, and ethnic background. Other variables are
14. b also possible.
15. c 35. Answers will vary but can include culturally
16. c mediated health practices that may interfere with the
17. T conventional medicine (ie, Western medicine) care plan
18. T or may need to be included in the care plan, traditional
19. F family roles (eg, family may want all discussion to be
20. T addressed to the patriarch of the family), and different
21. F worldviews (eg, sickness may be seen as punishment).
22. F 36. Answers may vary but could include use of videos,
23. F demonstrations, repetition, reading to the patient,
24. F providing the written material to a person chosen by the
25. F patient who has good literacy skills, and/or follow-up
26. c by home care.

25
26 Answers

37.

Patient White, Claudia

ID# 2783465 RM 836
BD 5-14-79 Mission Regional Hospital
Admit 4-2-28
Physician Steve Holsted

Date Time Nurse’s Notes

4-4-28 1120 FSBS teaching begun. Expresses reluctance to “stick” herself and verbalizes dislike of needles. Nurse demonstrated FSBS

procedure to her, explaining each step. Stated that puncture did not hurt when forearm used. Nurse explained alternative

site testing. FSBS was 145 mg/dL. Instructed on normal ranges for nonfasting blood sugar. Briefly discussed food

choices and avoiding concentrated sugars. States she is familiar with diabetic diet as her father was a diabetic also.--------

----------------------------------------------------------------------------------------------------------------------------------------------------M. Jackman, LPN

4-4-28 1630 Demonstrated steps of FSBS procedure with verbal cues. Able to perform puncture on forearm, although reluctant at

first. Needed cues to remember steps of glucometer use. FSBS was 126 mg/dL. Stated she was pleased that the

reading was “closer to what it should be.” Nurse provided positive feedback. Plans to do her FSBS at HS with nursing

supervision.-------------------------------------------------------------------------------------------------------------------------------------M. Jackman, LPN

CHAPTER 13
Safety
1. d 43. a
2. f 44. b, c
3. i 45. a, d
4. a 46. They may be confused for a variety of reasons,
5. c including unfamiliar surroundings and medications.
6. e When they get up, they may not realize that they are
7. b attached to tubes and cords, so they may pull them or
8. h trip over them. They may not clearly understand or
9. The Joint Commission remember directions from nurses, such as not to get up
10. Fall assessment rating scale without help.
11. Restraints 47. If a patient does not get assistance in a timely manner,
12. Code team he or she may attempt to get up and walk alone when it
13. Body mechanics is not safe to do so. This leads to falls and injuries that
14. Center of gravity could have been prevented.
15. Base of support 48. R—Rescue
16. Safety data sheet A—Alarm
17. c C—Confine
18. b E—Extinguish
19. a 49. P—Pull the pin.
20. c A—Aim the nozzle.
21. a, b, c, e S—Squeeze the handles.
22. a, d, f S—Sweep the nozzle from side to side at the base of
23. d the fire.
24. a, b, e 50. Consider the safety of your patients and yourself. When
25. a you are this tired, you are more at risk for making
26. b errors that could harm patients. You are not able to
27. a, b, c, d, f think clearly or make good decisions. Decline to work
28. c the 16-hour shift to keep everyone safe.
29. c 51. Yes, you have a responsibility to share this information
30. a because the safety of the patients is at stake. Your
31. b fellow student is in no shape to make nursing
32. a judgments or decisions about patient care. If she makes
33. b errors that harm a patient, you will know that those
34. b errors could have been prevented had you just spoken
35. c up. You should privately inform your instructor of the
36. d situation and let the instructor take care of it.
37. b 52. The material safety data sheet (MSDS) contains the
38. a, b, c, e, g information needed to know what first aid should be
39. c rendered. It is better to have looked up the information
40. d before such an accident occurs, but the book containing
41. b the MSDS for Cidex should be quickly available so
42. c your eye can be treated correctly.

27
CHAPTER 14
Medical Asepsis and Infection Control
1. e 43. c
2. h 44. d
3. k 45. b, e
4. a 46. 2, 7, 1, 3, 4, 5, 6
5. j 47. 2, 1, 4, 7, 3, 5, 6
6. b 48. b, d
7. c 49. Throat is swabbed and swab is sent to laboratory. There
8. i the bacteria from the swab are cultured and examined
9. d under the microscope. The bacteria appear round and in
10. f chains, so it is Streptococcus bacteria, the cause of strep
11. Normal flora throat. It can be stained with Gram stain to identify if it
12. Vector is gram-positive or gram-negative. Antibiotics will be
13. Chain of infection prescribed that kill Streptococcus bacteria.
14. Secondary 50. Infectious agent: Pneumonia bacteria
15. Systemic Reservoir: Man on airplane
16. Standard precautions Portal of exit: Exhaled air and saliva of man when
17. Transmission-based precautions coughing
18. Sterile technique Mode of transmission: Through the air
19. Sterilization Portal of entry: Nose and mouth of woman sitting next
20. Indirect contact to him
21. a, b, c, d Susceptible host: Woman sitting next to him
22. b 51. The stones in the rings are very difficult to clean
23. c thoroughly with hand hygiene. They can harbor
24. b bacteria that can be transferred from patient to patient.
25. d 52. Gloves do not eliminate the need for hand hygiene, and
26. b they only reduce hand contamination by 70% to 80%.
27. b, c, d Your hands can still be contaminated even though you
28. a, b, d, e, f are wearing gloves. Gloves do not eliminate the need
29. b, c for hand hygiene.
30. d 53. Plan to spend some time with this patient while you
31. e are in the room to perform routine tasks. Offer to bring
32. g the patient reading material that can be destroyed
33. b on discharge from transmission-based precautions,
34. f such as newspapers, magazines, puzzle books, and so
35. a on. Put the patient’s needs first. Be sure not to avoid
36. a, b, c, g spending time in the room or answering the call light
37. b just because the patient is on transmission-based
38. c precautions. Explain to visitors what to wear and assist
39. a them with personal protective equipment if needed so
40. a, c, e they are protected and can visit with the patient without
41. a concern.
42. a, b, c, d, f 54. b, c

28
 Chapter 14 Medical Asepsis and Infection Control 29

55. Skin integrity has been compromised, allowing bacteria 56. The temperature elevation and reddened, warm areas
to enter the subcutaneous tissue and blood through are part of the body’s inflammatory response, making
the abrasions and cuts, especially because dirt and the environment unfavorable for the bacteria to
gravel are embedded there. He also has a chronic multiply and to prevent the bacteria from spreading
illness (diabetes) and lacks rest and good nutrition, all throughout the body.
of which put him at risk for development of infection 57.
because they compromise his immune system.

Date Time Nurse’s Notes

5/12/28 0730 Assisted with bed bath, oral care, and grooming. Assisted to BSC. Voided 650 mL of clear, yellow urine. States she is

lonely and bored. Requested magazine. Contact precautions maintained throughout care.---------------------------V. Popel, LPN

5/12/28 0815 Magazine obtained and given to pt. Instructed her that it would have to be destroyed after contact precautions

discontinued. Verbalized understanding.--------------------------------------------------------------------------------------------------V. Popel, LPN

5/12/28 1015 Visitors instructed on need for contact precautions and how to perform hand hygiene, then don gown and gloves before

entering room. Verbalized understanding and performed tasks correctly.---------------------------------------------------V. Popel, LPN

5/12/28 1130 Visitors again instructed on following contact precautions and how to remove gown and gloves and perform hand hygiene

as they leave the room. Able to perform all tasks correctly.---------------------------------------------------------------------V. Popel, LPN
CHAPTER 15
Personal Care
1. h 41. a. Semi-Fowler position
2. j b. Reverse Trendelenburg position
3. i c. Fowler position
4. a d. Flat position
5. c e. Trendelenburg position
6. k 42. The purpose of using 2% triclosan products helps to
7. e reduce patients who are prone to MRSA.
8. b 43. When you wash the extremities from distal to proximal,
9. d you help return blood to the heart, or promote venous
10. f return. This improves circulation because it prevents
11. Activities of daily living blood from pooling in the extremities, especially the
12. Special mouth care legs, where clots can easily form.
13. Tinea capitis 44. Omit back massage if the patient has certain heart
14. Nits conditions because the back massage can stimulate the
15. Ocular prosthesis vagus nerve and slow the heart rate. Also omit back
16. Draw sheet massage if the patient has fractured ribs or vertebrae
17. Mitered corner because the pressure could cause pain.
18. Assisted care 45. You can wrap one or two gauze squares around a
19. Self care tongue blade and tape them in place to pad it. Then you
20. b can insert it in the side of the patient’s mouth and rotate
21. c it so the blade is vertical instead of flat. This will hold
22. a, d the patient’s mouth open while you perform oral care.
23. a, b, e 46. c. You want the patient to talk more to you about her
24. b feelings and self-esteem issues after having her breast
25. b, c removed.
26. a, c, d 47. and 48. You need to determine whether this is a good
27. b time to do the bath or if the patient prefers to wait
28. a until later when she is less fatigued. You also need to
29. a, b, c, d determine whether there are cultural concerns about
30. a, b, c, d, e, g, h you, as a male, assisting a female with a bath. You can
31. d ask if other male staff members have assisted her with
32. b personal care. If you have no background information
33. d on this, you will need to communicate with the patient
34. a, c, e or her family regarding objections to you assisting her.
35. b Assuming there are no objections, you will need to
36. d stay in the room and assist with this bath rather than
37. a, c, d walking out and leaving it for her to do by herself.
38. c Remember to preserve the patient’s modesty at all
39. d times during the bath.
40. b

30
 Chapter 15 Personal Care 31

49.

Date Time Nurse’s Notes

9-1-28 1017
Wife expressed concerns regarding patient’s inability to bathe at home due to shortness of breath in the shower and

inability to get out of the tub. Instructed to place a rustproof lawn chair or bench in shower so patient can sit down

while showering. Suggested that she obtain a terrycloth robe for patient to don after the shower so he won’t be short of

breath while drying off. Also suggested use of a lawn chair or bench in the tub and a handheld sprayer attached to tub

faucet rather than him sitting down in the tub. Patient nodded several times during discussion. Wife verbalized plans to

obtain a shower chair and terrycloth robe.-----------------------------------------------------------------------------------------------A. Smith, RN

CHAPTER 16
Moving and Positioning Patients
1. i (paralyzed) side. These exercises are passive because
2. j the patient is unable to move the right side inde-
3. g pendently. Active exercises may be done by the
4. h patient moving his left side to prevent weakness and
5. b promote joint motion while he is less active than
6. k usual.
7. e d. This helps prevent urinary complications of immo-
8. c bility such as kidney stones. It also helps prevent
9. a dehydration and thins mucus in the respiratory
10. d system.
11. Trochanter roll f. Because he has known orthostatic hypotension, it
12. Orthostatic hypotension is important to assist him to dangle so that he can
13. Shearing adjust to position changes gradually.
14. Position of function 41. The patient may grimace or moan.
15. Orthopneic position 42. A patient most at risk for skin breakdown might also
16. Sims’ be incontinent of urine and bowel movement; they also
17. Prone would have poor nutritional intake and would have
18. Supine reddened areas over bony prominences when inspected.
19. b 43. Ask the patient if they feel dizzy. Look for signs of
20. b, c, e intolerance of position change. If dizziness, nausea, or
21. c light-headedness is present, have the patient lie down
22. d again. If no signs are present, keep the patient sitting
23. a, c, d, e for a few more minutes and recheck vitals because the
24. b, c, e original vital sign changes were borderline safe. Be
25. a cautious about getting the patient up too quickly.
26. c 44. Take another set of vital signs. Assess the patient
27. b further for any sign of injury. Apply pressure to skin
28. c tear if necessary. If not, apply a dressing over the tear
29. a, d, e if it is bleeding. Ask the certified nurse assistant if
30. a he or she is hurt in any way. Make notes about what
31. b happened and call the physician. Explain what occurred
32. c and receive any new orders for care, including orders
33. d for treating the skin tear.
34. b 45. Documentation on the incident report (Fig. 16-1) and
35. d nurse’s note (Fig. 16-2) should include the following:
36. A sit-to-stand lift • Date and time of incident
37. A slide board or slide sheet to facilitate transfer of • Names of patient and others involved in the incident
patient from the stretcher to the bed • Description of what occurred
38. Place a bath blanket under the patient from the head to • Description of injuries sustained by patient—3-inch
the feet, and use it to move the patient to the stretcher. skin tear to left forearm; any apparent bruising
39. a, b, d, f • Vital signs after incident occurred—blood pressure
40. a. To help prevent pressure ulcers and respiratory 96/60 mm Hg; pulse 98 bpm; respirations 22 per minute
complications as a result of immobility. • Action taken by nursing staff—physician notified and
b. To prevent contractures of the joints on his right new orders received

32
CHAPTER 17
Vital Signs
1. n 22. Temporal, carotid, brachial, radial, femoral, popliteal,
2. g dorsalis pedis, and posterior tibialis pulses should be
3. h drawn on the figure in the correct anatomical locations.
4. k
5. p
6. l
7. f a. Temporal
8. m
9. a
b. Carotid
10. q
11. d
12. o
13. b
14. j
15. Febrile or hyperthermia c. Brachial
16. Auscultate
17. Cheyne–Stokes respirations
18. Muscle contraction normally produces about 25% of
body heat in the resting state. Shivering, an involuntary d. Radial
skeletal muscle response, can raise heat production
four to five times the normal amount. Newborns cannot
shiver and must have external sources of warmth to
maintain body heat.
19. Hematocrit e. Femoral
20. The answer should reflect at least two of the following
situations:
f. Popliteal
• After administration of intravenous medications that
may affect the vital signs
• Change in level of consciousness
• Unstable postoperative condition
• Uncontrolled bleeding g. Posterior tibial
• Pale, cold, and clammy skin
• Any time you suspect shock, stroke, pulmonary h. Dorsalis pedis
embolism, heart attack, or any other serious condition
• When something just does not feel right with the
patient’s condition. Never ignore those feelings. It has 23. a, d
been proved that we can subconsciously detect subtle 24. d
changes in a patient’s condition without being able to 25. b, c, e
consciously identify the change. 26. b, c, f, g
21. Aspirin administered to children younger than 15 years 27. Elevated hypertension is the term used to describes
with viruses has been associated with development a consistent pattern of systolic pressure between 120
of Reye syndrome, an acute and potentially fatal and 130 mm Hg. It is considered to be the precursor of
childhood disease that affects the central nervous hypertension.
system and liver.

33
34 Answers

28. Answer should include at least eight of the following 41. (100.6°F – 32) × 5/9 = C
factors: 68.6 5 = 343
Diabetes 343 ÷ 9 = 38.1°C
Kidney disease 42. (99.8°F – 32) × 5/9 = C
Age 67.8 × 5 = 339
Race 339 ÷ 9 = 37.7°C
Exertion or exercise 43. (37°C × 9) ÷ 5
Rest 333 ÷ 5 = 66.6
Circadian rhythm 66.6 – 32 = 98.6°F
Anxiety, stress, or emotions 44. (40.1°C × 9) ÷ 5
Medications 360.9 ÷ 5 = 72
Nicotine 72 + 32 = 104°F
Caffeine 45. c
Obesity 46. a, d
Overhydration 47. b, d
Dehydration 48. a
Hemorrhage 49. c
Increased intracranial pressure 50. b
29. Stroke volume describes the amount of blood that the 51. Answer should include data regarding orthostatic or
heart pumps from the left ventricle as a result of one positional hypotension and the fact that it results from
contraction. The cardiac output is the total amount of pooling of blood in the lower extremities, decreasing
blood pumped from the left ventricle in 1 minute. blood delivery to the brain and resulting in syncope.
30. Place the patient in modified Trendelenburg position The correct action is to assess vital signs, noting
(with the legs elevated higher than the heart). Do not decreased blood pressure and increased pulse rate.
lower the patient’s head. It might also be helpful to elevate the patient’s feet
31. Brachial artery in the antecubital area of the arm slightly above heart level. A cool, moist cloth to the
32. Thermogenesis is the body’s production of heat. forehead or neck would probably be comforting to the
33. Rate, depth, rhythm or pattern, respiratory effort patient. Reassure the patient that the experience is not
34. Fifth objective vital sign: oxygen saturation, or SpO2 really uncommon. Action that might have helped to
One subjective vital sign: presence and rating of pain prevent the orthostatic hypotension might include any
35. F of the following: Because this was the first time the
36. F patient had been out of bed since the anesthesia, before
37. F allowing the patient to walk toward the bathroom, have
38. T her sit upright with legs still on the bed for a minute
39. F or so, then have her dangle her legs on the side of the
40. T bed for a minute or two, then have her stand for a brief
Formulas for Questions 32–35: interval to assess whether she is going to get dizzy or
Formula: To go from Fahrenheit to Celsius: faint. This allows the body time for gradual adjustment
(F – 32) × 5/9 = C of blood pressure so that there is not a sudden drop of
1. Begin by subtracting 32 from the Fahrenheit pressure as soon as she stands up.
number. 52. The answer should reflect some type of description
2. Multiply that answer by 5. that includes at least a couple of these possible findings
3. Then divide the answer by 9. or any others that might also indicate poor cardiac
Formula: To go from Celsius to Fahrenheit: output. The volume or strength of the pulses may be
C × 9/5 + 32 = F faint, difficult to feel, or categorized as weak or 1+.
1. Begin by adding 32 to the Celsius number. The pulses may be thready or feeble and obliterate with
2. Multiply that answer by 9. light pressure. It is possible that the pulses would be
3. Then divide the answer by 5. too weak to palpate at all, requiring use of a Doppler
ultrasound to detect them.
 Chapter 17 Vital Signs 35

53. 11/07/28 0700 BP 148/94, T 99.8 (37.7), P-Irr 95 strong,

R 27, SpO2 98% room air. C/O Rt. Flank pain @ 6 on
0-10 scale._________________________________
Your name and credentials

Patient Lopes, Jane

ID# 146998 RM 128
BD 8-6-72 Mission Regional Hospital
Admit 11-6-28
Physician Jason Traxler

Date Time Nurse’s Notes

11-07-28 0700 Oral T 99.8˚F, P 95 and irreg, R 27 and unlabored, BP 148/94, 02 sat 98% on RA. Rates pain in her right flank at 6 on a

0 to 10 scale.--------------------------------------------------------------------------------------------------------------------------------M. Walker, LPN

CHAPTER 18
Applying Heat and Cold Therapies
1. i 25. Cold applications should be used at this stage. Any of
2. f the following methods of application would work for
3. a an ankle: refillable ice packs, refreezable commercial
4. b cold pack, or chemical cold pack.
5. c 26. Assess the ankle for skin integrity, sensation,
6. g temperature, color, and pain level.
7. d 27. No longer than 20 to 30 minutes at a time.
8. Rebound phenomenon 28. It will help to constrict the blood vessels, which, in
9. Aquathermia pad turn, helps to stop the bleeding. This is known as
10. Mottling hemostasis. It does not help the swelling already
11. a, c, e, f present to decrease, but the vasoconstriction will help
12. a, c, d prevent further swelling. The cold will also help to
13. b, e, f numb the sensation of pain.
14. d 29. Mr. May is at risk for falling or injury while he is being
15. a, c assisted into the tall whirlpool. Because of the depth of
16. Moist heat conducts heat better than air; therefore, it water, his age, and limited movement, there is a risk for
penetrates deeper. drowning. Also because of his age, he has a decreased
17. c temperature sensation, making it easier for hot water to
18. a, b, e, f burn him. He also has more difficulty maintaining his
19. b, c, d, e body temperature and may become chilled easily. There
20. Because of the increased blood flow to the perineum, is also the possibility of cross-contamination between
the patient is at risk for orthostatic hypotension upon patients.
standing. 30. A lift should be used to place Mr. May in the tub. He
21. Assess skin every 10 to 15 minutes for pallor, mottling, should never be left alone in the whirlpool bath. The
and complaint of burning or painful sensation. water temperature should be programmed into the
22. To protect the skin from frostbite whirlpool according to facility policy and monitored
23. 20 to 30 minutes closely to avoid burns. The temperature of the
24. Heat is contraindicated at this time because it will environment should be adequately warmed before bath,
increase swelling. It will dilate the blood vessels and a bath blanket should be used to prevent chilling.
that are still leaking fluid into the interstitial space, The tub should be thoroughly disinfected between
increasing the amount of bleeding and swelling. Heat patients.
should not be used until after all swelling has stopped
increasing, usually at least 2 to 3 days after injury.

36
 Chapter 18 Applying Heat and Cold Therapies 37

31.

Date Time Nurse’s Notes

1-23-28 17:30 C/O of aching, burning pain in right ankle at a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain she can

imagine. 3+ pitting edema of ankle and foot with reddish blue ecchymosis on posterior aspect of ankle, anterior ankle and

foot pink, ankle and foot warm. Ice-filled pack wrapped in towel and applied to ankle. Elevated left lower leg on 2 pillows.

Instructed to notify nurse if site begins to burn or ache worse.-----------------------------------------Nurse’s signature & credentials

1-23-28 17:45 Left ankle and foot cool and pink, with no increase in ecchymosis. States pain is at 5 1/2. States cold pack feels “pretty good.”

-----------------------------------------------------------------------------------------------------------------------------------Nurse’s signature & credentials

1-23-28 18:00 Cold pack removed. Skin over left anterior ankle and foot pink and cool. Ecchymosis the same. Pitting edema 3+. States pain

is down to a 4 and not burning as badly.-----------------------------------------------------------------------------Nurse’s signature & credentials

CHAPTER 19
Pain Management, Rest, and
Restorative Sleep
1. f medications all can impair the body’s ability to get
2. c adequate sleep. Caffeine and nicotine interfere with
3. b initiation of sleep, whereas alcohol causes awakening
4. g during the night. Individuals who work the night shift
5. j often have difficulty getting enough sleep during the
6. k day. Exercise is conducive to sleep when performed
7. d early in the day, but if performed within 1 to 2 hours of
8. a bedtime, it inhibits sleep in most people.
9. e Stress and anxiety—All humans experience stress and
10. i anxiety and often take those stresses and worries to
11. Holistic bed with them at night. Stress can prevent one from
12. Patient-controlled analgesia (PCA) falling asleep and cause one to awaken during the
13. Nociceptors night. Individuals who work in high-stress jobs often
14. Either substance P or prostaglandins complain of continual problems sleeping.
15. Either substance P or prostaglandins, whichever was Environmental—Room temperatures that are too
not used in question 14 warm or cold, hospital noises and bright lights,
16. Adjuvant waking the patient for nursing care, and other hospital
17. Analgesics routines interfere with a patient’s ability to sleep. An
18. Effleurage uncomfortable hospital bed can also play havoc with
19. Endorphins a patient’s comfort and sleep. Patients in intensive
20. Restorative sleep care units commonly complain of interruption of sleep
21. c from noise produced by other patients, equipment,
22. a, c, d and hospital staff, in addition to bright lights, beeping
23. b sounds, alarms, telephones, and pagers.
24. b, c, d 30. a, d, e
25. a, b, c, d 31. c
26. a 32. Sleep apnea
27. a, b, d, e 33. Restless legs syndrome
28. Progressive relaxation is a systematic process of using 34. Bruxism
the mind to actually relax the patient’s muscles from 35. Narcolepsy
the top of the head to the toes. By focusing the patient’s 36. Insomnia
conscious mind on the tightening and relaxing of 37. Sundowner syndrome
muscles, it interferes with perception of pain impulses, 38. d
and the physiological reaction of muscle relaxation can 39. a
directly relieve some types of pain. 40. c
29. The student’s answer should reflect a minimum of one, 41. d
and preferably two, points related to content from each 42. a
of the following three sections. 43. a
Lifestyle—Components of a lifestyle that many view 44. b
as normal may have detrimental effects on rest and 45. a
sleep. Caffeine, nicotine, alcohol, and sleep-inducing

38
 Chapter 19 Pain Management, Rest, and Restorative Sleep 39

46. Adjuvant analgesics either produce pain relief from A transcutaneous electrical nerve stimulation device,
a mechanism different from traditional analgesics or or TENS, is a battery-powered device with lead wires
by potentiating or increasing the effects of opiates, and electrode pads that you apply to the skin over the
opioids, and nonopioid drugs. A blood level of painful area. The device delivers electrical stimulation
anticonvulsants and antidepressants must be reached to the large-diameter nerve fibers, which is thought
and maintained before pain relief will be noticed, to work similarly to massage, by closing the gate and
generally taking 2 to 3 weeks. Anticonvulsants such stimulating the production of endorphins.
as gabapentin and carbamazepine, and antidepressants 48. Patient controlled-analgesia (PCA) allows the patient
such as amitriptyline, are used to treat nerve pain and to control the frequency and administration of his or
neuropathy. her pain medication using small doses of medication,
47. Effleurage is the repetitive, gentle, gliding stroking within preset boundaries. The PCA offers the patient
of your fingertips over the surface of the skin. This a sense of control over his or her own medication
technique is particularly effective during back massage and provides more consistent pain relief with less
to relax muscles or on the head to reduce tension medication. It reduces waiting for nurse response,
headaches. The method of relief is thought to stimulate provides rapid relief via the intravenous route, and
the closing of the gate and production of endorphins. reduces anxiety related to pain getting out of control.
Guided imagery is a method of using the mind to help It reduces the need for multiple injections. It enables
control the body and guide the patient toward a more patient more comfortable ambulation, therefore
relaxed state. This process can help the patient feel reducing complications of immobility.
more in control of emotions and thought processes, and 49. The student’s nurse’s note should include the date and
provide relief of discomfort and induction of rest or time; site of pain; description of characteristics such
sleep. The patient is asked to visualize a specific place as sharp, dull, stabbing, burning, aching; whether it is
that he or she would love to be, such as a beach or in a constant or intermittent; if anything brings it on or makes
hammock under the trees, and to feel all the comforts it worse; rating on a pain scale; and what the patient
of this place as you describe them in a soft, quiet, desires to be done (whether she wants medication or
melodious voice. nonpharmacological intervention, or both).
CHAPTER 20
Admission, Transfer, and Discharge
1. Discharge planning offered but the patient refused to sign it. Notify the
2. Separation anxiety attending physician regarding the situation.
3. Discharge instruction form 35. The student’s answer should reflect three or more of the
4. Transfer summary form following or any additional control issues the student
5. Leaving Against Medical Advice (AMA) may think of:
6. Medication reconciliation • There is a steady stream of hospital staff (usually
7. a, b, d, e strangers) at the patient’s bedside.
8. a, c, d • They all ask numerous questions, many of them
9. c repeated by several individuals.
10. b, d • Many of the questions are of a private nature, some
11. a, c, d, e being very personal, to the point of discomfort for the
12. c, d, e patient, and the patient may feel the answers to some
13. c of the questions are not the business of health-care
14. d providers.
15. a, b, c, d, e • The patient must sleep in a bed other than their own.
16. a, b, c, d • The patient must use a toilet other than their own and
17. a feels a distinct lack of privacy.
18. b • The patient must eat whatever food is provided
19. c regardless of how it was prepared and may have
20. a, b, d, e restrictions in their diet.
21. a, e • The patient may be awakened during the night for
22. d provision of nursing care. We basically control when
23. d the patient is allowed to sleep and when to awaken the
24. d patient for care 24 hours per day.
25. Safety and security • Sometimes we are unable to allow the patient to wear
26. Before every nursing task, especially medication their own sleepwear.
administration • Smoking within the facility is prohibited.
27. Explain what you are about to do before you do it. • The patient may be instructed to remain on bedrest,
28. a, b, c, therefore controlling the patient’s activity level.
29. a, c, d, e Interventions might include any of the following
30. a, c, d plus any additional interventions the student may
31. d think of:
32. a, b, c, d • Effective communication by health-care providers can
33. Social worker prevent some of the question duplication. Pay atten-
34. Your responsibility is to attempt to reason with the tion to what has already been documented by others.
patient and to explain why it is not in their best interest • Explain why some of the more personal questions are
to leave without authorization of the physician. If asked and how they may be applicable to their care.
that fails to convince the patient to stay, you will ask • Make certain the door to the patient’s room is closed
the patient to sign a Leaving Against Medical Advice when interviewing the new patient. Avoid asking
(AMA) form, which releases the hospital and physician questions out in the hall, at the nurse’s station, or in
from responsibility for the patient’s health status after any site where any other individuals could overhear.
leaving. If the patient refuses to sign the Leaving AMA • Make certain that orientation to facility includes the rou-
form, document in the nurse’s note that the form was tines and times of general activities, such as meal times,

40
 Chapter 20 Admission, Transfer, and Discharge 41

nursing rounds, physician’s rounds, morning blood • Maintain respectful and professional demeanor during
draws, and anything else that might be predictable. interactions and provision of care.
• Provide as much privacy as possible during examina- • Encourage independence and self-care when
tions, procedures, toileting, and personal care. Always appropriate.
remember that the patient has a different perspective 37. a. There are no duplications in ordered medications.
than your “medical” perspective. You may not feel b. Dosages are correct and any differences or changes
embarrassment regarding viewing of the human body, in dosage were intended.
but the patient may feel embarrassment when it is c. All previous home medications have either been
their body. continued or discontinued, not overlooked.
• Encourage the patient to bring their own pillows from d. Prescriptions have been provided for new medications.
home if desired for increased comfort. e. A written list of medications is provided to the
• Try to incorporate the patient’s normal routines, such patient.
as bathing at night before going to sleep or having a 38. It reduces anxiety, promotes patient compliance, allows
bedtime snack, as much as possible. patient a better sense of control, and reduces accidents.
• Always knock before entering the patient’s room. 39. Any four of the following: patient’s history of diseases
• Smile. Make eye contact (if culturally appropriate) and surgeries; family medical history; food, drug,
upon entering the patient’s room. seasonal, latex, environmental allergies; current
• Give the patient even simple choices any time that prescriptions, over-the-counter medications, herbs,
it is possible, such as selecting food choices within nutritional supplements, and illicit/recreational drugs;
a restricted diet or preference of a tub bath versus a or pertinent health habits, such as special diet, use of
shower. sleep aids, tobacco and alcohol use, or use of laxatives.
36. The student’s answer should reflect interventions 40. Vital signs, height, weight, fingerstick blood sugar
regarding respect and consideration, protection (most facilities), current complaints/discomforts/
of modesty and privacy, and encouragement of problems
independence. Some examples include: 41. Scales only. It is important to be accurate for such
• Respectfully acknowledge the cultural belief. reasons as medication dosage calculation, nutritional
• Provide explanation regarding the fact that there is not needs calculation, monitoring of fluid balance, and
a male nurse on duty, but that you will notify nursing nutritional status.
administration to determine whether it is possible to 42. The answer should be completely objective and without
schedule a male nurse for later shifts. such descriptive terms as gold, platinum, or diamond.
• Do not be afraid to ask the patient what you might The list should include the signature of two nurses.
do to make the situation more comfortable for him. An example would be: “Valuables placed in facility
He may be able to tell you some specific things that safe include: brown leather-like wallet, $1,3 00.00 (in
would decrease his discomfort in being cared for by a thirteen $100 bills), white metal watch that has “Rolex”
woman. printed on faceplate, a white metal ring that is a band
• If available, use male assistive personnel to assist with with a clear stone, a red cell phone imprinted with
toileting and personal hygiene. If not available, be dil- “Apple” and “5G iPhone,” and a black leather-like
igent in keeping the patient covered as much as pos- iPhone case imprinted with “Louis Vuitton.” ______
sible when administering personal care. Allow the _______________________________—First nurse’s
patient to perform his own perineal care if he is able, signature and credentials/Second nurse’s signature and
stepping away from the bedside and outside of the credentials
curtain if possible. 43. Assessment should include exact site of pain, level of
• If at all possible, allow the patient to wear his own pain using a scale of 0 to 10, characteristics of pain,
sleepwear. constancy of pain, how long pain has been present,
• Avoid eye contact as much as possible. what brings on the pain or makes it worse, what
• Use typical courtesies, such as knocking before the patient has done (both pharmacologically and
entering the room. nonpharmacologically) to attempt to relieve the pain,
• Be extra vigilant about pulling the curtain, closing the what, if anything, has been effective, what the patient
door during provision of personal care, and prevent- desires to be done for the pain at this time, and the
ing unnecessary exposure of his body during care. nurse’s signature and credentials.
CHAPTER 21
Physical Assessment
1. c 45. S1 is louder
2. e 46. A neurological examination includes vital signs; level
3. i of consciousness; orientation to four spheres; ability to
4. k follow simple commands; pupillary response to light
5. j (direct reflex, consensual reflex, and accommodation);
6. g speech clarity and appropriateness; left and right
7. d facial symmetry (eyelids, smile); movement, strength,
8. f and equality of hand grips; movement, strength, and
9. b equality of dorsal flexion and plantar flexion.
10. h 47. b, c, d
11. Signs 48. b, d, e, f, h, i
12. Symptoms 49. b, d, f
13. Palpation 50. Checking consensual reflex: First shine light in left eye
14. Adventitious breath sounds while observing size and rate of constriction of left pupil.
15. PERRLA Shine light in left eye again while observing size and rate
16. Paresthesia of constriction of right pupil. Repeat process for right
17. Halitosis eye. Both pupils should be the same size, constrict to both
18. Guarding sources of light stimulus, and constrict at the same rate.
19. Lethargic 51. CTA stands for clear to auscultation. This refers to
20. c the lungs and means that there is air moving in and
21. d out during respiration, and that no adventitious breath
22. a sounds are heard.
23. c, e, f 52. PMI stands for point of maximal impulse, which
24. b is located over the apex of the heart. One can feel
25. d the heart contraction by placing one’s fingertips
26. d over the PMI. This is generally located in the fifth
27. d intercostal space, in the left midclavicular line of the
28. a, b, c, e adult chest.
29. c 53. The purpose of performing an initial shift assessment is
30. b to establish a baseline regarding the patient’s condition.
31. d It is used to compare against any changes the patient
32. c may make, including improvement and deterioration.
33. c 54. Assessment of the lower extremities includes checking
34. b color and temperature of the feet; ability to move hip,
35. c knee, and ankle joints the full range of motion of normal
36. b function; for edema; for presence, strength, and equality
37. c of pedal pulses from left to right; capillary refill in
38. b nailbeds of both feet and compare length of time of refill
39. a, c, e, f in left toe vessels with that of the right; strength and
40. d equality of plantar flexion and dorsal flexion.
41. a, b, d, e 55. Assess the patient to ensure that she is awake, alert,
42. c and oriented in all four spheres. Observe her for
43. b strength during your interaction, such as during her
44. S1 and S2 speech and movement as you assess pressure points

42
 Chapter 21 Physical Assessment 43

for erythema, edema, and skin integrity. Assess her of extremities and strength of peripheral pulses.
mucous membranes for moisture and check her skin Assess apical pulse rate and characteristics. Assess for
turgor for elasticity. Offer her fluids to drink and assess shortness of breath upon exertion, discomfort, and pain.
her intake/output thus far today. Assess her radial and Also assess for weight gain. Assess safety factors such
pedal pulses for strength and equality, and assess her as bed position, rails, and call-light accessibility.
for discomfort and pain. Ensure that the bed is in the 57. Glasgow scores: eye response—2 points, motor
lowest position, the call light is within reach, and rails response—4 points, verbal response—2 points. Total
are up as needed according to policy. score: 8 out of 15.
56. Assess the patient’s lungs for adventitious breath Indicates moderate-to-severe neurological impairment.
sounds, respiratory rate and characteristics, and effort Taking into consideration that the blood pressure
to ensure that he is not getting into fluid overload is elevated to 184/98 mm Hg and the pulse rate is
problems. Review his intake/output thus far for decreased to 55 bpm and is weak further supports the
the day. Determine where he is with regard to fluid level of impairment. The vital signs indicate “increased
restrictions and volume of urine output. Assess any intracranial pressure.”
urine for amount, color, and clarity. Assess for edema 58.

Patient Whitehorse, Nathan

ID# 37128 RM 312
BD 2-12-77 Mission Regional Hospital
Admit-13-2028
Physician Lair

Date Time Nurse’s Notes

4/14/28 1115 BP–158/84, T–98.2ºF, P–70 2+ reg, even R–19 reg, even. Awake, alert, and oriented X4. SpO2 99%. Reports mild, dull, aching,

discomfort at site of lt. lower leg wound, rates it 4 on scale of 0 to 10. Denies need for pain med. or any other discomforts.

Speech clear & appropriate. Follows simple commands. Talkative. Smiling. Pupils 5 mm. PEARLA. Conjunctiva pink &

moist. Oral mucous membranes pink and moist. No JVD. Skin olive, warm, dry; turgor elastic. Heart sounds distinct and reg

70 bpm. Auscultated breath sounds CTA in 4 lobes with fine rales in RLL. Bowel sounds hypoactive in LLQ, active X3

quads. Abd. flat, soft, nontender to palpation. States last BM was last night and voided last about 1 hr ago. IV in lt. forearm

1
infusing 1000 mL / NS 30 mL/hr via pump. IV site drsg, intact, no erythema or edema. Lt. hand grip weaker than rt.
2

States due to stroke 5 yr ago. Cap refill brisk in hands bilat. and sluggish 5 seconds in feet bilat. Both feet cool, dry, olive,

without pallor. Lt. pedal pulse 1+, rt. is 2+. Lt. lower leg wound 4” x 3” x 4 mm deep, edges of wound erythematous, wound bed

pale with traces of pink, no granulation tissue. Minimal thin green drainage in wound, with 0.5” diameter dried green drainage

on drsg. Strong & equal dorsal & plantar flexion bilat. Encouraged to drink at least 1500 mL fluid this shift.

Acknowledges understanding and drinking lots of fluids. Encouraged to notify nurse if discomfort increases.-------------------------

--------------------------------------------------------------------------------------------------------------------------------------Student’s name and credentials

44 Answers

59.

Nathan Whitehorse
ID# 37128
Rm 312 BD: 2-12-91
PATIENT FLOW SHEET (PT STAMP)
Date: 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 0 0 0 0 0 0
7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 1 2 3 4 5 6
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Doctor’s Visit
Activity
Vital Signs
AM Care
Care Given

Turn
R-right L-left
S-supine P-prone S
Dressing
Wound Care
IV Therapy
% of Diet
Skin Intact
Warm-Dry/
Skin

Color WNL
Comfort Measures
Alert & Oriented
Sensory
Neuro/

Denies Pain
Denies Anxiety
O2 Therapy
Respiratory

Breath Sounds
Clear & Regular
TC & DB/IS
Pulse Regular
CV

Heart Tones
Telemetry # ___
Abdomen Soft
Bowel Sounds
GI

Present
BM
M/S Renal

Urine Clear
Foley Patent
Moves All
Extremities P
Side Rails Up
Call Light in Reach
Safety

Bed in Low
Position
Other

Braden Scale

Nurse’s Initials/ Student’s Student’s name

Signature initials and credentials

Nurse’s Initials/ RN
Signature Assessment
Time
CHARTING LEGEND ACTIVITY KEY (x1 or x2 = NURSES ASSISTING) O2 KEY HEART TONES KEY WOUND DRESSING KEY IV KEY
√ = within normal limits BED = bedrest ASL = asleep NC = nasal cannula CL = clear √ = dry and intact IP = patent
X = problem, see NN DAN = dangle BP = bedpan M = mask DIM = diminished D = dressing D = dressing
→ = no change CH = chair B/B = bedbath NRB = non-
COMFORT MEASURES
SLC = suture line care TU = tubing
p = exception is normal AMB = ambulate AST = assist rebreather mask I = irrigation HL = hep lock
EM = eggcrate mattress
for patient BR = bathroom SHR = shower C = central line
HP = heel protectors
n/a = not applicable TUB = tub BSC = bedside commode
 Chapter 21 Physical Assessment 45

60.

Frequent vs Monitoring Reason Frequent vs Monitoring Reason

Date Time Temp Pulse Resp BP Date Time Temp Pulse Resp BP
4-14-28 1115 98.2 70AP 19 153
84
46 Answers

61.

Kingfisher Regional Hospital

500 S. 9th
Kingfisher, OK 73750
405-375-3141 NEUROLOGICAL EVALUATION SHEET

Nathan Whitehorse
ID# 37128
2 3 4 5 6 7 8 9 Rm 312 BD: 2-12-91 (PT STAMP)

0000 0200 0400 0600 0800 1000 1200 1400 1600 1800 2000 2200

Pupil size: R L R L R L R L R L R L R L R L R L R L R L R L
See above 5 5
Pupil reactions: R L R L R L R L R L R L R L R L R L R L R L R L

Brisk = 3 3 3 3
Slow = 2 2

Fixed = 1 1

Motor response: R L R L R L R L R L R L R L R L R L R L R L R L
Obeys commands = 6 6 6 6
Localizes, defends
from pain = 5 5
Withdraws from
pain = 4 4
Abnormal flexion
(decorticate) = 3 3
Extension response
(decerebrate) = 2 2

Flaccid = 1 1

Eye opening: R L R L R L R L R L R L R L R L R L R L R L R L
Spontaneous = 4 4 4 4
To speech = 3 3
To pain = 2 2

None = 1 1

Verbal response:
Coherent speech = 5 5 5
Confused
conversation = 4 4
Inappropriate
words = 3 3
Incomprehensible
sounds = 2 2

Mute = 1 1

TOTALS 23 23

Nurse signature Student’s name and credentials Date 4/14/28

Nurse signature Date
CHAPTER 22
Surgical Asepsis
1. f 39. The tip of the syringe and the hub, shaft, and bevel of
2. h the needle must all be kept sterile.
3. g a. Plunger
4. b b. Barrel
5. c c. Tip
6. e d. Hub
7. a e. Shaft
8. Surgical asepsis or sterile technique f. Bevel
9. Surgical asepsis or sterile technique g. Measure dose here
10. Contamination h. Keep sterile
11. Sterile field 40. Answers will vary, but should include these principles:
12. Surgical conscience When working with sterile equipment and supplies, if a
13. Circulating nurse sterile item touches anything that is unsterile, the item
14. Scrub nurse or surgical technologist becomes unsterile. If it only touches other sterile items,
15. b, c, e it remains sterile. Unsterile items remain unsterile
16. b regardless of which items they touch.
17. a, c, d 41. Above waist level, below eye level, and in front of your
18. a, b, e body
19. a. Check for the expiration date to be sure it has not 42. Answers will vary but should include the following
expired. ideas: Stop. Remove your gloves, sanitize your hands,
b. Check for tears or open areas on the wrappers. and put on a new pair of sterile gloves (which you had
20. You could introduce pathogens into the bladder, a the foresight to bring into the room with you). Do not
sterile body cavity. Those pathogens could cause a turn your back on the sterile field during this process. If
bladder infection that could potentially spread to the you did not bring an extra pair of gloves into the room,
kidneys via the ureters. you will have to push the call light and ask someone
21. a, b, c to bring you a pair of sterile gloves in the correct size,
22. c then proceed with sanitizing your hands before putting
23. a on the new gloves. You must take responsibility for
24. b, c your break in technique to protect the patient from
25. a, c, d, e potential infection as a result of your error.
26. b 43. 3, 8, 1, 5, 9, 4, 2, 6, 7
27. c, d 44. On a nurse’s note, the following information should
28. b, d, e appear:
29. d 1-10-28. 1130. Chest tube inserted using sterile
30. a: 3, b: 2, c: 4, d: 1 technique by Dr. Jacob. Pain medication administered
31. S per order before procedure. Immediate return of
32. C 100 mL dark red fluid. Tolerated procedure well with
33. S pain med and is resting comfortably.
34. S 1-10-28. 1500. Chest tube cont to drain dark red
35. S fluid.——Student signature and credentials
36. C 45. On the intake and output sheet, the student should
37. S record 350 mL in the output column for drainage and
38. S label it “chest tube drainage.”

47
CHAPTER 23
Nutrition
1. b • Pregnancy or breastfeeding: Women who are expect-
2. c ing or breastfeeding need additional fluids to stay
3. f hydrated. Large amounts of fluid are used especially
4. l when nursing. The Institute of Medicine recommends
5. e that pregnant women drink 2.3 L (approximately
6. h 10 cups or 2,290 mL) of fluids daily and women who
7. d breastfeed consume 3.1 L (approximately 13 cups or
8. j 3,086 mL) of fluids a day.
9. a 35. Negative nitrogen balance occurs when more nitrogen
10. i is excreted by the body than is being consumed in
11. g the diet. It is a state of malnutrition that will prevent
12. k normal growth in children because there is not adequate
13. c, e nitrogen to develop new tissues required for growth.
14. a The same is true for a pregnant woman: The fetus
15. a, b, c will not develop normally because of a lack of usable
16. b, c nitrogen. Therefore, a positive nitrogen balance is
17. b required for the fetus to grow and develop.
18. a 36. LDL is the blood test that measures lower density
19. c lipoprotein and is the bad cholesterol. A low level is
20. a, c desired. HDL is the blood test that measures high-
21. d density lipoprotein and is the good cholesterol. A high
22. b value is desired.
23. c, e 37. Incomplete proteins lack one or more of the essential
24. a, b, d, e amino acids and are found in the following foods:
25. e nuts, corn, wheat, beans, seeds, and brown rice. Eating
26. a, b, c, e combinations of incomplete proteins provides the
27. a body with all nine amino acids needed for complete
28. c protein synthesis. By consuming two or more of the
29. a, c, d, f incomplete protein sources, the vegetarian is still able
30. c to meet his or her protein requirements. Commonly
31. d used combinations include red beans and brown rice;
32. c peanut butter and whole-wheat bread; brown beans
33. a, c, e and cornbread; black beans and corn tortillas; trail mix
34. Student’s answer may include any three of the with one of the nuts and some type of seeds, such as
following or any other factors that you deem almonds and sunflower seeds; or brown rice and corn
appropriate. tortillas. Any other combination of the incomplete
• Exercise: Increased perspiration related to exercise proteins should be acceptable.
increases the body’s need for water. 38. b, d, e, g
• Environment: Elevated temperatures in the summer, 39. b, e
along with high humidity levels, increase the need for 40. b, c
water. 41. b
• Illness: The body’s need for water is increased in 42. a, b, c
patients with fever, diarrhea, vomiting, or other 43. a
hypermetabolic processes.

48
 Chapter 23 Nutrition 49

44. Simple carbohydrates in both the candy and the cola 45. Eating increased levels of dietary fiber slows gastric
quickly raise the blood glucose to higher levels. This emptying, which promotes satiety or satisfaction of
stimulates increased insulin production, which rapidly hunger. This generally leads to an overall decrease in
decreases the glucose level. calorie intake.
46.

Patient Freeland, Beth

ID# 792283 RM 312
BD 6-4-70 Mission Regional Hospital
Admit 8-8-28
Physician Steve Holsted

Date Time Nurse’s Notes

8-10-28 1030 Instructed verbally on dietary needs of K+ and Mg+. Written list of sources provided, including spinach, white & sweet

potatoes, legumes, dairy, and bananas—all are high in both K+ and Mg+. Also OJ, molasses, tomatoes, apricots, trout, cod,

tuna, pork, peaches, and prunes for K+. Various nuts, oatmeal, avocado, halibut, peanut butter, and rice for Mg+. Asked

appropriate questions. Stated, “I will try to really increase amount of vegetables and fruits that I eat. I just got used to

eating fast foods, burgers and stuff.”------------------------------------------------------------------------Student’s signature and credentials

CHAPTER 24
Nutritional Care and Support
1. d 42. The Salem sump tube is a double-lumen tube, meaning
2. e that it has two separate channels inside the tube. One
3. f lumen is an air vent, and the other is for drainage of
4. a stomach contents, irrigation, instillation of medications,
5. j and obtaining gastric samples. The vent lumen extends
6. g like a “pig tail” from the side of the tube near the end
7. h that connects to the suction tubing. Some manufacturers
8. b make the pig tail blue to differentiate it as the air vent.
9. c The Levine tube also is a large-bore tube but has only
10. i one lumen. It can be used for the same purposes as the
11. Clear liquid diet Salem sump but does not have the air vent lumen to
12. Food intolerance allow equalization of vacuum pressure.
13. Pureed diet 43. Fold or pinch the tube at the junction where the syringe
14. Hemoglobin A1C inserts into the tube while you fill the syringe with formula.
15. Nasogastric tube 44. • Assess tube every 2 to 4 hours to ensure patency.
16. Full liquid diet • When necessary, irrigate clogged tube according to
17. TPN or total parenteral nutrition physician’s orders and facility policy.
18. PPN or partial parenteral nutrition • Monitor vacuum source settings for correct high or
19. Residual gastric volume low suction and intermittent or continuous suction
20. a, c, d, f every 2 to 4 hours.
21. d • Assess tubing connections to prevent accidental
22. a disconnection.
23. a • Assess color, amount, and consistency of gastric
24. c drainage.
25. b, d • Assess tube positioning and the method of securing
26. b tube so that tube does not put pressure on the naris,
27. c, d which can result in a pressure ulcer.
28. a • Manually clamp off the nasogastric tube and auscul-
29. e tate bowel sounds every 4 hours, noting hyperactive,
30. a hypoactive, and absent sounds.
31. a, c, e • Assess abdomen for abdominal distention and palpate
32. b the abdomen, noting firmness.
33. d • Assess patient for reports of nausea, vomiting, pain,
34. c, d cramping, abdominal fullness, and discomfort every
35. c 2 hours.
36. a, c, d • Assess for passage of rectal flatus, which may indicate
37. a, c, d, e the return of the bowel function known as peristalsis.
38. c • Provide mouth care and apply lip moisturizer every
39. a, b, d 2 hours to prevent drying of mucous membranes.
40. c • Provide ice chips if allowed to keep mouth moist.
41. Decompression of the stomach means to empty it (by • Monitor intake/output to prevent fluid-volume deficit
nasogastric suction) of all contents, including solids, or overload.
fluids, and gas. • Monitor the serum potassium level, noting a level
below-normal known as hypokalemia.

50
 Chapter 24 Nutritional Care and Support 51

45. An individual with binge eating disorder does not purge tube, and suction machine or flow meter for wall
after the eating binge. suction), indelible marker, and tape measure.
46. b 56. First, explain the entire procedure to the patient so they
47. c can cooperate as much as possible. Provide the patient
48. a with a glass of ice water and straw, encouraging the
49. a, b, c, d, e patient to sip and swallow, especially at your cue or
50. a, c prompt (probably one of the most helpful tips).
51. a, c, d, e Reassure the patient that you will stop if it becomes too
52. a, b, c uncomfortable, and then follow through with promise.
53. a, b, c, d, e Sit the patient in high-Fowler position. Select the most
54. First make certain that the patient is allowed to select patent nares. Hyperextend slightly the patient’s head
items from within choices on a medically ordered diet as you begin to insert the nasogastric tube. Once it is
to ensure the patient is able to have some foods they at the back of the throat, have patient flex the neck and
like. Assist patient to toilet before mealtime to avoid tuck the chin.
interruption because of toileting needs; the patient 57. Petroleum-based lubricants increase the risk for
may not resume eating after going to the bathroom in pneumonia from inhaling petrolatum vapor.
the middle of a meal. Prepare the overbed table before 58. Assess whether the insertion mark is still located
bringing meal tray, removing all unpleasant items that at the insertion point, measuring the length of
you would not allow on your own kitchen table during the tube point of insertion to distal end, and
meals, such as urinal, sputum-filled emesis basin or compare with recorded measurement; use the
tissues, or hairbrush. Wipe the table with wet cloth. irrigation syringe to aspirate all stomach contents.
Provide a warm, wet washcloth (one with soap and one Measure the amount of residual aspirate and check
without soap for rinsing) or a rinse-free bath wipe for pH with litmus paper. The pH should be acidic
the patient to wash their face and hands. Position the between 1 and 4.
patient in the best upright position allowed to optimize 59. Enfit connectors will prevent any equipment used
ease of eating. Position the overbed table directly in with enteral feedings from fitting with any other
front of the patient so their food is in front of them, syringes, tubing, and bags, so that only enteral
as it would be at home. Avoid placing the table along feeding and enteral medications can be given through
the side of the bed, which puts the “dining table” at them.
the patient’s side rather than in front of the patient. 60. Any six of the following: clammy skin, shakiness or
Placing the table in front of the patient helps to make nervousness, nausea, increased irritability, confusion,
it more like mealtimes at home and is more conducive dizziness, headache, weakness/fatigue, seizures, and
to eating. If the patient is able to feed themselves, unconsciousness. Your first intervention should be to
assist with tray setup as needed: Open containers, cut perform a fingerstick blood sugar test to determine the
up meat, butter bread, open condiments, and apply glucose level.
them if the patient desires. If patient is unable to 61. Provide a small glass of juice or 8 ounces of skim milk
feed themselves, proceed with feeding the patient. If along with a snack, such as peanut butter or cheese and
possible, sit down while feeding the patient. This shows a slice of whole-wheat bread. Recheck the fingerstick
the patient that you are not in a hurry, encouraging blood sugar test in 10 to 15 minutes
them to eat more. Avoid acting rushed. Make polite 62. Assess temperature, pulse rate, respiration rate,
conversation; ask about the patient’s life or family. blood pressure, and oxygen saturation. Determine the
Smile. degree of relief the patient is deriving from the pain
55. Gather the correct type and size nasogastric (NG) tube, medication by using a pain scale of 0 to 10. Determine
catheter-tipped irrigation syringe or 50-mL syringe, whether the patient feels a need for additional pain
container of water, litmus paper to measure pH, emesis relief. Assess for nausea and vomiting and whether
basin, towel or waterproof pad, washcloth, examination medication or other intervention is desired. If the
gloves, lubricating jelly, tape or device to secure tubing patient has vomited, assess the volume on the intake/
to nose, glass of ice water and straw, stethoscope, output record posted in the room. Assess overall affect
adapter to connect NG tube to suction, flashlight, for pinched or pained expression, listlessness and
tongue blade, suction setup (canister, long connecting lethargy, reluctance to make eye contact, and subdued
52 Answers

verbal responses. Assess the mucous membranes hypoactivity, or absence. Palpate abdomen for firmness
for dryness and the skin for pallor and clamminess. and tenderness. Assess that correct IV fluids are
Observe the shape of the abdomen, noting distention. hanging and infusing at correct rate and that IV site is
Auscultate for bowel sounds, noting hyperactivity, without erythema, edema, drainage, or tenderness.

Patient Hudson, Kay

ID# 7445690 RM 330
BD 06-18-75 Mission Regional Hospital
Admit 06-20-28
Physician Mitchell Davis

Date Time Nurse’s Notes

06-06-28 1940 Bowel sounds absent in LUQ and LLQ. Hypoactive bowel sounds in RUQ and RLQ. Abd distended and firm. C/O nausea and

abd pain rated at a 6 on 0-10 scale, 1 hour after IV pain med. Voided 250mL of dark amber urine in bedpan. IV of ½ NS

patent and infusing at 100mL/hr in L forearm. Skin cool, clammy and pale. Requests Something for nausea.-----------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------K. Kravisin, LVN

1945 Dr. Davis notified of changes in condition. Orders received to insert NG tube to low suction.---------------------K. Kravisin, LVN

1950 Zofran 4mg IV given for C/O nausea. #14 Fr NG tube inserted and attached to low suction. Tolerated procedure with only

minor gagging.------------------------------------------------------------------------------------------------------------------------------------K. Kravisin, LVN

2020 Resting with eyes closed, resp reg and even at 14/min.---------------------------------------------------------------------------K. Kravisin, LVN
CHAPTER 25
Diagnostic Tests
1. d 36. a
2. e 37. c
3. g 38. d
4. a 39. a, b, d, e, f
5. b 40. b
6. h 41. b, c
7. c 42. d
8. d 43. c, d
9. b 44. a, b, c
10. c 45. b, c
11. a 46. b
12. f 47. a, b, e
13. White 48. b, d
14. White 49. To diagnose severe anemias and cancerous tumors, and
15. White to stage Hodgkin’s disease
16. Clotting 50. Arteriogram and venogram
17. White 51. Glucose tolerance test (GTT)
18. Red 52. Bone marrow aspiration
19. White 53. Documentation exercise
20. White 0700 Remains NPO for capsule endoscopy, routine
21. d meds held.
22. f 0750 Assisted with belt and recorder for capsule
23. g endoscopy. In place around waist.
24. e 0800 Swallowed camera capsule with moderate difficulty.
25. b C/O the capsule being “huge and hard to swallow.”
26. a No further c/o disc. Recorder switched on.
27. c 1000 Routine meds administered, no longer NPO.
28. b, c, d 1215 Ate all of lunch without difficulty. Sitting up in
29. c, d bed, reading. No c/o disc.
30. a, b, c, d 1240 C/O stomach cramping and assisted to BR. Passed
31. c mod amt of soft, semi-formed maroon stool. No
32. c evidence of camera capsule in toilet.
33. b 1945 Passed camera capsule. Noted in toilet. Recorder
34. a, b, c turned off and recorder/belt removed and del to
35. a, d interventional radiology dept.

53
CHAPTER 26
Wound Care
1. b 26. a, b
2. d 27.
3. f A. Closed
4. a B. Open
5. e C. Open
6. c D. Open
7. g 28. a
8. h 29. d
9. i 30. c, d
10. Abrasion 31. b
11. Granulation tissue 32. d
12. Laceration 33. d
13. Dehiscence 34. c
14. Sinus tract 35. a
15. Evisceration 36. b, d, e, f
16. Serosanguineous 37. a, c
17. Sanguineous 38. b
18. Serous 39. b, c, e, f
19. a, c, d, f 40. c
20. b 41. a, b, c, e, g
21. c 42. a, b, c, e
22. d 43. b
23. a 44. c
24. c 45. a
25. a, b, c, d 46.

A laceration B puncture wound C abrasion D penetrating wound E contusion

47. Call for help to bring in sterile supplies. Cover exposed 49. Position in low-Fowler with knees flexed to relieve
organs with sterile gauze soaked in normal saline, and pressure.
continue to keep moist with sterile saline. Keep IV patent and fluids at ordered rate.
48. Exposed organs for color changes indicating necrosis Reassure the patient.
(blue, purple, black) 50. No
Vital signs every 15 minutes to assess for shock

54
 Chapter 26 Wound Care 55

51. The drug may interfere with the body’s inflammatory 54. Wound culture and sensitivity; a different antibiotic if
response and delay healing. patient is already taking one
52. The wound—for redness, open areas, drainage, and 55.
odor
53. Vital signs; laboratory results (white blood cell count);
what antibiotic the patient is taking, if any

Patient Nguyen, Chan

ID# 6487953 RM 804
BD 5-5-44 Mission Regional Hospital
Admit 6-27-28
Physician Steve Holsted

Date Time Nurse’s Notes

6-30-28 0930 Drsg. change to coccyx stage 3 pressure injury. Wound is 2.7 cm long and 3.7 cm wide, 2 cm deep at proximal end and 1 cm

deep at distal end. Distal portion is deep red in color in a 0.5 cm x 2 cm area. Sm. amt. of yellow drng. noted @ approx.

9 o’ clock. Remaining wound bed is pink. Mod. amt. of serosanguineous drng. on old drsg. Sterile wet-to-damp drsg

completed. Wound filled loosely with 2 wet 4 x 4, covered with 1 damp 4 x 4, and 1 abd. drsg. Tolerated with c/o minor

discomfort during packing of wound.-----------------------------------------------------------------------------------------------J. Nightwalker, RN

6-30-28 1040 Resting quietly with eyes closed. Resp. deep and reg. at 14/min.---------------------------------------------------------J. Nightwalker, RN
CHAPTER 27
Musculoskeletal Care
1. d 38. a, b
2. g 39. a
3. a 40. c
4. c 41. d
5. h 42. b
6. b 43. a, c
7. e 44. d
8. Joint replacement 45. a
9. Residual limb 46. a. Acetabulum
10. Physical therapist b. Head of femur
11. Continuous passive motion 47. The patient should stand between the back legs of the
12. Skin walker for better balance. If the patient walks too far
13. Skeletal behind the walker, they can lose balance and fall.
14. b 48. The patient may be bearing weight on the axillary pads
15. c, d rather than on her hands and wrists. The pressure on the
16. a nerves in the axilla can cause nerve damage, resulting
17. b in pain and tingling in her forearms and hands.
18. d 49. The patient does not have to refrain from crossing the
19. b legs or adducting the leg; there is no need for them to
20. a use an abduction pillow, the hospital stay is shorter, and
21. The purpose of the abduction pillow is to keep the hip rehabilitation is quicker.
abducted after a lateral-approach total hip replacement. 50. d
This prevents dislocation of the prosthesis. The 51. b
abduction pillow is kept in place while the patient is in 52. Explain the importance of following the physician’s
bed to allow musculature to heal around the prosthesis. orders to keep the knee flexible. Encourage the patient
22. R—Rest to use relaxation breathing and other techniques to help
I—Ice her cope with the discomfort, and leave the CPM on
C—Compression as ordered. Offer medication if it is within the ordered
E—Elevation time frame to make her more comfortable.
23. b 53. Handle the cast with the palms of your hands to prevent
24. a, b, d causing indentations that could cause pressure on the
25. d skin beneath the cast. Use pillows to prop the cast as
26. c it dries so air can circulate around it and so that it does
27. d not dry flat in one area, also causing pressure.
28. b 54. The pins go through the skin directly into the bone,
29. a providing a pathway for pathogens to enter the bone.
30. b, c This would cause a serious infection. The area must be
31. c kept clean and free of drainage that could encourage
32. c bacterial growth.
33. a, c, e 55. The bed needs to be in the lowest position for patient
34. a, c safety; however, if the weights are resting on the floor,
35. a no traction is being applied to the patient’s limb, so the
36. d bone ends are not being aligned. The ropes must be
37. a, c shortened for the weights to hang freely.

56
 Chapter 27 Musculoskeletal Care 57

56. Validate the patient’s understanding that his hip can Explain how adducting the leg, especially past the
dislocate with too much flexion. Explain how the hip midline, can pull the prosthetic femur head out of the
components are replaced and that the muscles have prosthetic acetabular cup.
not yet healed from surgery, so they cannot hold the 57.
components in place as they did with his natural hip.

Patient James, Phyllis

ID# 245689 RM 157
BD 05-02-74 Mission Regional Hospital
Admit 3-7-28
Physician Steve Holsted

Time Time Time

3-9-28
Date __________________ 1420 1615

Sensation R WNL WNL

L WNL WNL

Edema R None None

L 1+ 2+

Skin Temperature R Warm Warm

L Warm Warm

Skin Color R Pink Pink

L Red Red

Toes – Less than Toes – Within 3

Capillary Refill R 3 seconds seconds
Toes – Less than Toes – Within 3
L 3 seconds seconds

Movement R Wiggles toes freely Wiggles toes freely

L Wiggles toes freely Wiggles toes slightly

Pulses R Present and strong Present and strong

Present but difficult

L Present and strong to feel

Pain R 0 0

L 4 5
58 Answers

58. Because there has been a change that could be

significant, it is good to explain further in the nurse’s
notes and to observe closely for further changes.

Patient Phyllis James

ID# 245689 RM 157
BD 05-02-74 Mission Regional Hospital
Admit 03-07-28
Physician Steven Holsted

Date Time Nurse’s Notes

03-09-28 1614 Changes in neurovascular checks noted: L ft edema ↑ to 2+, color of ft and lower leg remains red, limited ability to wiggle

toes on L ft, and p pulse on lt ft difficult to palp. Pain rating ↑ from 4 to 5. Dr. Holsted notified.-------------J. Pierce, LPN
CHAPTER 28
Respiratory Care
1. d 45. a, b, d
2. h 46. b
3. l 47. a
4. j 48. a
5. k 49. b, c
6. i 50. a
7. g 51. b
8. b 52. a
9. f 53. c
10. a 54. a, b
11. c 55. a, b, d, e
12. Inhalation or inspiration 56. d
13. Sputum 57. e
14. Pneumothorax 58. b
15. Exhalation or expiration 59. h
16. Tension pneumothorax 60. g
17. Tracheostomy 61. c
18. Crepitus 62. a
19. Atelectasis 63. f
20. a, c 64. Fluid and blood mixed together—pulmonary edema
21. a 65. Bacterial infection
22. b 66. Viral infection
23. a, b, c, e 67. Breathing smoke or soot
24. a, b, c, e 68. Contains blood—tuberculosis or some pneumonia
25. d infections
26. a, d 69. d
27. 3, 5, 1, 4, 2, 6 70. Elevated carbon dioxide levels make your blood acidic.
28. b The brain gets the message that the pH is lowering and
29. d responds by increasing your respirations.
30. b, d 71. His brain is accustomed to higher levels of carbon
31. b, c, e, dioxide because of his chronic disease. His brain
32. c increases respirations when his oxygen levels are low.
33. c 72. Explain that too much oxygen is dangerous for him
34. a because it can override his normal stimulus to breathe,
35. b which is low oxygen levels. So his supplemental
36. c oxygen must remain at low levels, even though he is
37. a short of breath. It would not be safe to turn it up.
38. a, b, e, g 73. Remove the nail polish from a different fingernail and
39. c try again. If the reading is still low, place a disposable
40. c sensor on a different location, such as the nose, earlobe,
41. b or forehead. Check your equipment for proper function.
42. b 74. Insert an oral airway to prevent the tongue from
43. b obstructing the airway until the patient is fully
44. a, b conscious.

59
60 Answers

75. A fresh tracheostomy tube with an obturator, a new • Decreases the length of time that the chest tubes have
tracheostomy holder, and a suction catheter and glove kit to remain in place
76. Assess her respiratory status. Auscultate her lung • Decreases how long the patient must remain in the
sounds and assess her respiratory rate, rhythm, and hospital
quality. Check her pulse oximetry. • Allows the patient to be more mobile as it can
77. Any three of the following: easily be suspended from a strap while the patient
• Provides a very consistent level of negative pressure is ambulating
that is not dependent on suction regulators, patient 78. Nurse’s Note and Output on Intake and Output
position, or fluid in the tubing Record:

Patient Woods, Nick

ID# 432678 RM 614
BD 6-10-00 Mission Regional Hospital
Admit 5-09-28
Physician Steve Holsted

Date Time Nurse’s Notes

5-12-28 1430 SOB after exertion of standing at bedside to urinate. Resp. 24 and sl. labored. Voided 300 mL dk amber urine. 200 mL

red drng, noted in chest tube chamber since 1330. B/P 118/74. Air in water seal chamber unchanged at 4.----------------------

--------------------------------------------------------------------------------------------------------------------------------------------------------M. Baxter, RN

5-12-28 1440 Physician notified of 200 mL red output in chest tube collection chamber since 1330 and B/P drop from 138/86 at 1200 to

118/74 at 1430.------------------------------------------------------------------------------------------------------------------------------------M. Baxter, RN

Patient Nick Woods Date 5-12-28 Shift 6700-1900

Intake Output

1300 300mL urine

450mL Chest tube drng
CHAPTER 29
Fluids, Electrolytes, and Introduction
to Acid-Base Balance
1. h 42. 7.35, 7.45
2. b 43. a, b, c
3. g 44. a
4. a 45. 7
5. c 46. 7.1, 14
6. f 47. 0, 6.9
7. d 48. Hydrogen (H+), hydroxide (OH-)
8. a 49. Hydroxide (OH-), hydrogen (H+)
9. Buffer 50. Hot, dry skin; dry mucous membranes; nonelastic skin
10. Acidosis turgor; fever
11. Diffusion 51. A true fluid-volume deficit, also known as
12. Bicarbonate hypovolemia, only results when there is an equal loss
13. Osmosis of both fluid and the electrolytes contained in that fluid.
14. Alkalosis The water-to-solute ratio must remain balanced even
15. Filtration though there is a loss, as would be the case when an
16. Milliequivalents individual hemorrhages. With blood loss there is equal
17. Plasma loss of water and solid components of the blood, such
18. b as electrolytes, protein, red blood cells, white blood
19. a cells, and thrombocytes. If there is loss of fluid only,
20. c, f resulting in the increase of electrolyte concentration in
21. d the remaining body fluid, it is called dehydration.
22. b, c, d 52. Many older adults experience a declining sense of
23. b, d thirst as a result of changes in the brain. They also
24. c have diminished kidney functions and an overall lower
25. a, b, d body content of water. If the individual is also confused
26. b, d or unable to get their own fluids to drink, the risk for
27. a, c, d, e inadequate fluid intake is compounded.
28. a, c, d, e, g 53. Because an equal loss of fluids and electrolytes
29. d occurred, maintaining the balance; an example would
30. a, c, d, e, f, h be hemorrhage.
31. d 54. Student should list a variety of these interventions:
32. b, e • Administer physician-ordered diuretics and monitor
33. b, c for effectiveness.
34. a, b, d • Maintain supplemental oxygen as ordered.
35. a • Assess vital signs, including oxygen saturation,
36. a, c every 4 hours or more often as indicated. Monitor
37. 4,700 mg for elevated blood pressure, increased pulse rate and
38. Insulin, glucose volume, and fever.
39. Mg+ or magnesium • Auscultate breath sounds and heart sounds at least
40. Ca+ or calcium every 4 hours, noting adventitious, decreased, or absent
41. Parts hydrogen breath sounds and muffling of S1 and S2 heart sounds.

61
62 Answers

• Carefully monitor intake and output (I&O) and pro- 55. 10 mEq = 750 mg
vide teaching regarding I&O. 20 mEq = 1,500 mg
• Monitor urine output every 2 to 3 hours or even 56. You must agitate the bag of IV solution and potassium
hourly if inadequate urine excretion is suspected. to prevent a concentration of potassium chloride from
• A continuous indwelling Foley catheter must be in forming, or settling out, at the bottom of the bag.
place if you need to monitor hourly output. Infusion of the solution without properly mixing it
• Restrict fluids, if ordered. would carry the risk for infusing higher than desired
• Assess daily weights at the same time of the day, pref- concentrations of potassium chloride in a short period.
erably before breakfast, using the same scales and 57. A patient with severe osteoporosis may experience
with the patient wearing the same type garment. a fracture without trauma, which then causes the
• Assess extremities and dependent body sites for individual to fall because the broken bone is no longer
edema. able to bear the person’s weight. It is important to
• Monitor electrolyte, urinalysis, complete blood cell remember that even though a patient has a healthy
count result, and chest x-ray results. serum calcium level, they may have a severe deficit of
• A low-sodium diet may be ordered. Monitor meal calcium in the bones. Bone density tests help detect this
trays to ensure there are no extra salt packets or situation early.
high-sodium foods. 58.

Patient Field, Sally

ID# 34623 RM 209
BD 7-19-57 Mission Regional Hospital
Admit 9-1-28
Physician Steve Holsted

Date Time Nurse’s Notes

9-2-28 1900 BP–158/86, T–99.2, P–102 reg, 2+, R–28 reg & even. SpO2–93% on O2 4 L/min per NC. Denies pain or discomfort. Still has

rales in all 5 lobes. Becomes dyspneic with exertion. Skin pink, warm, dry, elastic. Oral mucosa pink. 2+ pedal edema in

ankles bilaterally. Lying supine. Fluids restricted to 500 mL this 12-hr. shift. I–500 mL, O–660 mL. NO BM.-------------------

---------------------------------------------------------------------------------------------------------------------------------Student’s name and credentials

CHAPTER 30
Bowel Elimination and Care
1. c 40. b, c
2. e 41. b
3. h 42. c, d
4. g 43. a
5. j 44. d
6. d 45. The student should address any four of these
7. a components or anything else the student may think of
8. i that would be appropriate:
9. f • Change in activity level
10. b • Change in dietary and fluid intake
11. Stoma • Drinking tap water from a source different from
12. Colostomy patient’s home water source
13. Impaction • Negative side effects of medication or laxatives
14. Siphon administered or withheld while hospitalized
15. Ileostomy • Negative side effects of surgery
16. Kayexalate enema • High stress levels and emotional problems
17. Melena • Structural changes resulting from surgical procedure
18. Peristalsis • Chemical changes
19. Return flow or Harris Flush • Food allergy to something served to the patient
20. Normal flora
21. b
The student should include at least one
22. a
intervention that would be appropriate for
23. c
each component that might increase risk for
24. b
constipation in the hospitalized patient.
25. a
26. d 46. Appearance of stoma, including size and edema, color,
27. a, d moisture level, appearance of peristomal skin, the skin
28. a, b surrounding the stoma, characteristics of the effluent/
29. a, d fecal drainage, intactness of faceplate, and fullness of
30. b, c appliance bag
31. a 47. When one-third to one-half full; when odor is an issue;
32. b, c when the patient asks; when there is leakage
33. a, b 48. The student should express several feelings—
34. a for example, fear, anxiety, disgust, humiliation,
35. a, b, d embarrassment, anger, disbelief, or any other thing that
36. b, f the student can come up with. Check to ensure that the
37. d intervention relates to the component that increases risk
38. c for constipation in the hospitalized patient.
39. b, d

63
64 Answers

49.

Patient Fisher, Mivin

ID# 23232 RM 333
BD 10-5-47 Mission Regional Hospital
Admit 7-8-28
Physician Steve Holsted

Date Time Nurse’s Notes

7-8-28 0730 750 mL SS enema administered per orders without problems. Up unassisted to bathroom to expel enema. Returned lg. amt.

soft, formed, brown stool expelled. States feels much better.---------------------------------------------Student’s name and credentials
CHAPTER 31
Urinary Elimination and Care
1. g 40. a
2. d 41. c
3. h 42. a
4. a 43. b
5. j 44. e
6. b 45. c
7. c 46. d
8. i 47. a
9. e 48. f
10. f 49. b
11. Dialysis 50. a, d
12. Specific gravity 51. d
13. Urinary retention 52. b
14. Stress incontinence 53. T
15. Urge incontinence 54. F
16. Blood urea nitrogen 55. T
17. Indwelling catheter 56. T
18. Straight catheter 57. F
19. Urinary diversion 58. T
20. Urinary tract infection (UTI) 59. b
21. c 60. a
22. a: 3 61. b
b: 5 62. b
c: 1 63. a
d: 4 64. c
e: 2 65. d
23. b 66. a, c
24. a, b, d 67. a
25. d 68. b
26. c 69. T
27. a 70. F
28. a 71. F
29. c 72. T
30. b, d, e 73. T
31. a, d, e 74. T
32. c 75. T
33. c 76. T
34. b 77. b, d
35. b 78. Perform a bladder scan to determine the presence of
36. a residual urine in the bladder.
37. c 79. Straight catheter for residual urine and obtain a
38. c specimen for culture and sensitivity
39. b 80. Insert an indwelling catheter.

65
66 Answers

81. You must restart the 24-hour urine collection. Find the
patient’s assigned nurse and explain what happened.
Offer to get a new container from the laboratory and
restart the collection with new signs and times. Discard
the first void and begin the collection anew.
82.

Patient Mathai, Suhani

ID# 1354682 RM 11614
BD 1-19-83 Mission Regional Hospital
Admit 5-3-28
Physician Steve Holsted

Date Time Nurse’s Notes

5-4-28 0800 Urinary drng. bag contains 350 mL dark amber urine c mucus strings. IV of D5W infusing at 60 mL/hr.---------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------S. Ludlow, LVN

5-4-28 0900 Dr. Holsted notified of no additional output X1 hr and increased mucus in urine. Orders received.-------------------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------S. Ludlow, LVN

5-4-28 0915 Closed irrigation of cath. using 90 mL NS. Little return noted, ↑mucus noted in urine.-------------------------------S. Ludlow, LVN

5-4-28 1245 Urine output 450 mL. Bladder scan shows 300 mL residual urine. Dr. Holsted notified. Orders received.--------------------------

---------------------------------------------------------------------------------------------------------------------------------------------------------S. Ludlow, LVN

5-4-28 1310 #14-Fr. Foley cath. d/ced per order. Mucous plugs notes on old cath. #16-Fr. Foley inserted per order. Immed return of

350 mL amber urine noted. Tot. procedure without c/o pain or discomfort.-----------------------------------------------S. Ludlow, LVN
CHAPTER 32
Care of Older Adults
1. c 45. a, b, c
2. a 46. c
3. d 47. c
4. b 48. c
5. Ageism 49. a, b, c
6. Illusion 50. Answers will vary but could include: (1) checking
7. Hallucination water temperature to prevent burns or to prevent the
8. Dementia patient from becoming chilled; (2) pulling curtains to
9. Alzheimer provide privacy and maintain the patient’s dignity;
10. Cataract (3) disinfecting shower chairs, tubs, and lifts to
11. Glaucoma prevent cross-contamination; (4) mopping up all
12. Age-related macular degeneration spills to prevent anyone from slipping on wet floors;
13. Myocardial infarction (5) never leaving a resident unattended while he or she
14. Geri-chair is bathing, to prevent accidents; and (6) obtaining the
15. Residents help of other staff when transferring patients in and out
16. a of tubs, whirlpools, or showers.
17. c 51. Answers will vary but could include: (1) ensuring
18. b that dentures are inserted for meals; (2) assessing
19. d whether the food needs to be finely chopped or
20. b pureed; (3) feeding or assisting the patient to eat;
21. a (4) monitoring and recording amount of food eaten;
22. c (5) ensuring that adequate fluids are ingested;
23. a, b, c, d, e (6) providing supplemental protein and carbohydrate
24. d drinks as needed; (7) monitoring for weight loss
25. a, c, d on a weekly or monthly basis; (8) checking the meal
26. c card to ensure the resident is receiving the correct diet;
27. 75- to 84-year-old (9) making sure the patient is seated upright; and
28. 85- to 99-year-old (10) trying to make mealtime pleasant by conversing
29. 65- to 74-year-old with the residents.
30. Centenarians 52. Answers will vary but could include: (1) changing linen
31. a, b, c as often as needed and checking linens frequently to
32. c keep the resident comfortable and to decrease risk
33. c for skin irritation and breakdown; (2) providing
34. a scrupulous perineal skin care to prevent skin
35. a, b breakdown; (3) monitoring and documenting frequency
36. b of bowel movements to avoid severe constipation and
37. a impaction; (4) changing incontinence pad or underwear
38. d as soon as it is wet or soiled to prevent skin breakdown;
39. a, b, d (5) applying a skin barrier cream to prevent skin
40. c breakdown; and (6) maintaining the resident’s privacy
41. a, b, c, d and dignity during changes.
42. a, b, c, d 53. Answers will vary but could include the following:
43. b (1) Encourage activity and assist as needed.
44. c (2) Reposition the resident frequently, checking

67
68 Answers

pressure points and providing pillows to diminish oral cavity is free of sores and teeth are in good repair;
the weight on dependent areas. (3) Encourage the assessing abdomen for signs of constipation; assessing
resident to sit out of bed in a chair. (4) Provide if resident has been receiving the correct diet; asking
passive or assisted range-of-motion exercise. resident about the appetite change; assessing resident’s
(5) Encourage participation in self-care activities psychosocial well-being; asking resident about food
to the extent possible. preferences; and asking dietitian to assess resident’s
54. F nutritional status. Multiple factors can influence a
55. T person’s appetite; therefore, it is important that an
56. T assessment is thorough and covers all possible sources
57. T of the change.
58. T 65. Answers will vary but should include some of the
59. T following: bruising in hidden or unexpected areas;
60. T sores or bruises in multiple stages of healing; evidence
61. T of biting, burns, lacerations, fractures, or dislocations;
62. Answers will vary but could include the following: sedation; malnutrition or dehydration; excessively poor
poor activity tolerance related to loss of heart hygiene; or inappropriate clothing. Some behaviors
muscle elasticity; chest pain with activity because might include depression, fearfulness, despondency,
of fatty deposits in the coronary arteries; cold or failure to make eye contact when asked about abuse,
pale extremities because of decreased circulation; not in possession of his or her own money or credit
hypertension because of narrowing of blood vessels; cards, or odd deference shown to caregiver.
feeling cold because of decreased circulation; 66. Answers will vary but should include many of the
sores on the feet because of decreased circulation; following concepts: Old age is not all doom and gloom.
and poorly healing wounds because of decreased Older adults have a lifetime of experience on which
circulation. they draw as they continue on their journeys of self-
63. Answers will vary but can include the following: actualization. Many are the matriarchs or patriarchs of
suggesting the facility conduct craft-making projects, their families and are enjoying seeing their children and
board or card games, discussion groups, book clubs, grandchildren grow and succeed. Many older adults
instrument playing or listening to music, watching still work every day, often volunteering their time to
movies, word puzzles, or picture puzzles. These help others. Older persons still enjoy life, intellectual
activities not only alleviate boredom but also can stimulation, relationships, affection, love, and
sharpen cognitive skills, encourage development of spirituality. Nurses may inadvertently stereotype older
relationships, provide an opportunity for conversation, adults, assuming they are enfeebled, weak, or fragile.
and provide an opportunity for more exercise. They may address the older adult by his or her first
64. Answers will vary but should include assessing recent name, which some elders might find offensive. Often,
changes in body weight to get an accurate sense with no malice intended, nurses may take a paternalistic
of the effects of decreased appetite; performing a tone with older adults, diminishing the older adult’s
physical examination to assess for underlying physical sense of autonomy and dignity. To avoid these actions,
problems; assessing whether any new medications nurses should treat each person with dignity, respect,
have been ordered; making sure dentures fit well and/or professionalism, and care.
 Chapter 32 Care of Older Adults 69

67.

Patient Baxter, Donald

ID# 13572 RM 409
BD 4-19-51 Mission Regional Hospital
Admit 4-12-28
Physician Steve Holsted

Date Time Nurse’s Notes

4-12-28 1400 Teaching regarding medication regimen side effects and adverse reactions begun. Wife and pt. state it is difficult for him

to remember to take medications 4x each day. Noon and suppertime pills are often forgotten. Unsure of the purpose of

some medications and states “They all look alike. Small, white, and round.”--------------------------------------------------K. Haase, RN

4-12-28 1445 T.C. to Dr. Holsted, explained problems with four-times-a-day medication regimen. Orders received to give potassium

supplement with AM meds and Lyrica (leg pain medication) with suppertime pill.-----------------------------------------K. Haase, RN

4-12-28 1520 Teaching on medications continued. Wife and pt. feel confident that he can manage medications twice per day. Pt. able to

explain purpose of each med. and when he is to take it. Wife verbalized adverse reactions and side effects to report to

Dr. Holsted. Meds. in pill organizer for one week.--------------------------------------------------------------------------------------K. Haase, RN

CHAPTER 33
Care of the Surgical Patient
1. g 42. d
2. i 43. c
3. d 44. a, b, d
4. a 45. It is partially dependent on facility policy. However,
5. b the minimum should include monitoring vital signs
6. c every 15 minutes, if they are stable, for the first hour.
7. e Then assessments can be lengthened to every 30 to
8. h 60 minutes, according to facility policy. The
9. f assessments are performed at progressively
10. k lengthening intervals over the first 24 hours.
11. j 46. Kidneys and liver
12. Intubation 47. Serum albumin, hematocrit, prealbumin, transferrin, or
13. Extubation hemoglobin
14. Laparoscopic 48. There is clear evidence that bathing or showering with
15. Malignant hyperthermia chlorhexidine before surgery is effective in preventing
16. Approximation surgical site infections.
17. Postanesthesia care unit 49. It means that her white blood cell count (WBC) is
18. Dehiscence abnormally low, which reduces the ability of her body
19. Antiembolism hose to fight off infection. Surgery will be postponed until
20. Sequential compression devices the low WBC has been evaluated.
21. b 50. Hemorrhage
22. b 51. Pregnancy test or human chorionic gonadotropin test
23. a (hCG)
24. d 52. The student should list any eight of the following:
25. a • Information regarding preoperative preparations,
26. b including diagnostic tests, nothing-by-mouth (NPO)
27. e status, skin shave or scrub, intestinal preparation,
28. e insertion of tubes or IVs, and administration of preop-
29. a erative medications
30. e • What the patient can expect in the operating room
31. d (OR), including equipment, bright lights, cold tem-
32. c peratures, and masked staff members wearing caps
33. c and gowns that make it difficult to identify each one
34. c • Describe general roles of the various OR team mem-
35. a, b, c, d bers who will be responsible for the patient’s care
36. c, d • What the patient will and may experience postopera-
37. b, c, d tively once in the postanesthesia care unit
38. a, b, e, f, g • Actions the patient can take to help prevent complica-
39. c tions, decrease discomfort, shorten recovery time, and
40. d optimize healing
41. a, b, c, e 53. The circulating nurse

70
 Chapter 33 Care of the Surgical Patient 71

54.

Patient Kirby, Terri

ID# 987123 RM 617
BD 10-1-93 Mission Regional Hospital
Admit 4-7-28
Physician Steve Holsted

Date Time Nurse’s Notes

4-8-28 1015 Preoperative teaching began. Leg exercises, T, C, & Dp Br demonstrated and explained. Return demonstration accurate.

Verbalized understanding of importance.-------------------------------------------------------------------Student’s signature and credentials

CHAPTER 34
Phlebotomy and Blood Specimens
1. h (3) Lavender
2. n (4) Gray
3. e 29. Heel of infant, fingertip of older child and adult
4. a 30. It can cause the vein to collapse.
5. f 31. The tourniquet is to block blood from returning to
6. c the heart in the superficial veins so that they will
7. o distend.
8. j 32. If a patient has had a mastectomy on one side, avoid
9. k drawing blood from that arm. Once lymph tissue
10. g has been surgically removed, the lymph fluid does
11. b not move and remains static, a condition known as
12. d lymphostasis. To decrease risk for infection, use the
13. i opposite arm for venipuncture.
14. m 33. The anaerobic specimen is drawn first.
15. l 34. Remove the safety needle from the syringe and place it
16. a, c in the sharps container.
17. b, c, e Attach syringe to the blood transfer device so the
18. d device is at the bottom. Push the evacuated tube onto
19. a the internal needle of the blood transfer device. Keep
20. b the tube vertical, and it will fill from the bottom. Do not
21. c push on the plunger of the syringe. Follow the correct
22. d order of draw.
23. a, b, c, d, e, g, i 35. (1) Blood cultures or yellow
24. b, c, e (2) Light blue
25. b, c, e (3) Red, red/gray, gold
26. d, e (4) Green
27. b, d, e, f (5) Lavender/pink
28. (1) Yellow (6) Gray
(2) Green (7) Yellow with acid citrate dextrose

72
 Chapter 34 Phlebotomy and Blood Specimens 73

36.

Patient Kurbo, Turbi

ID# 987123 RM 617
BD 10-1-93 Mission Regional Hospital
Admit 4-7-28
Physician Steve Holsted

Date Time Nurse’s Notes

4-8-28 1315 Blood drawn with 1 stick, from median cubital vein at lt. antecubital without difficulty, for lytes BMP, and CBC.-------------

---------------------------------------------------------------------------------------------------------------------------Student’s signature and credentials

CHAPTER 35
Researching and Preparing
Medications
1. d c. Right route
2. f d. Right patient
3. g e. Right date and time
4. h f. Right documentation
5. a g. Right indication
6. b 41. a. As you remove the medication from the cart, bin, or
7. i Pyxix MedStation
8. e b. Before placing it in the medication cup and returning
9. c the container to the drawer
10. Generic name c. At the bedside, before opening the medication
11. Prescription medications 42. Count the number of medications to be administered on
12. Parenteral route the medication administration record (MAR) and count
13. Mucosal route the number of medicines you are taking to the room.
14. Adverse effects Verify that the numbers match.
15. Allergic reaction 43. Teach the patient to avoid taking the medication with
16. Physician’s Desk Reference grapefruit juice because it can interfere with drug
17. Nursing drug guide absorption, leading to increased blood levels and
18. Medication administration record increased adverse effects.
19. a, b, d, e, f 44. The frequency of administration is missing. Notify
20. a, c the health-care provider and ask for the frequency and
21. c, d verify the remaining order.
22. d 45. Vital signs
23. b 46. If the blood pressure or pulse is low
24. a 47. Tarry stools, bleeding gums, bleeding from the rectum
25. c or vagina, nosebleeds, elevated blood levels
26. a 48. Blood pressure
27. a, c 49. Assess the need for giving stool softeners or laxatives;
28. d if the patient is having liquid or frequent stools, hold
29. c the medication.
30. a 50. Check the fingerstick blood sugar.
31. a, b, d, e 51. Assess for signs of bleeding ulcers such as tarry stools,
32. a especially in older adults.
33. d 52. The purpose of tall man letters in drug names is to help
34. a distinguish between drugs with confusing or similar
35. a, c, d, e names and thus prevent medication errors.
36. d 53. 40 mg 20 mg
=
37. a, b, e 1 tablet X tablet(s)
38. c, d
40X = 20
39. d
40. a. Right medication 40X 20
=
b. Right dose 40 40
X = 0.5 tablet (IF tablet is scored)
74
 Chapter 35 Researching and Preparing Medications 75

54. First, you must convert milligrams to grains because 50 mg 75 mg

=
the tablets you have on hand are in grains. 1 tablet X tablet(s)
Conversion 60 mg 600 mg
= 50X = 75
1 gr X gr
50X 75
60X = 600 =
50 50
60X 600
= X = 1.5 tablets (of the 50-mg tablets IF they are scored)
60 60
57. 20 mEq 50 mEq
=
X = 10 gr This is the equivalent to the health-care 5 mL X mL
provider’s order of 600 mg.
20X = 250
Calculation 5 gr 10 gr
=
1 tablet X tablet(s) 20X 250
=
20 20
5X = 10
X = 12.5 or 13 mL per dose
5X 10
= 58. • Take a deep breath and focus on preparing the
5 5
patient’s medications.
X = 2 tablets • Obtain the ordered medications, one at a time.
55. 2 mg 6 mg • Carefully verify the six rights and do the safety
=
1 tablet X tablet(s) checks. Check the patient’s allergies.
• Calculate the dose needed to ensure that you are
2X = 6
giving the correct dose.
2X 6 • Place the unopened medicines in a medicine cup.
=
2 2 Close and lock the cart or bin.
• Take the medicines to the patient’s room. Check the
X = 3 tablets
patient’s blood pressure and heart rate to determine
Safety: Anytime you calculate that you are to
administer more than just one or two tablets,
whether it is safe to give the antihypertensives and
double-check your math. It is also just good cardiac glycosides.
practice to have another nurse confirm the • Perform the third safety check and administer the
dosage. This is doubly true when giving poten- medications.
tially dangerous drugs, such as anticoagulants. • Document the medications you have administered.
56. Yes Explain any medications that were held or not given
25 mg 75 mg in the nurse’s notes.
=
1 tablet X tablet(s)
25X = 75
5X 75
=
25 25
X= 3 tablets (of the 25-mg tablets)
76 Answers Chapter 35 Researching and Preparing Medications 76

59.

Patient Washington, Ebonie HOSPITAL MEDICATION ADMINISTRATION RECORD

ID# 4982376 RM 409
BD 2-7-77
Mission Regional Hospital
Admit 4-22-28
Physician Steve Holsted

Date Date Drug - Dose - Route - Frequency Admin Date Date

Ordered Reord. Time 4-24-28 4-25-28

4-22-28 Amiodarone 200 mg PO bid 0900 0900 WK

2100

4-22-28 Amlodipine 10 mg PO bid daily 0900 0900 WK

4-22-28 Valsartan 320 mg PO daily 0900 0900 WK

4-22-28 Nitroderm TTS 10 patch changes daily 0900 0900 WK

4-22-28 Tylenol 325 mg PO every 4–6 hr 0920 WK

Prn moderate to severe pain

Initials/Signature/Shift

7AM–7PM WK Whitney Knight, LPN

Patient Washington, Ebonie

ID# 4982376 RM 409
BD 2-7-77 Mission Regional Hospital
Admit 4-22-28
Physician Steve Holsted

Date Time Nurse’s Notes

4-24-28 0900 C/O severe headache through the night that kept her from sleeping well.------------------------------------------------W. Knight, LPN

4-24-28 0920 Tylenol 325 mg given PO for c/o severe headache. Resting with cool cloth on forehead and lights turned down.-----------------

--------------------------------------------------------------------------------------------------------------------------------------------------------W. Knight, LPN

4-24-28 1000 Resting quietly in darkened room. States headache is “getting better. I think I can sleep now.” Resp. even at 14/min.-------

--------------------------------------------------------------------------------------------------------------------------------------------------------W. Knight, LPN

CHAPTER 36
Administering Oral, Topical,
and Mucosal Medications
1. f 39. b, c, e
2. h 40. a
3. j 41. d
4. i 42. c
5. b 43. a
6. c 44. b, c, d
7. l 45. a, b, d, e
8. k 46. a, c, e
9. a 47. d
10. d 48. c
11. e 49. a: 3, b: 5, c: 4, d: 2, e: 1
12. g 50. After confirming that you have permission to crush any
13. Oral route medications in tablet form, crush each tablet separately.
14. Enteric-coated Mix the resulting powder with 1 to 2 teaspoons of ice
15. Sustained-release cream or applesauce, and give to the patient to swallow.
16. Topical route 51. Mix omeprazole with apple or orange juice instead
17. Transdermal route of water. Flush the tube with the juice also to prevent
18. Respiratory route clumping of the granules and to preserve their enteric
19. Narcotics coating. Metoprolol can be crushed and mixed with a
20. Mucosal route small amount of water for administration. The tube can
21. a, b, c be flushed with water also.
22. c 52. It makes it possible for you to identify each drug during
23. d administration; this is pertinent in case an interruption
24. a occurs during the administration process. For example,
25. a, c, e if you were administering medications through an
26. b enteral tube and accidentally spilled one medication,
27. d you could identify which medication the patient did not
28. c receive. Another situation might arise in which you are
29. a, b, d at the bedside preparing to administer the medications
30. b and the health-care provider walks in and discontinues
31. c one of the medications that you have already crushed.
32. d In this example, you would be able to identify which
33. a medication to stop. If the medications were all mixed
34. b, d together in one cup, you would be unable to remove the
35. c discontinued medication.
36. c 53. c
37. a, c, e 54. Always check drug allergies before administering
38. b, d, e medications, and especially check ingredients of
combination medications.

77
78 Answers

55.

Patient Odell, Dean

ID# 9607890 RM 408
BD 6-6-70 Mission Regional Hospital
Admit 8-11-28
Physician Steve Holsted

Date Time Nurse’s Notes

8-12-28 0900 Digoxin 0.25 mg held. Dig. level 2.0. Apical pulse 56. Physician notified.--------------------------------------------------------V. Popel, LPN

8-12-28 0925 T.C. from Dr. Holsted. Orders received.-----------------------------------------------------------------------------------------------------V. Popel, LPN

HOSPITAL MEDICATION ADMINISTRATION RECORD

Codes For Injection Sites
A- Left Anterior Thigh H - Right Anterior Thigh Dean Odell
B-
C-
Left Deltoid
Left Gluteus Medius
I - Right Deltoid
J - Right Gluteus Medius
Adm 8-11-28
D- Left Lateral Thigh K - Right Lateral Thigh DOB 06-06-1970
E-
F-
Left Ventral Gluteus
Left Lower Quadrant
L - Right Ventral Gluteus
M - Right Lower Quadrant
ID # 9607890
G- Left Upper Quadrant N - Right Upper Quadrant
ALLERGIES: DATE DATE DATE
DATE DATE ADMIN.
ORDERED REORD.
DRUG - DOSE - ROUTE - FREQUENCY
TIME 8/11/28 8/12/28
08-11-28 Digoxin 0.25mg PO daily 0900 VP VP

Patient Name: Dean Odell Mission Regional Hospital

ID# 9607890
Physician’s Order Sheet

Date Orders
08-12-28 0925, Stop digoxin 0.25mg. Give no digoxin X2 days then start
digoxin 0.125mg po daily on 08-14-28,

To DK Marvel/V Popel, LVN

CHAPTER 37
Administering Intradermal,
Subcutaneous, and Intramuscular
Injections
1. f 8. b
2. g 9. d
3. h 10. j
4. e 11. First-pass metabolism
5. c 12. Air-lock
6. a 13. and 14.
7. i

Tip (Luer-Lok)
a.
Barrel c. Plunger
b.

d. Flange
3mL
21/2
11/2

2
1/2

e. Bevel

g. Hub

f. Shaft

15. In a sharps container; a hard plastic, impervious 27. a, c

container 28. a
16. Fatty, blood vessels, and nerves 29. d
17. Sterile 30. c
18. Tuberculosis 31. c
19. 0.1 mL intradermal 32. c
20. Left ventral forearm 33. a
21. Lipoatrophy 34. c
22. Lipohypertrophy 35. a
23. c 36. c
24. b 37. b
25. e 38. a
26. e 39. a

79
80 Answers

40. 2.6 mL in a standard 3-mL syringe (rounded to the

nearest 1/10th)

3mL
21/2
11/2
1/2

2
1
2.6 mL

41. 0.7 mL in a standard 3-mL syringe or 0.7 mL in a

tuberculin (TB) syringe
0.7 mL in a TB syringe would be most accurate.

3mL
21/2
11/2
1/2

2
1
0.7 mL

mL
1.0
.1
.2

.3

.4

.5

.6

.7

.8

.9
0.7 mL

42. 3-mL syringe, draw up 1 mL medication

3mL
21/2
11/2
1/2

2
1

1 mL

43. U-100 insulin syringe, draw up 22 units of insulin

USE U-100 ONLY

UNITS
100
10

20

30

40

50

60

70

80

90
5

15

25

35

45

55

65

75

85

95

(Opposite side)

22 units

44. TB syringe, draw up 0.75 mL medication

mL
1.0
.1
.2

.3

.4

.5

.6

.7

.8

.9

0.75 mL
 Chapter 37 Administering Intradermal, Subcutaneous, and Intramuscular Injections 81

45. TB syringe, draw up 0.1 mL purified protein derivative

(PPD)

mL
1.0
.1
.2

.3

.4

.5

.6

.7

.8

.9
0.1 mL

46. U-100 insulin syringe, 17 units

USE U-100 ONLY

UNITS
100
10

20

30

40

50

60

70

80

90
5

15

25

35

45

55

65

75

85

95
(Opposite side)

17 units

47. U-100 insulin syringe, Novolin R 3 units should be

drawn up first, followed by NPH 12 units. The syringe
should have a total volume of 15 units. The Novolin R
3 units should be shaded in toward the plunger end of
the syringe followed by the NPH 12 units toward the
syringe tip end of the syringe.

3 units Novolin R
drawn first
USE U-100 ONLY
UNITS
100
10

20

30

40

50

60

70

80

90
5

15

25

35

45

55

65

75

85

95

(Opposite side)

12 units NPH
drawn last

15 units total

48. Lantus insulin cannot be mixed with any other type

insulin.
82 Answers

49. A standard 3-mL syringe, 22 gauge, ⫻ 1⬙ needles,

alcohol wipe, gauze pad or cotton ball, elastic bandage,
examination gloves
50.

Patient Hall, Melisa

ID# 3411576 RM 307
BD 3-1-71 Mission Regional Hospital
Admit 8-19-28
Physician Steve Holsted

Date Time Nurse’s Notes

8-20-28 0135 C/O abd. incision pain at 8 on a scale of 0 to 10. Describes pain as sharp, stabbing pain that worsens with movement.

Denies nausea. Crying.-------------------------------------------------------------------------------------------Student’s signature and credentials

8-20-28 0145 Stadol 2 mg administered IM in rt. ventrogluteal site. 180 mL hot cocoa provided and drank. Repositioned to rt. side.

Back rub given.------------------------------------------------------------------------------------------------------Student’s signature and credentials

8-20-28 0215
Reports pain down to 4. States thinks she can sleep now.-----------------------------------------Student’s signature and credentials
CHAPTER 38
Intravenous Therapy
1. k 34. c
2. h 35. b
3. j 36. a
4. b 37. a (but becomes b quickly)
5. a 38. a
6. c 39. a
7. f 40. a
8. i 41. c
9. e 42. a
10. d 43. b, c
11. g 44. a
12. m 45. d
13. l 46. c, e
14. Extravasation 47. Winged butterfly
15. Plasma 48. Prime or priming
16. Flange 49. Any four of the following: cephalic, basilic, median
17. Sclerosed cubital, median antebrachial, and accessory cephalic
18. Precipitate veins
19. Vesicant 50. 100 × 12 1200
= = 20 gtts per minute
20. Drug–drug interaction 60 60
21. Packed red blood cells 51. 75 × 10 750
= = 12–13 gtts per minute
22. Thrombus 60 60
23. b, c, d 52. 125 × 20 2500
= = 41–42 gtts per minute
24. c 60 60
25. a, b, d 53. 30 × 60 1800
= = 30 gtts per minute
26. b 60 60
27. c 54. 50 × 12 600
= = 20 gtts per minute
28. e 30 30
29. c 55. 100 × 20 2000
= = 66–67 gtts per minute
30. d 30 30
31. c, d 56. 100 × 20 2000
= = 100 gtts per minute
32. a 20 20
33. b

83
84 Answers

57.

Patient Baggs, Shandy

ID# 668899 RM 500
BD 4-22-81 Mission Regional Hospital
Admit 7-10-28
Physician Steve Holsted

Date Time Nurse’s Notes

7-10-28 1325 IV initiated in rt. forearm with 22 g intracath with 3 sticks. 1000 mL D 5 1/2 NS with 40 mEq KCL infusing per pump at

80 mL/hr. Denies site discomfort.----------------------------------------------------------------------------Student’s signature and credentials