The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?

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Question 1 of 9

The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. What nursing intervention should be included in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity. A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity. B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity. D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.

Question 2 of 9

A nurse is teaching about the energy needed at rest to maintain life-sustaining activities for a specific period of time. What is the nurse discussing?

Correct Answer: B

Rationale: The correct answer is B: Basal metabolic rate (BMR). BMR refers to the minimum amount of energy required to maintain basic physiological functions at rest. It accounts for about 60-75% of total energy expenditure. It is essential for sustaining life-sustaining activities such as breathing, circulating blood, and maintaining body temperature. Incorrect Choices: A: Resting energy expenditure (REE) is the total amount of energy expended by the body while at rest, including BMR and additional energy for daily activities. C: Nutrient density refers to the amount of nutrients per calorie in a food item, not the energy needed at rest. D: Nutrients are essential substances in food required for growth, maintenance, and repair, but they do not specifically refer to the energy needed at rest.

Question 3 of 9

A hospice nurse is well aware of how difficult it is to deal with others pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome?

Correct Answer: C

Rationale: The correct answer is C: Emotional exhaustion. Dealing with others' pain daily can lead to burnout and emotional exhaustion for the nurse. This can result in decreased empathy and effectiveness in providing care. Healthy practices such as self-care, setting boundaries, and seeking support can help prevent emotional exhaustion. Choice A: Inefficiency in the provision of care is incorrect because emotional exhaustion may affect the quality of care but does not necessarily lead to inefficiency. Choice B: Excessive weight gain is incorrect as it is not directly related to the emotional toll of dealing with others' pain. Choice D: Social withdrawal is incorrect as it is a potential outcome of emotional exhaustion but not the primary concern in this scenario.

Question 4 of 9

The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

Correct Answer: C

Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement. Summary of Incorrect Choices: A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach. B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage. D: Measuring from the tip of the nose to the earlobe to

Question 5 of 9

A nurse wants to reduce data entry errors onthe computer system. Which action should the nurse take?

Correct Answer: D

Rationale: The correct answer is D because charting on the computer immediately after care is provided reduces the chances of forgetting important details and ensures accuracy. It also allows for real-time documentation, improving patient care. Choice A is incorrect as using the same password all the time poses a security risk. Choice B is incorrect as sharing passwords compromises confidentiality. Choice C is incorrect as printing out and reviewing notes at home does not address data entry errors on the computer system.

Question 6 of 9

A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?

Correct Answer: A

Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed. B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals. C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer. D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.

Question 7 of 9

An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting?

Correct Answer: A

Rationale: The correct answer is A: The patient and family should be viewed as a single unit of care. In hospice care, the focus is on providing holistic care not only to the patient but also to their family members. This approach recognizes that the patient's well-being is interconnected with that of their loved ones. By viewing the patient and family as a single unit of care, hospice providers can address not just the physical symptoms but also the emotional, social, and spiritual needs of both the patient and their family. This principle emphasizes the importance of supporting the patient and their family through the end-of-life journey. Summary: - Choice B is incorrect as hospice care aims to manage symptoms effectively to improve quality of life. - Choice C is incorrect as hospice care typically involves a collaborative interdisciplinary team working towards common goals. - Choice D is incorrect as hospice care often prioritizes providing end-of-life care in a comfortable setting preferred by the patient.

Question 8 of 9

A nurse is completing an OASIS data set on apatient. The nurse works in which area?

Correct Answer: A

Rationale: The correct answer is A: Home health. The Outcome and Assessment Information Set (OASIS) data set is specifically used in the home health care setting to assess the patient's condition and needs. This includes collecting data on the patient's health, functional status, and living environment to determine the appropriate care plan. In contrast, choices B, C, and D are incorrect because OASIS is not utilized in the intensive care unit, skilled nursing facility, or long-term care facility settings. These settings have their own assessment tools and documentation requirements that are different from OASIS used in home health care.

Question 9 of 9

Which data found on a patient’s health history would place her at risk for an ectopic pregnancy?

Correct Answer: B

Rationale: The correct answer is B: Recurrent pelvic infections. Pelvic infections can lead to scarring and blockage of the fallopian tubes, increasing the risk of ectopic pregnancy. Ovarian cysts and oral contraceptives are not directly linked to ectopic pregnancies. Heavy menstrual flow does not inherently increase the risk of ectopic pregnancy.

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