Title: Exam 7 - Safety in Pharmacology
Course: NUR 1008C Transition to Prof Nursing > Section: Module 8

Q: The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Of the following strategies, which has the best chance of maintaining patient compliance?
- Performing 20 minutes of aerobic exercise daily with 10 minute warm-up and cool-down periods
- Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity
- Instructing the patient on the evils of not exercising, and getting her to take responsibility for her current health status
- Arranging for the patient to join a gym that she will have to pay, for so that she does not need to depend on insurance
A: Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity
If right: Keeping a log may increase adherence to an exercise prescription. Cross-training (combination of exercise activities) provides variety to combat boredom and increases the potential for total body conditioning as opposed to daily aerobic exercise. “Blaming” a patient for his or her health status is usually counterproductive. Instead, the nurse should instruct the patient about the physiological benefits of a regular exercise program. Developing a plan of exercise that the patient may perform at home may improve compliance.
If wrong: Keeping a log may increase adherence to an exercise prescription. Cross-training (combination of exercise activities) provides variety to combat boredom and increases the potential for total body conditioning as opposed to daily aerobic exercise. “Blaming” a patient for his or her health status is usually counterproductive. Instead, the nurse should instruct the patient about the physiological benefits of a regular exercise program. Developing a plan of exercise that the patient may perform at home may improve compliance.

Q: The nurse is working with the patient in developing an exercise plan. The patient tells the nurse that she just will not participate in a formal exercise program. The nurse then suggests that exercise activities can be incorporated into activities of daily living. The patient seems to be agreeable to that concept. Of the following activities, which would be considered a moderate-intensity activity?
- Doing laundry
- Making the bed
- Ironing
- Folding clothes
A: Folding clothes
If right: Low-intensity ADLs include doing the laundry, making the bed, ironing, and washing dishes. Moderate-intensity ADLs include sweeping the kitchen or sidewalk, washing windows, folding clothes, and vacuuming.
If wrong: Low-intensity ADLs include doing the laundry, making the bed, ironing, and washing dishes. Moderate-intensity ADLs include sweeping the kitchen or sidewalk, washing windows, folding clothes, and vacuuming.

Q: The nurse is ambulating a patient in the hall when she notices that he is beginning to fall. The nurse should
- Grab the patient and hold him tight to prevent the fall.
- Gently lower the patient to the floor.
- Jump back and let the patient fall naturally.
- Push the patient against the wall and guide him to the floor.
A: Gently lower the patient to the floor.
If right: If the patient has a fainting episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient’s body weight. Then extend one leg and let the patient slide against the leg, and gently lower the patient to the floor, protecting the patient’s head. Grabbing the patient will shift the nurse’s center of gravity and may lead to a back injury. Allowing the patient to fall could lead to head injury for the patient. Pushing the patient against the wall could also cause the patient to hit his head and cause injury.
If wrong: If the patient has a fainting episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient’s body weight. Then extend one leg and let the patient slide against the leg, and gently lower the patient to the floor, protecting the patient’s head. Grabbing the patient will shift the nurse’s center of gravity and may lead to a back injury. Allowing the patient to fall could lead to head injury for the patient. Pushing the patient against the wall could also cause the patient to hit his head and cause injury.

Q: In assisting the patient to exercise, the nurse should
- Expect that pain will occur with exercise of unused muscle groups.
- Set the pace for the exercise class.
- Force muscles or joints to go just beyond resistance.
- Stop the exercise if pain is experienced.
A: Stop the exercise if pain is experienced.
If right: Assess for pain, shortness of breath, or a change in vital signs. If present, stop exercise. Let each patient exercise at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise.
If wrong: Assess for pain, shortness of breath, or a change in vital signs. If present, stop exercise. Let each patient exercise at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise.

Q: The patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move his right arm and leg. The nurse understands that
- Active range of motion is the only thing that will prevent contractures from forming.
- Passive range of motion must be instituted to help prevent contracture formation.
- Range-of-motion exercises should be started 2 days after the patient is stable.
- Range-of-motion exercises should be done on major joints only.
A: Passive range of motion must be instituted to help prevent contracture formation.
If right: When patients cannot participate in active range of motion, the nurse must institute passive range of motion to maintain joint mobility and prevent contractures. Passive range of motion can be substituted for active when needed. For the patient who does not have voluntary motor control, passive range-of-motion exercises are the exercises of choice. Unless contraindicated, the nursing care plan includes exercising each joint (not just major joints) through as nearly a full range of motion as possible. Initiate passive range-of-motion exercises as soon as the patient loses the ability to move the extremity or joint.
If wrong: When patients cannot participate in active range of motion, the nurse must institute passive range of motion to maintain joint mobility and prevent contractures. Passive range of motion can be substituted for active when needed. For the patient who does not have voluntary motor control, passive range-of-motion exercises are the exercises of choice. Unless contraindicated, the nursing care plan includes exercising each joint (not just major joints) through as nearly a full range of motion as possible. Initiate passive range-of-motion exercises as soon as the patient loses the ability to move the extremity or joint.

Q: The patient has been in bed for several days and needs to be ambulated. Before ambulation, the nurse
- Removes the gait belt to allow for unrestricted movement.
- Has the patient get up from bed before he has a chance to get dizzy.
- Has the patient look down to watch his feet to prevent tripping.
- Dangles the patient on the side of the bed.
A: Dangles the patient on the side of the bed.
If right: Some patients experience orthostatic hypotension—a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. Assist the patient to a position of sitting at the side of the bed, and dangle for 1 to 2 minutes before standing. The nurse needs to provide support at the waist so that the patient’s center of gravity remains midline. This is achieved with the use of a gait belt. A gait belt encircles the patient’s waist and may have handles attached for the nurse to hold while the patient ambulates. The patient should maintain as normal a walking posture as possible with the head erect.
If wrong: Some patients experience orthostatic hypotension—a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. Assist the patient to a position of sitting at the side of the bed, and dangle for 1 to 2 minutes before standing. The nurse needs to provide support at the waist so that the patient’s center of gravity remains midline. This is achieved with the use of a gait belt. A gait belt encircles the patient’s waist and may have handles attached for the nurse to hold while the patient ambulates. The patient should maintain as normal a walking posture as possible with the head erect.

Q: The structure that is responsible for returning oxygenated blood to the heart is the
- Pulmonary artery.
- Pulmonary vein.
- Superior vena cava.
- Inferior vena cava.
A: Pulmonary vein.
If right: The pulmonary vein carries oxygenated blood to the heart. The pulmonary artery carries deoxygenated blood from the heart to the lungs. Both venae cavae return blood to the right atrium of the heart.
If wrong: The pulmonary vein carries oxygenated blood to the heart. The pulmonary artery carries deoxygenated blood from the heart to the lungs. Both venae cavae return blood to the right atrium of the heart.

Q: The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing?
- 12
- 13
- 20
- 23
A: 23
If right: The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.
If wrong: The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

Q: The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement?
- Monitor vital signs every 15 minutes.
- Apply brace to right knee.
- Elevate right knee and apply ice.
- Check pulses in right foot.
A: Elevate right knee and apply ice.
If right: Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
If wrong: Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.

Q: The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient’s anxiety?
- Tell the patient to close his eyes.
- Explain the procedure.
- Turn on the television.
- Ask the family to leave the room.
A: Explain the procedure.
If right: Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient’s anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient’s anxiety.
If wrong: Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient’s anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient’s anxiety.

Q: The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage
- I.
- II.
- III.
- IV.
A: I.
If right: Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.
If wrong: Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.

Q: The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder?
- The binder creates pressure over the abdomen.
- The binder supports the abdomen.
- The binder reduces edema at the surgical site.
- The binder secures the dressing in place.
A: The binder supports the abdomen.
If right: The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
If wrong: The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.

Q: The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?
- Allowing the solution to flow from the most contaminated to the least contaminated
- Scrubbing vigorously when applying solutions to the skin
- Cleansing in a direction from the least contaminated area
- Utilizing clean gauge and clean gloves to cleanse a site
A: Cleansing in a direction from the least contaminated area
If right: Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
If wrong: Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

Q: The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk?
- Gentle cleaners and thorough drying of the skin
- Absorbent pads and garments
- Positioning with use of pillows
- Therapeutic beds and mattresses
A: Gentle cleaners and thorough drying of the skin
If right: Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.
If wrong: Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.

Q: The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?
- Sterile technique
- Clean dressings and no touch technique
- Double bagging of contaminated dressings
- Ability of the caregiver
A: Clean dressings and no touch technique
If right: Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.
If wrong: Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.

Q: The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient?
- Obtain assistance and use the drawsheet to place the patient into the new position.
- Place the patient in a 30-degree supine position.
- Utilize a transfer sliding board and assistance to slide the patient into the new position.
- Elevate the head of the bed 45 degrees.
A: Utilize a transfer sliding board and assistance to slide the patient into the new position.
If right: When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient’s body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
If wrong: When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient’s body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

Q: The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
- At least 3 hours
- Not longer than 30 minutes
- Less than 2 hours
- As long as the patient remains comfortable
A: Less than 2 hours
If right: When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.
If wrong: When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

Q: The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?
- Readiness for enhanced nutrition
- Impaired physical mobility
- Impaired skin integrity
- Chronic pain
A: Impaired skin integrity
If right: After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.
If wrong: After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.

Q: A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?
- Nasal cannula
- Simple face mask
- Partial non-rebreather mask
- Non-rebreather mask
A: Nasal cannula
If right: Nasal cannulas deliver oxygen from 1 to 6 L/min. A patient with COPD should never receive more than 3 L/min because this decreases the drive to breathe, resulting in hypoventilation. All other devices are intended for flow rates greater than 6 L/min.
If wrong: Nasal cannulas deliver oxygen from 1 to 6 L/min. A patient with COPD should never receive more than 3 L/min because this decreases the drive to breathe, resulting in hypoventilation. All other devices are intended for flow rates greater than 6 L/min.

Q: Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is
- The beginning of the systolic phase.
- The opening of the aortic valve.
- S_3, the third heart sound.
- Regurgitation of the mitral valve.
A: Regurgitation of the mitral valve.
If right: A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S_1. The third heart sound, S_3, is heard with heart failure.
If wrong: A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S_1. The third heart sound, S_3, is heard with heart failure.

Q: The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign?
- Ineffective tissue perfusion
- Risk for infection
- Imbalanced nutrition: less than body requirements
- Acute pain
A: Ineffective tissue perfusion
If right: The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient’s nursing diagnosis, but the data provided do not support this nursing diagnosis.
If wrong: The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient’s nursing diagnosis, but the data provided do not support this nursing diagnosis.

Q: The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient’s Braden scale total score?
- 15
- 17
- 20
- 23
A: 20
If right: With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.
If wrong: With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.

Q: A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend?
- A bowl of cereal with whole milk and a banana
- A cup of nonfat yogurt with granola, and a handful of dried apricots
- Whole wheat toast with butter, a side of cottage cheese
- Omelet with sausage, cheese, and onions
A: A cup of nonfat yogurt with granola, and a handful of dried apricots
If right: Diets high in potassium, fiber, and calcium and low in fat are best for someone who is managing hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter is high in fat.
If wrong: Diets high in potassium, fiber, and calcium and low in fat are best for someone who is managing hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter is high in fat.

Q: The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient’s willingness and ability to increase mobility, which intervention is most important for the nurse to complete?
- Encourage the patient to sit up in the chair.
- Provide analgesic medication as ordered.
- Explain the risks of immobility to the patient.
- Turn the patient every 3 hours while in bed.
A: Provide analgesic medication as ordered.
If right: Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient’s willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient’s ability to increase mobility.
If wrong: Maintaining adequate pain control and patient comfort increases the patient’s willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient’s willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient’s ability to increase mobility.

Q: A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find
- Blood in the sputum.
- Distended jugular vein.
- Peripheral edema.
- Crackles in the lungs.
A: Crackles in the lungs.
If right: The left coronary artery supplies the left ventricle of the heart; damage to the muscle in the left ventricle leads to pulmonary congestion and frothy sputum, and crackles may be heard. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Blood in the sputum is indicative of an infection such as tuberculosis.
If wrong: The left coronary artery supplies the left ventricle of the heart; damage to the muscle in the left ventricle leads to pulmonary congestion and frothy sputum, and crackles may be heard. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Blood in the sputum is indicative of an infection such as tuberculosis.