Question

An 80-year-old Hispanic female is admitted to the nursing home after being hospitalized with bilateral lower leg ulcers.

Her medical history includes osteoarthritis, peripheral vascular disease (PVD), and chronic obstructive pulmonary disease (COPD). At the time of admission, her leg ulcers were Stage II. Her admitting vital signs are: BP 120/60 mm Hg, temperature 98.6°F, pulse 64/min and regular, respirations 24/min, and pain rated 3/10. The pain is dull at both leg ulcer sites. Physician orders include a regular diet, activity as tolerated, and oxygen at 2 L/min PRN for dyspnea. Keep oxygen saturation between 92% and 96%.

Which assessment finding is most consistent with COPD?

Answer 1

Correct Answers:

Adventitious lung sounds

Rationale :

🫁Patients with COPD commonly develop abnormal breath sounds because of airflow obstruction and retained secretions.

🌬️Wheezes, rhonchi, crackles, or diminished breath sounds can occur depending on the type and severity of COPD.

🩺The presence of adventitious lung sounds is therefore more consistent with chronic pulmonary disease than the other findings listed.

🔊Assessment of lung sounds and oxygenation is especially important because this resident already has a diagnosis of COPD.

📌Core Message

COPD commonly produces abnormal/adventitious breath sounds because of airway obstruction, mucus, and impaired airflow.

Answer 2

Correct Answers:

“I started an antidepressant two weeks ago. My energy is returning, but I still don’t feel any happier.”

Rationale :

⚠️During the early weeks of antidepressant therapy, a patient's energy may improve before depressed mood improves.

🧠This period can increase concern for suicide risk because the patient may now have more energy to act on suicidal thoughts.

💊Most antidepressants require several weeks for full mood improvement, so persistent sadness at two weeks can still occur.

🚨A patient whose energy improves while depression persists requires careful assessment for suicidal thoughts, intent, and plans.

📌Core Message

Early antidepressant treatment can create a high-risk period when energy returns before mood improves, requiring suicide assessment.

Answer 3

Correct Answers:

Quality and Safety Education for Nurses

Rationale :

🎓QSEN was developed to strengthen the competencies nurses need to provide safe, high-quality healthcare.

🏥Its major competencies include patient-centered care, teamwork, evidence-based practice, quality improvement, safety, and informatics.

📖QSEN concepts are incorporated into nursing education to prepare students and new graduate nurses for clinical practice.

🧩The initiative focuses specifically on developing the knowledge, skills, and attitudes required for modern nursing care.

📌Core Message

QSEN prepares nurses with essential competencies in safety, quality, teamwork, evidence-based practice, informatics, and patient-centered care.

Answer 4

Correct Answers:

0.5ml

Rationale :

🧮Use Desired ÷ Available × Volume to calculate the medication volume.

💉The desired dose is 5,000 units, while the available concentration is 10,000 units/mL.

➗Calculating 5,000 ÷ 10,000 × 1 mL gives 0.5 mL.

✅Therefore, each prescribed subcutaneous dose requires 0.5 mL of heparin.

📌Core Message

A 5,000-unit dose from 10,000 units/mL requires 0.5 mL.

Answer 5

Correct Answers:

Competent nursing practice

Rationale :

🛡️The strongest protection against malpractice is consistently providing competent care that meets professional standards.

📋Malpractice occurs when a nurse breaches the standard of care and causes patient harm.

👩‍⚕️Following policies, using appropriate clinical judgment, documenting accurately, and maintaining competence reduce legal liability.

🏆Safe and competent nursing practice is therefore the nurse's best legal safeguard.

📌Core Message

The best protection against malpractice is competent nursing practice that meets the standard of care.

Answer 6

Correct Answers:

A resident with osteoarthritis

Rationale :

🦴Osteoarthritis is a long-term degenerative joint disorder that frequently produces persistent or recurrent pain.

⌛Chronic pain generally persists beyond normal healing time and may continue for months or years.

🚶Joint degeneration can cause ongoing pain, stiffness, and impaired mobility in residents with osteoarthritis.

♾️Because osteoarthritis is a chronic condition, its associated discomfort is classified as chronic pain.

📌Core Message

Osteoarthritis commonly causes long-term musculoskeletal pain, making it a classic source of chronic pain.

Answer 7

Correct Answers:

"You are safe here."

Rationale :

🤲The immediate nursing priority is to establish physical and emotional safety for the survivor.

🏠Saying “You are safe here” provides reassurance without blaming, judging, or pressuring the patient.

🫶Trauma-informed care emphasizes support, control, dignity, and validation after sexual assault.

🔐Creating a safe environment helps establish trust and allows further assessment and care to proceed appropriately.

📌Core Message

Sexual-assault care should begin with safety, reassurance, nonjudgmental communication, and trauma-informed support.

Answer 8

Correct Answers:

The patient is tearful and sad and continuously discusses her losses.

Rationale :

😢Tearfulness and sadness are common emotional manifestations of grieving.

🕯️Repeatedly discussing losses indicates that the patient is actively processing anticipated or actual loss.

🌧️Terminal illness can produce anticipatory grief as patients recognize impending losses involving health, independence, relationships, and life itself.

💭These behaviors directly support the nursing diagnosis of grieving.

📌Core Message

Sadness, tearfulness, and repeated discussion of losses are direct indicators of grieving.

Answer 9

Correct Answers:

Placing ID tags as directed on the body and covering provided.

Rationale :

🏷️Correct identification of the deceased is a critical legal responsibility during postmortem care.

⚰️Facilities follow specific procedures for attaching identification tags before the body is transferred.

🔎Proper identification protects against misidentification and maintains an accurate legal chain of documentation.

📑The nurse must follow institutional policy regarding identification, valuables, documentation, and disposition of the body.

📌Core Message

Proper identification and documentation of the deceased are essential legal components of postmortem care.

Answer 10

Correct Answers:

two and one half tablets

Rationale :

💊The prescribed dose is 50 mg, and each tablet contains 20 mg.

➕Use the formula Desired dose ÷ Dose per tablet to determine the number of tablets.

📐Calculating 50 ÷ 20 gives 2.5 tablets.

✂️Because the tablets are scored, one tablet can safely be divided into halves, allowing administration of 2½ tablets.

📌Core Message

A 50-mg dose supplied as 20-mg scored tablets requires 2½ tablets.

2 :
Which statement by a client with depression should the nurse identify as requiring immediate follow-up?

3 :
What is the name of the project that was started to help new graduate nurses build their needed competencies?

4 :
Your patient is to receive heparin 5000 units SC every 12 hours. The available Heparin is 10,000 units per mL. Calculate the amount to be given in each dose.

5 :
Which of the following is the nurse's best legal safeguard against any malpractice issue?

6 :
Which of the following residents would be classified as having chronic pain?

7 :
Which of the following statements should the emergency department nurse make to a victim of a rape?

9 :
Which of the following nursing actions is a legal responsibility of post mortem care?

10 :
The physician prescribed 50 mg of a medication to be given to a patient daily. The pharmacy dispenses the medication as 20 mg scored tablets. How many tablet(s) will be given to the patient each day?

2 : Which statement by a client with depression should the nurse identify as requiring immediate follow-up?

3 : What is the name of the project that was started to help new graduate nurses build their needed competencies?

4 : Your patient is to receive heparin 5000 units SC every 12 hours. The available Heparin is 10,000 units per mL. Calculate the amount to be given in each dose.

5 : Which of the following is the nurse's best legal safeguard against any malpractice issue?

6 : Which of the following residents would be classified as having chronic pain?

7 : Which of the following statements should the emergency department nurse make to a victim of a rape?

9 : Which of the following nursing actions is a legal responsibility of post mortem care?

10 : The physician prescribed 50 mg of a medication to be given to a patient daily. The pharmacy dispenses the medication as 20 mg scored tablets. How many tablet(s) will be given to the patient each day?

2 :
Which statement by a client with depression should the nurse identify as requiring immediate follow-up?

3 :
What is the name of the project that was started to help new graduate nurses build their needed competencies?

4 :
Your patient is to receive heparin 5000 units SC every 12 hours. The available Heparin is 10,000 units per mL. Calculate the amount to be given in each dose.

5 :
Which of the following is the nurse's best legal safeguard against any malpractice issue?

6 :
Which of the following residents would be classified as having chronic pain?

7 :
Which of the following statements should the emergency department nurse make to a victim of a rape?

9 :
Which of the following nursing actions is a legal responsibility of post mortem care?

10 :
The physician prescribed 50 mg of a medication to be given to a patient daily. The pharmacy dispenses the medication as 20 mg scored tablets. How many tablet(s) will be given to the patient each day?