322,a1
What major complication is associated with oral intake in the client with a decreased level of consciousness? A. Hypotension B. Aspiration C. Nausea D. Tachycardia
B. Aspiration
You are the nurse caring for a patient who presented to the emergency department after running a marathon in the summer heat. Patient presents withhas a fever of 104.0f, hot and dry skin, tachycardia, tachypnea and confusion. This patient is likely experiencing? A. Heat exhaustion B. Heat stroke C. Sepsisd. D. Hypothermia
B. Heat stroke
An older adult client has an elevated serum creatinine level. This client is at greatest risk for which medication-related effect? A. Increased absorption B. Impaired excretion C. Idiosyncratic effects D. Delayed gastric emptying
B. Impaired excretion
What is the rationale for asking the client whether they have noticed any new or changed moles? A. Changes in existing moles or the appearance of new moles can indicate melanoma. B. Transition from pustules to moles can indicate psoriasis C. The appearance of new moles is a sign of vitamin D deficiency. D. Excessive eccrine sweat gland production can cause the emergence of a new mole.
A. Changes in existing moles or the appearance of new moles can indicate melanoma.
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client? A. Increased intracranial pressure B. Decreased intracranial pressure C. Hypervolemia D. Hypovolemia
A. Increased intracranial pressure
An 18-year-old client has given birth to a very-low-birth-weight preterm infant. Which intervention should the nurse consider to prevent the newborn from losing body temperature? A. Provide isolette or radiant warmer care to the newborn. B. Give the newborn a warm water bath. C. Administer vitamin K to the newborn. D. Hold the newborn close, rocking gently.
A. Provide isolette or radiant warmer care to the newborn.
What does ABC..D rule stand for?
Airway Breathing Circulation (perfusion) Disability
s2?
Dub (heart is filling with blood)Aortic/Pulmonary valves closeLoudest at baseTricuspid/Mitral valves are open
Define: Hypercapnia
Excessive carbon dioxide in the blood stream.
What can altered cognitive function in an older adult be a primary symptom for?
Infection ! - See altered cognitive function do a CBC panel
Your person has hepatitis, conjunctiva is yellow. Why?
Jaundice
What are the main cognitive functional areas?
Orientation Memory Attention and concentration Intelligence Abstract reasoning
Which lobe of the brain does ... Key in understanding the world around you. Processes sense of touch and puts together information from all your other senses?
Parietal
What is the appropriate clinical management for this complication from dysfunctional cellular regulation? - Thrombocytopenia
Patient must be on bleeding precautions.
What are the four main types of incontinence?
Stress, urge, overflow, function Incontinence
What assessment model does staging for cancer model?
TNM T - tumor size and spread N - node involvement M - metastasis involvement
Define: conduction
The process of losing heat through physical contact with another object or body
Define: evaporation
The process of losing heat through the conversion of water to gas
Define: Convection
The process of losing heat through the movement of air or water molecules across the skin
What does the respiratory assessment determine?
Ventilation, Perfusion, Diffusion
Which are the correct ranges for respiratory rate in an infant and adult?
adult - 12-20 breaths/min infant - 30-60 breaths/min
How often should you give breaths to a patient that is not breathing?
at normal respiratory rate,12-20 (infant 30-60 breaths/min) - follow up with medication that will vasodilate the lungs
A 65-year-old client has come to the clinic for a yearly physical. The client reports enjoying good health, but also reports having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest? A. Take herbal laxatives, such as senna, each night at bedtime. B. Increase carbohydrate intake and reduce protein intake. C. Reduce the amount of stress the client currently experiences. D. Increase daily intake of water.
D. Increase daily intake of water.
A patient with acute myeloid leukemia (AML) has a neutrophil count that persists at less than 100/mm3. What should the nurse cautiously monitor this patient for? A. Abdominal cramps B. Hypotension C. Seizure activity D. Infection
D. Infection
Is this characteristic of a benign or malignant neoplasm? - Usually progressive and slow, may come to a standstill or regress.
benign (rate of growth characteristic)
Is this characteristic of a benign or malignant neoplasm? - Grows by expansion without invading the surrounding tissue; usually encapsulated.
Benign (mode of growth characteristic)
High levels of ... INR, PT, PTT means the pt. is at risk of clotting or bleeding?
Bleeding and vice versa ELEVATED = RISK FOR BLEEDING LOW = RISK FOR CLOTTING
What are the three assessment cues for the Glasgow Coma Scale?
eye opening, verbal response, and motor response
Define angiogenesis
formation of new blood vessels -- a process that allows tumors to enlarge by supplying additional blood vessels for tumor growth and metastasis
What are the four lobes of the brain?
frontal, parietal, temporal, occipital
What is anoxia/hypoxia?
oxygen deprivation
Define: Radiation
this involves the transfer of heat from one object to another, with no physical contact involved
A client is confused and it has progressed significantly. Which would be the priority for this client? A. Support B. Education C. Safety D. Cognitive interventions
C. Safety
What is hemoptysis? Causes?
Coughing up blood or bloody sputum Causes: chronic bronchitis, pneumonia, bronchogenic carcinoma, TB, bronchiectasis, aspergilloma
Which diagnostic test would be used if a malignancy is suspected? A. Skin scrapping B. Tzanck smear C. Patch test D. Biopsy
D. Biopsy
The nurse is caring for a client with ineffective clotting who states they have pain in both knees that began this week. The nurse notes bruises on both knees. Based on the ineffective clotting and the report of pain, what does the nurse suspect is the cause of the pain? A. Abuse B. Thromboembolism C. Inflammation D. Bleeding
D. Bleeding
How many L of O2 flow can you pass through a nonrebreather safely?
10L-15L/min
How many L of O2 flow can you pass through a Venturi mask safely?
4-6L/min
The nurse is conducting a cardiac assessment. Where does she place the stethoscope to hear the mitral valve?
5th intercostal space, just left of the mid clavicular line
Cancers in children differ greatly from cancers in adults. Pediatric patients often are diagnosed with leukemias , lymphomas, sarcomas, or central nervous system tumors. These cancers often arise from what tissues? (Select all that apply) A. Primitive embryonal (mesodermal) B. Epithelial tissue C. Neuroectodermal tissues D. Endothelial tissue E. Myocardial tissue
A. Primitive embryonal (mesodermal) C. Neuroectodermal tissues
What organ is the primary site of heat loss in the body? A. Skin B. Kidneys C. Heart D. Lungs
A. Skin
Which of the following are populations at risk of impaired oxygenation/gas exchange? A. older adults B. adolescents C. pregnant women D. infants E. young children
A. older adults D. infants E. young children
What are the first two diagnostic test to assess O2 status?
ABG (arterial blood gas) and Chest XRay
What is the appropriate clinical management for this complication from dysfunctional cellular regulation? - abnormal CMP
Asymptomatic elevation of electrolytes and creatinine levels to acute kidney injury.
The nurse is observing the respiratory effort of a client and notes that the client's intercostal spaces are retracting on inspiration. The nurse will assess the client for the presence of which condition? A. Thoracic muscle tenderness B. Obstruction C. Impaired perfusion D. Barrel chest
B. Obstruction
What the the four types of BIOPSY's for cancer screening?
Bone marrow biopsy, excisional biopsy, needle biopsy, sentinel node biopsy
The nurse is caring for a client with an acute condition with the potential to affect the respiratory system. What intervention would be most appropriate to PREVENT respiratory complications? A. Carry out wound care as prescribed. B. Apply a pulse oximeter to the client. C. Maintain the client in a semi-Fowler's position. D. Maintain the client in NPO status.
C. Maintain the client in a semi-Fowler's position.
Define: Hypotension
Can occur when a client moves from a sitting to standing position.
What does a increased D-dimer test indicate regarding bleeding?
Clot!
The nurse assists and educates clients about the structure and function of the digestive system. The nurse is reviewing the processes involved during digestion. What is the best explanation the nurse can give the client about the process of peristalsis? A. Process of swallowing B. Process of transferring broken-down food elements into the circulation for transport C. Act of chewing D. Alternate contraction and relaxation of muscles that sends food down through the digestive tube
D. Alternate contraction and relaxation of muscles that sends food down through the digestive tube
A student has joined the marching band at high school and the band begins practicing outside during hot summer weather. Which health promotion guidance will the school nurse teach the student? A. Ensure adequate glucose intake on practice days B. Eat high-potassium foods on the morning of practices C. Avoid drinking when not thirsty to prevent hyponatremia D. Consume commercial oral rehydration drinks on practice days.
D. Consume commercial oral rehydration drinks on practice days.
What is the main nursing education that you should give to patients with poor oxygenation?
Incentive spirometry (the breathing ball thing) & Pursed-lip breathing
What is ischemia?
insufficient tissue oxygenation --- an inadequate blood supply to an organ or part of the body, especially the heart muscles.
Is this characteristic of a benign or malignant neoplasm? - Cells are undifferentiated with anaplasia and atypical structure that often bears little resemblance to cells in the tissue of origin.
malignant (cell characteristics)
Red Flag Symptoms of Perfusion
chest pain, fluid overload w/ respiratory distress
What does CMP measure?
electrolytes and kidney function
Which brain region is responsible for thermoregulation?
hypothalamus
In an initial patient assessment, a pulse of 58 and respirations of 18 are known to be what type of data?
objective
Which lobe of the brain does ... Responsible for visual perceptions, including color, form, and motion?
occipital
Primary nursing intervention?
prevention
What does secondary care for cognitive clinical management call for?
screening for older adults
Which lobe of the brain does ... Processing auditory information, encoding memory, processing affect/emotions, language, and visual perception
temporal
Tertiary nursing prevention?
treatment and collaborative care
Place then nursing management steps in the correct order ... - apply O2 - education - raise the head of bed - administer medications - give breaths
1. raise the head of bed 2. apply O2 3. give breaths 4. administer education 5. education
How many L of O2 flow can you pass through a nasal cannula safely?
1L-6L
A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? A. Increased blood pressure with narrowed pulse pressure. B. Rapid pulse and decreased capillary refill. C. Sudden diaphoresis and retractions. D. Absence of bruising at contusion sites.
B. Rapid pulse and decreased capillary refill.
The nurse is caring for a client who has been prescribed 8L/minute of oxygen by the provider. Which oxygen delivery device with the nurse consider using? A. Nonrebreather mask B. Simple mask C. Nasal cannula D. Bag valve mask
B. Simple mask
An infant has had diarrhea for several days. What assessment will the nurse make to identify risks from the diarrhea? A. Heart tones B. Activity Level C. Skin Turgor D. Lung sounds
C. Skin Turgor
The nurse is aware that which of the following nutrients promotes normal blood clotting? A. Magnesium B. Vitamin C C. Zinc D. Vitamin K
D. Vitamin K
What does alert and oriented x4 mean?
Meaning they know the answer to... person, place, time, situation/event
Which is an expected outcome for a client undergoing a bowel training program? A. Have a soft, formed stool at regular intervals without a laxative. B. Have a formed stool at least twice a day for 2 weeks. C. Continue to use laxatives, but use one less irritating to the rectum. D. Use oil-retention enemas on a regular basis for elimination.
A. Have a soft, formed stool at regular intervals without a laxative.
Which pathogens are associated with complications with cellular regulation. (select all that apply) A. Hepatitis B B. HIV C. HPV D. Helicobacter pylori E. MRSA
A. Hepatitis B C. HPV D. Helicobacter pylori
A group of students are reviewing the structure and function of the renal system. The students demonstrate understanding when they identify what as the functional unit? A. Nephron B. Bowman's capsule C. Convuluted Tubule D. Glomerulus
A. Nephron
Von Willebrand factor is important for what stage of the clotting process? Vasoconstriction Activation of clotting factors Intrinsic pathway Adhesion of the platelet plug
Adhesion of the platelet plug
Your patient's O2 sat is 92% and respiratory rate is at 16 bpm. What is your priority nursing intervention? A. Apply a nasal cannula at 2L/min B. Complete a more thorough assessment C. Apply a venturi mask at 6L/min with the use of a humidifier D. Use a bag and mask
B. Complete a more thorough assessment - a lower bpm could be normal for the patient
The nurse is performing a neurological assessment on a child. The previous examination noted the child to be alert but answering questions inappropriately. In this exam, the child only responds to vigorous stimuli. What is the priority nursing action? A. Have a second nurse assess the client. B. Notify the health care provider. C. Reassess the client in 15 minutes. D. Document the findings and continue to monitor.
B. Notify the health care provider.
Your patient's O2 sat is 70% and respiratory rate is at 4 bpm. What is your priority nursing intervention? A. reassess the patient's vitals B. call rapid response and begin to use Breath and Mask C. apply a non-rebreather D. use a. nasal cannula at 6L
B. call rapid response and begin to use Breath and Mask
What are two essential techniques when collecting a stool specimen? A. using a no-touch method and toilet paper B. hand hygiene and wearing gloves C. wearing goggles and an isolation gown D. following policies and selecting containers
B. hand hygiene and wearing gloves
If a patient cannot ventilate on their own, what do you do?
BVM - bag-valve-mask Bag and Mask is only used on APNEIC Patients
Is this characteristic of a benign or malignant neoplasm? - Well differentiated cells that resemble the cells in the tissue of origin.
Benign (cell characteristics)
Is this characteristic of a benign or malignant neoplasm? - Does not spread by metastasis.
Benign (metastasis characteristic)
Your patient's O2 sat is at 75% and respiratory effort appears to be difficult with intercostal retractions. What is your priority nursing intervention? A. Apply a Venturi mask at 6L/min B. Apply Nasal cannula at 4L/min C. Apply a non-rebreather at 15L/min D. Apply a Venturi mask at 4 L/min
C. Apply a non-rebreather at 15L/min
The nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group? A. Dysuria B. Hematuria C. Enuresis D. Anuria
C. Enuresis (aka bed wetting, involuntary control of bladder)
An adult client has sought care because he has a two-day history of stool that is "black like road tar." How should the nurse best respond to this aspect of the client's history? A. Tell the client to use an over-the-counter laxative for the next 2 to 3 days. B. Encourage the client to increase his intake of fluids and soluble fiber. C. Refer the client for treatment of a possible gastrointestinal bleed. D. Refer the client to a dietitian for treatment of a possible vitamin deficiency.
C. Refer the client for treatment of a possible gastrointestinal bleed.
What symptoms are expected findings for a patient with severe hypothermia? (select all that apply) Cardiac dysrhythmia Acid-base imbalance Agitated delirium d. Bradycardia Increased peristalsis Severe hypotension
Cardiac dysrhythmia Acid-base imbalance Bradycardia Severe hypotension
What is the appropriate clinical management for this complication from dysfunctional cellular regulation? - anemia
Carefully monitor for fatigue and hypoxia.
What is mitosis?
Cell division that generates new cells for growth and repair. The division of one cell into two genetically identical daughter cells
Which of the following is not considered a secondary care for cellular regulation? A. Mammography for breast cancer. B. Prostate-specific antigen for prostate cancer. C. Colonoscopy and guaiac testing for occult blood in stool for colon cancer. D. Prophylactic surgery for those at risk.
D. Prophylactic surgery for those at risk.
When performing an historical assessment on a patient with compromised cellular regulation, you would expect to find all the following except what? A. Usually asymptomatic in the early stages. B. Discovery of an abnormal lump in the body. C. Unexplained bleeding, pain, cough, fatigue. D. Synaesthesia and dysarthria.
D. Synaesthesia and dysarthria.
All of the following are true in your assessment of an infant or child except... A. these pts. are at higher risk for airway compromise due to everything being small for them except for their tongue B. count the respiratory rate for one full minute C. watch for retractions, nasal flaring, grunting, or head bobbing D. acrocyanosis is normal within the first couple of days of birth
D. acrocyanosis is normal within the first couple of days of birth < FLASE, its only normal for the first couple of hours as their blood starts to adequately diffuse to their extremities
The nurse is studying pathophysiology of the respiratory system. Which mechanism is involved in the movement of oxygen and carbon dioxide at the alveolar level? A. Ventilation B. Active transport C. Diffusion D. Osmosis
Diffusion
What are Piaget's stages of development?
sensorimotor: 0-2 yrs preoperational: 3-6 concrete operational: 7-11 formal operational: 12+
If a pt. is presenting with chest pain what are the first two priority test?
Test: ECG & Lab: troponin (elevated troponin = ischemia of the heart)
Red Flag Symptoms of Cognition Impairment
lethargy, irritability, inconsolable
Is this characteristic of a benign or malignant neoplasm? - Variable and depends on the level of differentiation; the more undifferentiated the cells, the more rapid the rate of growth.
malignant (rate of growth characteristics)
What is the appropriate clinical management for this complication from dysfunctional cellular regulation? - neutropenia
monitor closely for fever, meticulous hand hygiene and infection control, protective isolation - pt is at high risk for infection !
The nurse is assessing a client's cognitive capabilities. What will the nurse assess to determine if the client is cognitively intact? Select all that apply. - Memory - Heart sounds - Abstract reasoning - Judgment - Speech
- Memory - Abstract reasoning - Judgment - Speech
What does the acronym CAUTION stand for and relate to?
- red flag symptoms for cancer C - change in bowel or bladder A - a sore that does not heal U - unusual bleeding or discharge T - thickening or lump in the breast or elsewhere I - indigestion + nausea + vomiting O - obvious changes in warts or moles + ongoing weight loss N - nagging cough
The nurse is called into a toddler's room. The toddler's parent says "My toddler is having trouble breathing." What is the priority nursing action? A. Assess patency of the child's airway. B. Apply a pulse oximeter to monitor oxygen levels. C. Notify the health care provider. D. Place the child on 100% oxygen.
A. Assess patency of the child's airway.
A client who sustained a pulmonary contusion in a motor vehicle crash develops a clot in the lungs. What is the priority nursing concern with this client? A. Ineffective breathing pattern B. Acute pain C. Activity intolerance D. Excess fluid volume
A. Ineffective breathing pattern
A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured? A. Axillary B. Skin surface C. Oral D. Rectal
D. Rectal
Define: Orthopnea
Increased difficulty breathing when lying flat.
The nurse is caring for a client with an altered level of consciousness. What action is the priority for this client? A. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. B. Maintain a clear airway to ensure adequate ventilation. C. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain D. Position the patient to prevent injury and ensure dignity.
B. Maintain a clear airway to ensure adequate ventilation.
The nurse is caring for a client with peripheral edema. When elevating the client's legs to the level of the heart, what will the nurse expect to occur? Select all that apply. - Increase in urine output - Increased warmth in the lower extremities - Decrease in blood pressure - Reduction in the venous hydrostatic pressures of the legs - Increase in arterial perfusion to the feet
- Increase in urine output - Reduction in the venous hydrostatic pressures of the legs
A nurse is providing care to a patient who is receiving chemotherapy. The nurse notes that the patient has lost most of the hair on her head. The nurse documents this finding as which of the following? A. Alopecia B. Jaundice C. Photosensitivity D. Hypopigmentation
A. Alopecia
A nurse is a caring for a post-operative client. What instruction should the nurse provide to the client as a precautionary measure to prevent clotting complications? A. Avoid sitting in one position for long periods of time. B. Try to relax with pillows under the knees. C. Perform deep-breathing exercises every 2 hours. D. Refrain from elevating legs above the heart.
A. Avoid sitting in one position for long periods of time.
A community health nurse is providing a teaching session on how to reduce the risks of cardiovascular disease. What statement by the client indicates to the nurse that the client's need further education? A. I will limit the amount of cigarettes smoked daily. B. I will participate in regular exercise. C. I will limit consumption of alcohol to two drinks daily. D. I will reduce my sodium intake.
A. I will limit the amount of cigarettes smoked daily.
A geriatric nurse practitioner is assessing older adults. The nurse practitioner knows that older adults sometimes have difficulty following directions during a neurologic examination or diagnostic procedure. What strategies can the nurse practitioner use to examine older clients? A. Provide brief instructions, one step at a time. B. Spread the exam over 2 to 3 days. C. Offer incentives and positive feedback. D. Suggest a nurse or an examiner who is of their age.
A. Provide brief instructions, one step at a time.
The parents of a child with ineffective clotting ask the nurse about appropriate activities and sports that they should encourage the child to participate in. What activity would be the safest for the nurse to suggest? A. Swimming B. Rugby C. Soccer D. Gymnasticsaa
A. Swimming
The nurse is caring for a child with a bacterial respiratory infection, a fever, headache, and chest pain. Which additional assessment findings would cause the nurse the most concern? A. Tachypnea with retractions B. Oxygen saturation level of 96% C. Pale skin color D. Numbness and tingling in bilateral arms
A. Tachypnea with retractions
Red Flag Symptoms of Oxygenation
Wheezing, stridor, apnea, grunting, retracting, nasal flaring, cyanosis dyspneic + fluid in lungs = red flag WASGRCN
About 10 days after giving birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition? A. Impaired tissue integrity B. Excessive clotting C. Impaired thermoregulation D. Ineffective clotting
B. Excessive clotting
The nurse is caring for a 6-year-old child who has a history of febrile seizures and is admitted with a temperature of 102.2°F (39°C). What is the nurse's highest priority? A. Provide family teaching related to the child's history. B. Institute safety precautions. C. Encourage the child to do his or her own self-care D. Offer age-appropriate activities.
B. Institute safety precautions.
A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? A. Use the stethoscope over the newborn's garment. B. Place the newborn skin-to-skin (kangaroo care) with the mother. C. Place the newborn's crib close to the outer wall in the room. D. Delay weighing the infant, as the scales may be cold.
B. Place the newborn skin-to-skin (kangaroo care) with the mother.
The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and notes tachypnea, and when moving the gown, observes petechial hemorrhages on the skin of the chest. The client's oxygen saturation is 89%. The client states they feel pain in their chest. What is the priority nursing action? A. Increase IV fluids for possible hemorrhage. B. Raise the head of bed and notify the provider. C. Administer pain medication. D. Request medications for an allergic reaction.
B. Raise the head of bed and notify the provider.
A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A. "Would you say that you're prone to getting mouth ulcers?" B. "Do you brush and floss daily?" C. "Do you use tobacco, whether smoking or chewing?" D. "How often do you usually go to the dentist in a year?"
C. "Do you use tobacco, whether smoking or chewing?"
A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A. Assess ability to clear oral secretions. B. Assess for signs of infection. C. Assess for a patient airway. D. Assess for ability to communicate.
C. Assess for a patient airway.
The nurse is assessing a client's hand as shown. What is the nurse assessing? (image of a nurse pressing on a clients nails/nail bed) A. Skin turgor B. Temperature C. Capillary refill D. Nail clubbing
C. Capillary refill
The nurse is caring for a 79-year-old who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of what postsurgical complication? A. Hemorrhage B. Infection C. Clotting D. Respiratory distress
C. Clotting
A 51-year-old man is being discharged from the hospital following treatment with anticoagulants for excessive clotting and a clot in the right leg. What will the nurse include in the discharge education? A. Alternate the type of anticoagulant drug each month. B. Change the route of administration to intravenous if oral medications are ineffective. C. Consider safety measures to prevent bleeding and know the signs of bleeding. D. Massage the leg daily to promote circulation.
C. Consider safety measures to prevent bleeding and know the signs of bleeding. AKA BLEEDING PRECAUTIONS
A nurse is planning hygiene for a client who is confused. The nurse understands the need to provide an environment that will aid her in the care of this client. What is the priority nursing action? A. Delegate this task to someone else since it's not the nurse's responsibility to perform hygiene for clients. B. Refuse to bathe the client because the nurse and client have not established a rapport. C. Create a calming environment with little stimuli. D. Ask several staff to be in the room for safety since the client is sometimes agitated.
C. Create a calming environment with little stimuli.
An older adult client with mild hypothermia has been admitted to the health care facility. Which intervention will the nurse use to promote comfort and sleep for the older adult client? A. Keep an attendant with the client. B. Use a bright light at night for safety. C. Ensure that the environment is warmer. D. Raise the side rails of the bed.
C. Ensure that the environment is warmer.
What is the most important lifestyle changes a client can make to improve cardiovascular health? A. Living a more sedentary lifestyle. B. Eating a diet high in fat. C. Exercising at least 150 minutes per week. D. Getting more rest and limiting alcohol intake.
C. Exercising at least 150 minutes per week.
A nurse is caring for a 5-hour-old newborn. The primary care provider has asked the nurse to maintain the newborn's temperature between 97.7° F and 99.5° F (36.5° C and 37.5° C). Which nursing intervention would be the best approach to maintaining the temperature within the recommended range? A. Delay weighing the infant, as the scales may be cold. B. Use the stethoscope over the newborn's garment. C. Place the newborn skin-to-skin (kangaroo care) with the mother. D. Place the newborn's crib close to the outer wall in the room.
C. Place the newborn skin-to-skin (kangaroo care) with the mother.
From which score on the Glasgow Coma Scale does the Nurse start to become very concerned regarding a patients cognition?
10 and below, at 8... likely need to intubate
You see a pic of a cute baby with blue fingers, toes, and lips. What is this called?
Cyanosis
Define: Dyspnea
Difficult or labored breathing.
Define: Tachypnea
Respiratory rate greater than normal for age.
The cytoplasm within a cell is currently stable within the cell membrane. This cell is in what state? A. Homeostasis B. Meiosis C. Excitability D. Mitosis
A. Homeostasis
The kidneys receive approximately what percentage of the cardiac output? A. 40% B. 5% C. 25% D. 15%
C. 25%
Define: Diastolic Pressure
Can occur when a client moves from a sitting to standing position. (di = died, at rest)
Which lobe of the brain does ... Voluntary movement, expressive language, and managing higher level executive function?
Frontal
Which device is best used to help determine if a patient has hypoxemia?
Pulse ox
What are some NON-modifiable risk factors for oxygenation?
age, air pollution, and allergies
What is pancytopenia?
decrease in RBCs, WBCs, and platelets -- typically because of bone marrow suppression
What are the four types of tissue?
epithelial, connective, muscle, nervous
When considering cell regulation, malignant neoplasms are distinguished from benign neoplasms by what? (select all that apply) - Cell characteristics - Rate of growth - Cell type - Manner of growth - Capacity to invade/ metastasize - Potential to cause death
- Cell characteristics - Rate of growth - Manner of growth - Capacity to invade/ metastasize - Potential to cause death
Which of the following represents S1? - Systole - Lub - Dub - Diastole - Mitral and tricuspid valves close - Mitral and tricuspid valves open and blood fills in the ventricles - Heard loudest at apex - Aortic and pulmonic valves close - Blood is pushed through pulmonary and aortic arteries
- Systole - Lub - Mitral and tricuspid valves close - Heard loudest at apex - Blood is pushed through pulmonary and aortic arteries (S1 - first sound of the heart)
Is this characteristic of a benign or malignant neoplasm? - Gains access to blood and lymph channels to metastasize to other areas of the body.
Malignant (a metastasis characteristic)
Is this characteristic of a benign or malignant neoplasm? - Grows by invasion sending out processes that infiltrate the surrounding tissue.
Malignant (mode of growth characteristic)
What is meiosis?
Meiosis is a type of cell division that produces gametes with half the normal amount of chromosomes
What does SBAR stand for?
Situation Background Assessment Recommendation
Do these risk factors elevate or decrease body temperature? - exercise - drug use - alcohol use - fever - digestion - hypothyroidism
elevate: - exercise - digestion - fever. decrease: - drug use - alcohol use - hypothyroidism
What is the limbic system responsible for.?
emotion, behavior, motivation, long-term memory
Secondary nursing intervention?
screening!
What is the appropriate clinical management for this complication from dysfunctional cellular regulation? - nausea and vomiting
small frequent meals, fluids to prevent impaired perfusion, and medications
What are some modifiable risk factors of oxygenation?
smoking, vaping, drinking, weight, sedentary lifestyle, head injury, chronic diseases, immunosuppression, intubation, medication overdose, seizure, stroke
Which is the primary preventable cause of skin cancer? A. Fair skin B. Excess melanin C. Exposure to UV radiation D. Skin disease
C. Exposure to UV radiation
How many L of O2 flow can you pass through a simple mask safely?
5-8L/min (5L @ minimum)
What is the order you would use oxygenation tools for a patient who is decreasingly not stable? @85-90% PO2 @80-85% PO2 @ less than 80% PO2
@85-90% PO2 -- nasal cannula @80-85% PO2 - venturi mask or simple mask @ less than 80% PO2 - non-rebreather - you bag and mask apneic patients !
A client is being discharged after having a right-sided modified radical mastectomy. After teaching the client about ways to minimize lymphedema, the nurse determines that the teaching was successful based on which client statement? A. "I should use lotion on my hands after working in my garden." B. "I need to avoid wearing tops that have elastic in the sleeves." C. "I should have my blood pressure taken in my right arm." D. "I need to limit my driving to once a week."
B. "I need to avoid wearing tops that have elastic in the sleeves."B. "I need to avoid wearing tops that have elastic in the sleeves."
A nursing student observes that the babies in the nursery are wrapped up warmly and are wearing knit caps. Which explanation by the nursery staff would be correct? A. "The caps and blankets simulate the temperature of the mother's womb that they are used to." B. "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes." C. "Studies show that newborns like the extra warmth." D. "That's how we have always done it, and it seems to work out well."
B. "Newborns lose body heat easily and need to be kept warm until their body temperature stabilizes."
The nurse is caring for an older adult whose family has brought them to the clinic due to concerns for cognitive impairment. What test will the nurse anticipate the health care provider will order first? A. Culture and Sensitivity B. Complete blood count C. Chest xray D. Complete metabolic panel
B. Complete blood count
You notice that your patient's oxygen saturation has dropped from 93% to 89%. What is the first nursing intervention that you should take? A. apply nasal cannula at 2L B. raise the head of bead C. recheck the oxygen saturation D. leave the patient be
B. raise the head of bead
What are the red flag symptoms of cancer?
C.A.U.T.I.O.N - C - change in bowel or bladder A - a sore that does not heal U - unusual bleeding or discharge T - thickening or lump in the breast or elsewhere I - indigestion + nausea + vomiting O - obvious changes in warts or moles + ongoing weight loss N - nagging cough
Which statement best describes the function of fibrinogen? A. Helps maintain osmotic pressure. B. Helps prevent or modify some types of infectious diseases. C. Functions primarily as an immunological agent. D. Plays a key role in forming blood clots.
D. Plays a key role in forming blood clots.
The nurse needs to assess the oxygen status of a client who is suddenly experiencing shortness of breath. What is the most appropriate noninvasive measurement technique? A. Arterial blood gas analysis B. Assessment of the rate and depth of respiration C. Pulmonary function tests D. Pulse oximetry
D. Pulse oximetry
The nurse prepares to assess a school-age child's cognitive functioning. According to Piaget, which area is not necessary to assess for cognition? A. Environmental stimulation B. Social interaction C. Physical maturity D. Work ethic
D. Work ethic
The nurse assesses that a client is shivering. Which intervention is most appropriate to prevent further stress on the body? A. applying a cooling blanket B. providing a warm sponge bath C. promoting good ventilation by using an electric fan D. applying a blanket
D. applying a blanket
The nurse is providing care for a client with a recent cardiac diagnosis and is explaining the structure and function of the heart. Place the events of circulation in the correct sequence, beginning with the entry of blood into the right atrium. Use each item once. ... - Oxygenated blood is pumped into circulation. - Deoxygenated blood returns to the heart from the venous system. - Oxygenated blood enters the left atrium. - Blood passes through the mitral valve. - Blood passes through the tricuspid valve. - Blood is pumped from the right ventricle to the lungs.
FROM RT Atrium --> Blood passes through the tricuspid valve. (tri before bi/mi)--> Blood is pumped from the right ventricle to the lungs. --> Oxygenated blood enters the left atrium. --> Blood passes through the mitral valve. --> Oxygenated blood is pumped into circulation. --> Deoxygenated blood returns to the heart from the venous system.
Define: Systolic pressure
Indicates how much pressure the blood is exerting against the arterial wall. Maximum blood pressure during contraction of the ventricles.
What is the first step of clinical management for the nurse with a patient with poor oxygenation?
Raise the Head of Bed !
What is the first step that should be taken with a patient with an airway risk?
Raise the Head of Bed!!!
Define: Pulse pressure
The difference between the systolic and diastolic blood pressure.
What is diffusion?
The movement of particles from an area of high concentration to an area of low concentration.
What is the appropriate PPE for a nurse for a patient who is in isolation due to infection precautions?
gown, gloves, mask
What does primary care for most clinical management call for?
healthy lifestyle - exercise, diet, preventative health care check-ups, socializing, activity, avoiding substance abuses, alcohol and smoking
What is anemia?
low RBC count -- pt. is at risk for bleeding !
What is neurtopenia?
low WBC's - pt. is at risk for infection!!
What is thrombocytopenia?
low platelet count -- pt. is at risk for bleeding !
