CMS Fundamentals

double-lumen (cannula)

- an outer cannula fits into the stoma and keeps the airway open - an inner cannula fits snugly into the outer cannula and locks into place - an obturator is a thin, solid tube the provider places inside the tracheostomy and uses as a guide for inserting the outer cannula, and removes immediately after outer cannula insertion - this device allows removing, cleaning, reusing, discarding, and replacing the inner cannula with a disposable inner cannula - it is useful for clients who have excessive secretions

Limit each suction attempt to no longer than ____ to ____ seconds to avoid hypoxemia and the vagal response.

10, 15

Use suction pressure no higher than ____ to ____ mm Hg.

120, 150

sodium (expected range)

136 to 145 mEq/L

Provide tracheostomy care every ____ hr to reduce the risk of infection and skin breakdown.

8

calcium (expected range)

9 to 10.5 mEq/L

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

A At the basic level, thinking is concrete and based on a set of rules (obtaining the prescription for diet progression).

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A By threatening the client, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive.

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

A By using the electronic database, the nurse takes the initiative to increase their knowledge base, which is the first component of critical thinking.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing the pain.

A Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care

A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training in surgical treatments for obesity D. Educating acute care nurses about postoperative complications related to obesity

A Identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings.

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address." B. "I will review the past medical history on the client's record to get more information." C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

A Prioritize the client's problems during the planning step of the nursing process

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.

A The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside.

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A, B A. It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that the client understands the information the surgeon gave them. B. It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. The nurse also should verify that the client understands the information the surgeon has provided.

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs.

A, B, C A. Learning from the experience of peers can improve critical thinking. B. Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking. C. Improving knowledge by learning new information about evidence-based practice improves the nurse's ability to think critically.

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A, B, C A. The nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation. B. Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication. C. The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).

A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care

A, B, C Tertiary health care involves the provision of specialized and highly technical care. A. The care nurses deliver in intensive care units. B. The care nurses deliver in oncology treatment centers. C. The care nurses deliver in burn centers.

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the type of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A, B, C, E It is within the range of function for a CNA to provide basic care to clients (bathing, assisting with ambulation, assisting with toileting, measuring and recording vital signs).

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client states, "I do not understand how to use a nebulizer."

A, B, D A. Initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client. B. Initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients. D. Initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge.

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test

A, B, D Complete an incident report regarding a medication error, a needlestick, and an omission of a prescription.

A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers

A, B, D Restorative health care involves intermediate follow-up care for restoring health and promoting self-care. A. Home health care is a type of restorative health care. B. Rehabilitation facilities are a type of restorative health care. D. Skilled nursing facilities are a type of restorative health care.

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) A. Ensure that the client has possession of their valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. C. Assess how the client tolerates the transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer form for the receiving facility.

A, B, D, E A. Account for all of the client's valuables at the time of transfer. B. On the day of the transfer, confirm that the receiving facility is expecting the client and that the room is available. D. Provide the nurse at the receiving facility with a verbal transfer report in person or via telephone. E. Complete any documentation for the transfer, including a transfer form and the client's medical records.

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) A. Explain the roles of other care delivery staff. B. Begin discharge planning. C. Inform the client that advance directives are required for hospital admission. D. Document the client's wishes about organ donation. E. Introduce the client to their roommates.

A, B, D, E A. The client's hospitalization is likely to be more positive if the client understands who can perform which care activities. B. Unless the client is entering a long-term care facility, discharge planning should begin on admission. D. Upon hospital admission, required request laws direct providers to ask clients older than 18 years if they are organ or tissue donors. E. Any action that can reduce the stress of hospitalization is therapeutic. Introductions to other clients and staff can encourage communication and psychological comfort.

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

A, C, D A. The provider must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions. C. A pharmacist must be knowledgeable about any medication dispensed for the client, including its actions, effects and interactions. D. A registered nurse must be knowledgeable about any medication administered, including its actions, effects, and interactions.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "They said they hurt after walking about 10 minutes." C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp.

A, D, E A. Objective data includes information the nurse measures (vital signs). D. Objective data includes information the nurses observes (skin appearance). E. Objective data includes information from the observations of others (family and staff).

A nurse manager is assigning the care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

B A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care.

A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of torts is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality

B Administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor consented for receiving the sedative.

A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients

B Identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations.

A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

B In this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them. This is an example of autonomy.

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity

B The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety.

A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document.

B, C B. The day and time confirm the recording of the correct sequence of events. C. Documentation must be factual, descriptive, and objective, without opinions or criticism.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B, C, D B. Fluid permeation of the sterile drape or barrier contaminates the field. C. Prolonged exposure to air contaminates a sterile field. D. Turning away from the sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B, C, D B. To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. To complete this assignment safely, the AP should make sure the client uses a front-wheeled walker. D. To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication.

A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.

B, C, D, E B. The HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code. C. The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location. D. The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical record. E. The HIPAA Privacy Rules states that nurses can only photocopy a client's medical record if it is to be used for transfer to another facility or provider.

A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) A. Advance directives status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency

B, C, E B. It is essential to include the names and contact information of providers and community resources the client will need after they return home. C. The client will need written information detailing home medication and dietary therapy. A client who has had knee arthroplasty typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications (constipation). E. It is essential to include the names and contact information of providers and community resources the client will need after returning home. For example, a client who had a knee arthroplasty might require physical therapy at home until able to travel to a physical therapy department or facility.

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B, C, E The right supervision and evaluation, the right direction and communication, and the right circumstances are some of the five rights of delegation. They also include the right task and the right person.

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing.

B, D B. This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. D. If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid

B, E B. Medicare is federally funded. E. Medicaid is federally funded.

BMI formula

BMI = weight (kg) / height (m^2)

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association. B. Fill out an incident report. C. Report the observations to the nurse manager on the unit. D. Leave the nurse alone to sleep.

C Any nurse who notices behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager.

A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

C Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources.

A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

C Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of microorganisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke. B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler

C Providing nasopharyngeal suctioning is within the scope of practice of the PN.

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Updating the plan of care for a client who is postoperative B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury

C The application of a condom catheter is a noninvasive, routine procedure that can be delegated to an AP.

A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record

C The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit.

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk

C, D, E C. Showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a provider's prescription. D. Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription. E. Repositioning a client every 2 hr is an appropriate nurse-initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider's prescription.

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C, D, E C. The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves. D. Any objects dropped onto the sterile field during the setup are sterile. Touch them with sterile gloves. E. One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

D A speech-language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties.

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietician D. Occupational therapist

D An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D Beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverence C. Integrity D. Discipline

D Discipline includes using a systematic approach to thinking. Using a head-to-toe approach ensures the nurse is thorough and calculated in getting information about the client's physical status.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

D Nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing

D The greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life-threatening.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from her body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it.

decreased adverse effects

NURSING ACTIONS: one medication can counteract the adverse effects of another medication EXAMPLE: ondansetron (an antiemetic) counteracts the adverse effects of nausea and vomiting that results from chemotherapy

increased blood levels, leading to toxicity

NURSING ACTIONS: one medication can decrease the metabolism of a second medication and therefore increase the serum level of the second medication and lead to toxicity EXAMPLE: fluconazole (an antifungal) inhibits hepatic medication-metabolizing enzymes that affect aripiprazole (an antipsychotic) and thereby increases blood levels of aripiprazole

decreased therapeutic effects

NURSING ACTIONS: one medication can increase the metabolism of another medication and therefore decrease the blood level and effectiveness of that medication EXAMPLE: phenytoin increases hepatic medication-metabolizing enzymes that affect warfarin and thereby decreases the blood level and the therapeutic effect of warfarin

increased therapeutic effects

NURSING ACTIONS: taking some medications together can increase their therapeutic effect EXAMPLE: clients who have asthma inhale albuterol (a beta-adrenergic agonist) 5 min prior to inhaling fluticasone (a glucocorticoid) to increase the absorption of fluticasone

increased adverse effects

NURSING ACTIONS: taking two medications that have the same adverse effects together increases the risk of or worsens these adverse effects EXAMPLE: diazepam and hydrocodone with acetaminophen both have CNS depressant effects; the risk increases when clients take both concurrently

subjective data

Nurses should document this as direct quotes, within quotation marks, or summarize and identify the information as the client's statement. It should be supported by objective data so charting is as descriptive as possible.

objective data

This should be descriptive and should include what the nurse sees, hears, feels, and smells. Document without any derogatory words, judgments, or opinions. Document the client's behavior accurately. Instead of writing "client is agitated," write "client pacing back and forth in the room, yelling loudly."

dehydration (expected findings)

V/S: hypothermia (hypovolemia) or hyperthermia (dehydration), tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia NEUROMUSCULOSKELETAL: dizziness, syncope, confusion, weakness, fatigue, seizures (rapid/severe dehydration) GI: thirst, dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, acute weight loss RENAL: oliguria OTHER: diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor

overhydration (expected findings)

V/S: tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure NEUROMUSCULOSKELETAL: confusion, muscle weakness, altered LOC, paresthesias, visual changes, seizures GI: increased motility, ascites RESPIRATORY: dyspnea, orthopnea, crackles OTHER: pitting edema, distended neck veins, weight gain, skin pallor and cool to touch

extrapyramidal symptoms

abnormal body movements — tremors, rigidity, restlessness, acute dystonia (spastic movements of the back, neck, tongue, face), drooling, agitation, shuffling gait; these can take a few hours or months to develop NURSING ACTIONS: more common with medications affecting the CNS (those that treat mental health disorders) - keep clients safe when movements and balance are uncontrollable

CN V (trigeminal)

assess the face for strength and sensation MOTOR: Test the strength of the muscle contraction by asking the client to clench their teeth while you palpate the masseter and temporal muscles, and then the temporomandibular joint. Joint movement should be smooth. SENSORY: Test light touch by having the client close their eyes while you touch the face gently with a wisp of cotton. Ask the client to tell you when they feel the touch.

CN VII (facial)

assess the face for symmetrical movement MOTOR: Test facial movement and symmetry by having the client smile, frown, puff out the cheeks, raise the eyebrows, close their eyes tightly, and show their teeth.

CN XI (spinal accessory)

assess the head and shoulders for strength Place your hands on the client's shoulders and ask them to shrug their shoulders against resistance; then turn the head against resistance of your hand.

Monitor ABGs and administer inhaled ______-_______ _______ (albuterol). The client can require intubation of a tracheostomy for severe manifestations.

beta-adrenergic agonists

expected sounds for the thorax and lungs

bronchial, bronchovesicular, vesicular

angioedema

causes swelling of the deep tissues—usually of the lips, face, and neck—but can affect other parts of the body (the GI system); onset can be within the first 24 hr following dosing, or can develop after long-term exposure; NSAIDs and ACE inhibitors are the most common medication that can cause angioedema

tyramine (medication interaction)

consuming foods that contain tyramine (avocados, figs, aged cheese, yeast extracts, beer, smoked meats) while taking monoamine oxidase inhibitors (MAOIs) can lead to hypertensive crisis CLIENT EDUCATION: if taking a MAOI, avoid foods high in tyramine

Administer __________ to treat mild rashes and hives, and to decrease angioedema and urticaria.

diphenhydramine

Treat anaphylaxis with _______, _______, and _______. Provide respiratory support and notify the provider.

epinephrine, bronchodilators, antihistamines

grapefruit (medication interaction)

grapefruit juice seems to act by inhibiting presystemic medication metabolism in the small bowel, thus increasing the absorption of some oral medications (nifedipine — an calcium channel blocker); this combination can result in increased effects or intensified adverse reactions CLIENT EDUCATION: do not drink grapefruit juice or consume grapefruit if taking a medication it affects

expected bowel sounds

high-pitched clicks and gurgles 5 to 35 times/min

medication-medication interactions

increased therapeutic effects, increased adverse effects, decreased therapeutic effects, decreased adverse effects, and increased blood levels, leading to toxicity

primary intention (healing)

little or no tissue loss; edges approximated, as with a surgical incision; heals rapidly; low risk of infection; no or minimal scarring (EX. closed surgical incision with staples, sutures, or liquid glue to seal laceration)

secondary intention (healing)

loss of tissue; wound edges widely separated, unapproximated (pressure injury, open burn areas); longer healing time; increase for risk of infection; scarring; heals by granulation (EX. pressure injury left open to heal)

bronchial sounds

loud, high-pitched, hollow quality, expiration longer than inspiration over the trachea

bronchovesicular sounds

medium pitch, blowing sounds and intensity with equal inspiration and expiration times over the larger airways

35 to 39.9 (BMI)

obesity class 2

40 and above (BMI)

obesity class 3

30 to 34.9 (BMI)

obesity class I

25 to 29.9 (BMI)

overweight

nephrotoxicity

primarily the result of antimicrobial agents and NSAIDs; impaired kidney function can interfere with medication excretion, leading to accumulation and adverse effects NURSING ACTIONS: aminoglycosides can cause kidney damage - monitor blood creatinine and BUN levels of clients taking nephrotoxic medications

hematologic effects

relatively common and potentially life-threatening NURSING ACTIONS: bone marrow depression can result from anticancer medications and hemorrhagic disorders from anticoagulants and thrombolytics - instruct clients taking an anticoagulant to report bruising, discolored urine or stool, petechiae, and bleeding gums to the provider immediately

anticholinergic effects

result from muscarinic receptor blockade and affect the eyes, smooth muscle tone, exocrine glands, and heart NURSING ACTONS: have clients sip fluids to relieve dry mouth - tell clients to wear sunglasses outdoors to prevent photophobia - suggest that clients urinate before taking the medication to lessen urinary retention - to prevent constipation, instruct clients to increase dietary fiber and fluids and to increase exercise - remind clients to avoid activities that could lead to overheating, because there is a decreased ability to produce sweat to cool the body

vesicular sounds

soft, low-pitched, breezy sounds, inspiration three times longer than expiration over most of the peripheral areas of the lungs

late manifestations of hypoxia

stupor; cyanotic skin, mucous membranes; bradypnea; bradycardia; hypotension; cardiac dysrhythmias

early manifestations of hypoxia

tachypnea; tachycardia; restlessness, anxiety, confusion; pale skin, mucous membranes; elevated blood pressure; use of accessory muscles, nasal flaring, adventitious lung sounds

antacids, vitamin C (medication interaction)

taking aluminum-containing antacids with citrus beverages can result in excessive absorption of aluminum CLIENT EDUCATION: avoid taking vitamin C supplements or drinking citrus juices at the same time as medications that contain aluminum

dairy (medication interaction)

tetracycline can interact with a chelating agent (milk) to form an insoluble, unabsorbable compound CLIENT EDUCATION: take tetracycline at least 1 hr before or 2 hr after consuming any dairy products; follow provider instructions for other medications that should not be taken with dairy

25 (BMI)

the upper boundary of a healthy weight

caffeine (medication interaction)

theophylline (a methylxanthine for asthma control) and caffeine can result in excessive CNS excitation CLIENT EDUCATION: avoid consuming beverages containing caffeine if taking theophylline, or for other medications are instructed by the provider

medication-food interactions

tyramine, vitamin K, dairy, grapefruit, caffeine, ana antacids, vitamin C

vitamin K (medication interaction)

vitamin K can decrease the therapeutic effects of warfarin and put clients at risk for developing blood clots CLIENT EDUCATION: if taking warfarin, maintain an intake of dietary vitamin K to avoid sudden fluctuations that could affect the action of warfarin

tertiary intention (healing)

widely separated; deep; spontaneous opening of a previously closed wound; closure of wound occurs when they are free of infection and edema; risk of infection; extensive drainage and tissue debris; closed later; long healing time (EX. abdominal wound initially left open until infection is resolved and then closed)