EAQ Corrections - Test 2 prep

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Which information would the registered nurse provide to a student about the importance of nursing documentation for risk management

"a nurses documentation is the evidence of care that a client receives.", "the nurses would note assessments and significant changes the the client's health.", "nurses would always document the primary health care providers' responses whenever they are contacted"

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis

Carina

Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall

Document the incident in the occurrence report tool

Statement regarding an interpreter is correct

Interpreting not only the language but also the culture is important

after reviewing information about oxygenation for 4 clients with COPD, which client will the nurse plan to teach about the use of home long-term continuous oxygen therapy

PaO2 of 55; SpO of 88

Assessment

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client

Implementation

The nurse is performing nurse care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation

Validation

The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking?

Irrigate the would with 100 mL normal saline until clear: 6 AM - 2 PM - 8 PM

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning

Sequence of steps used to meet the client's needs

Which definition is correct to explain the nursing process

which term describes synovial joint movement away from the midline of the body

abduction

which client muscle strength assessment data is consistent with a a score of 3 on the muscle-strength scale

active movement against gravity but not against resistance

which clinical finding enables the nurse to conclude that the heparin therapy is effective in a client who has atrial fibrillation with rapid ventricular response and is started on a continuous heparin infusion

an activated partial thromboplastin time (aPTT) is twice the usual value

a client returns from the post-anesthesia care unit after a rotator cuff repair. Which action would the nurse take?

assess for capillary refill in the nail beds

which client assessment data would correspond to a muscle-strength rating of 3

can complete ROM against graviy

Which factor would elevate a clients oxygen saturation

carbon monoxide

how would the nurse determine if a client is experiencing the therapeutic effect of valsartan

check the blood pressure

which nursing interventions would provide safe oxygen therapy

checking for tubing kinds, post 'no smoking' signs in the clients' rooms

Which pathophysiological changes in the lungs occur with emphysema?

collapse of alveolar walls, trapping of air in distal lung structures, increases in pulmonary artery pressures

a client who has a fractured femur with buck traction keeps slipping down in bed. Which action would the nurse take?

elevate the foot of the bed

to prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care

encourage early mobility

which synovial joint movement is described as turning the sole away from the midline of the body

eversion

which level of Maslow's hierarchy of needs does the nurse fulfill by fitting a client who nearly died of asphyxiation with an oxygen mask

first level the first level of Maslow's hierarchy of needs includes the most basic and physiologic needs like air, water, and food. the second level includes safety and security needs, which involve physical and psychological needs the third level includes love and belonging needs like interpersonal relationships the fourth level encompasses self-esteem needs

which therapeutic effect of digoxin would the nurse expect

increased contractile force of the myocardium

which assessment finding would the nurse consider abnormal

joint crepitation, muscular atrophy, tenderness of the spine

which actions could the registered nurse assign to an LPN caring for the client with traction or a cast

monitoring skin integrity around the cast, marking circumference of any drainage on the cast, checking color, temperature, capillary refill, and pulses distal to the cast

the nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise

promotes elimination of CO2

which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain

providing oxygen, assessing vitals, obtaining a 12-lead EKG, drawing blood for cardiac enzymes, auscultating heart sounds, administering nitroglycerin

which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain

relieved by sublingual nitroglycerin

Which instruction will the nurse include in a teaching plan for a client taking a calcium channel blocker such as nifedipine

report peripheral edema, avoid drinking grapefruit juice, change to a standing position slowly

which example is classified as flat bone

scapula, sternum

which statement describes a nurse's correct understanding about skeletal muscles

skeletal muscle accounts for about half of a human being's body weight

which action would the nurse take to determine a client's pulse pressure

subtract the diastolic from the systolic reading

which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective

triglycerides

which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks

diuretics, low-salt diet, daily weight checks, fluid restriction, intake and output, oxygen administration

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse assesses the recorded vital signs. Which vital sign assessment requires reassessment?

respiratory rate of 14 breaths/minute, blood pressure of 120/80 mm Hg, oxygen saturation of 95%

which symptom will the nurse include as a reason to withhold the medication when teaching a client about digoxin therapy

yellow vision

the nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include

you will need to apply them in the morning before you lower your legs from the bed to the floor

Continuity of care by the nursing staff, collection of data about the client's clinical condition, engagement in a caring relationship without assumptions

Which factors enable the nurse to know a client better

which statement would the nurse identify as the purpose of the nitroglycerin patch

decreased cardiac preload reduces cardiac workload

how would the nurse instruct a client with arthritis to take aspirin when the client states that the aspirin causes stomach irritation

with food and a full glass of water

which instruction will the nurse provide about an angiotensin II receptor blocker (ARB) prescribed to a client with hypertension

"Stop the medication if swelling of the mouth, lips, or face develops", "Have blood drawn for potassium levels 2 weeks after starting the medication"

the client can complete range of motion with gravity eliminated. Which grade would the nurse assign to the client's muscle strength?

2; grade 1 indicates no joint motion and slight evidence of muscle contractility, grade 2 indicates complete range of motion with gravity eliminated, grade 3 is indicated by complete range of motion against gravity only, grade 4 is complete range of motion against gravity with some resistance

Actual nursing diagnosis

A client with bilateral oral swelling, pain, and trismus underwent surgical extraction of an impacted tooth 5 days ago. The documentation supports utilizing which type of nursing diagnosis for the client's acute pain

"I identified impaired skin integrity in a pressure ulcer document upon finding redness in the client's hip"

Which example demonstrates clinical decision-making by the nurse

Global health informatics, community health informatics

Which example illustrates public or population health informatics

Nursing diagnoses involve the client when possible, N.D involve the sorting of health problems within the nursing domain, N.D involve clinical judgement about the client's response to health problems

Which feature distinguishes nursing diagnosis from medical diagnosis

Ensure that the three principles of the Joint Commission's Universal Protocol are adhered to before starting a surgery on a client, refrain from depending on the use of electronic monitoring devices completely because they are not always reliable, file an occurrence report in case of an error in technique when administering medication intravenously

Which information would the registered nurse provide to the nursing student regarding identifying and eliminating potential hazards

which tissue connects the clients tibia to the femur at the knee joint

ligaments

while caring for a client in traction, which action would the nurse delegate to a licensed practical nurse (LPN)

padding traction connections, assisting the client with passive and active range-of-motions (ROM) exercises

which exercises would the nurse incorporate into the plan of care while the client is on bed rest after a cerebrovascular accident resulted in right hemiplegia

passive rang of motion exercises

which therapeutic effect is associated with digoxin prescribed to a client with HF

slows and strengthens cardiac contractions

which instruction would the nurse give a client while performing mcmurray's test

to flex, rotate, and extend the knee

a client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen

to increase oxygen concentration to heart cells

Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization

to visualize the disease process in the coronary arteries

a client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force

use lift sheets to pull up, transfer, and position the client

the nurse is caring for a client admitted with chronic obstructive pulmonary disease(COPD). which laboratory test would the nurse monitor for hypoxia

which action would the nurse take to obtain subjective data about a client's respiratory status


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