EAQ - Fundamentals

When assessing a client who is receiving palliative care, which question regarding spiritual health is correct?

"What is your source of spiritual strength during hard times?" Rationale: Helps the nurse to understand the client's spiritual practices and facilitate quality care.

The client complains of pain in the abdomen and nausea at mealtime. An x-ray technician also approaches at the same time for a routine x-ray. Which order of nursing actions is correct?

1. Administering the analgesic as prescribed 2. Administering medications to decrease nausea 3. Assisting the client with feeding 4. Assisting the x-ray technician for the x-ray

What are the events of communication throughout the nursing process?

1. Assessment: Assessing the medical records and diagnostic tests. 2. Intrapersonal analysis of assessment findings. 3. Planning: Documenting expected outcomes. 4. Implementation: Performing verbal, visual, auditory, and tactile health-teaching activities. 5. Evaluation: Identifying the factors affecting the outcome.

Place in order the steps the population-health nurse would use to support decisions regarding needed preventive services for a growing local immigrant population on the edge of the city's downtown area.

1. Conduct a health needs assessment. 2. Identification of health priorities. 3. Determination of social and environmental factors that may impact the health priorities. 4. Identification of options to meet identified needs. 5. Consideration of the acceptability and feasibility of the options to the community.

What are the steps involved in applying a surgical mask?

1. Find the top edge of the mask. 2. Hold the mask by its two strings/loops. 3. Secure the two top ties at the back of the head with the ties above the ears. 4. Tie the two lower ties snugly around the neck with the mask well around the chin. 5. Gently pinch the upper metal band around the bridge of the nose.

What is the order of donning PPE?

1. Gown 2. Mask 3. Goggles 4. Gloves

According to Benner , the nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest.

1. Novice 2. Advanced beginner 3. Competent 4. Proficient 5. Expert

A dying client who has reached the stage of acceptance in the grieving process appears peaceful but demonstrates a lack of involvement with the environment. Which intervention by the nurse would best address this behavior? Ignore the client's behavior when possible. Accept the behavior the client is exhibiting. Explore the reality of the situation with the client. Encourage participation within the client's environment.

Accept the behavior the client is exhibiting. Rationale: Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse would accept this behavior. Ignoring the behavior does not convey a willingness to listen and denies the client's feelings. The client is in acceptance—it is unnecessary to point out the reality of the situation. It is counterproductive to encourage the client to become involved with the environment.

A dying client is coping with feelings regarding impending death. During which stage of grieving would the nurse primarily use nonverbal interventions? Anger Denial Bargaining Acceptance

Acceptance Rationale: Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse would be quiet but available. During the anger stage the nurse would accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse would accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse would listen intently but not provide false reassurance. The bargaining stage requires verbal communication.

A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate?

Adjust the dial on the unit until the client states that the pain is relieved.

Which action would the nurse take first for a postsurgical client who is still intubated but becoming restless, with an increased pulse rate and blood pressure, when it has been 4 hours since the last dose of pain medication? Notify the provider. Perform a full physical assessment. Administer the prescribed pain medication. Play soft, relaxing music to help calm the client.

Administer the prescribed pain medication. Rationale: Because the client is intubated, the nurse cannot fully assess for pain, but the person is displaying signs of it. The nurse would administer the prescribed pain medication, especially if it has been several hours since the last dose. There is no need to notify the provider or perform a full physical assessment. Playing soft, relaxing music, although it can help relieve pain, is not the best action for a postsurgical client because it is not sufficient to manage pain.

Which strategy would the nurse use to improve chronic disease management (CDM) that addresses the organizational level as described in the social-ecologic model? Advocate for policies at worksites to support CDM. Provide educational opportunities to individuals regarding CDM. Encourage individuals to participate in CDM peer support groups. Support development of organizational networks in the community to enhance CDM.

Advocate for policies at worksites to support CDM. Rationale: A strategy to advocate for policies at local worksites to support CDM address organizational level variable in the social-ecologic model. Educational opportunities target individual level variables such as knowledge, attitudes, and behaviors. Peer support groups reflect approaches at the interpersonal level of the model. Development of networks or relationships between community organizations to enhance CDM addresses community level factors according to the social-ecologic model.

Which action would the public health nurse take to enhance primary prevention efforts in the described community? Community Description: Lower incomes, high rate of pedestrian and motor vehicle accidents, sidewalks in poor condition, no access to trails for physical activities such as walking or biking

Advocate to community leaders to prioritize the area for infrastructure improvements. Rationale: Public health nurses advocate for the vulnerable. The root of the issues in the community are the infrastructure problems.

Which precaution would the nurse implement for herpes zoster?

Airborne

The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client's plan of care? Select all that apply. One, some, or all responses may be correct. Ask the client about the acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes.

Ask the client about the acceptable level of pain. Administer the pain medications regularly around the clock. Rationale: The nurse works together with the client to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals.

Which nursing intervention is correct for a client in skeletal traction?

Assess the pin sites at least every shift and as needed.

A client calls out to all nursing staff members who pass by the door and asks them to get something. How can the nurse best manage this problem while meeting this client's needs? Assign one staff member to approach the client regularly and interact with the client. Close the door to the room so that the client cannot see the staff members as they pass by. Inform the client that one staff member will come in frequently and check whether the client has any requests. Arrange for a variety of staff members to take turns going into the room to see whether the client has any requests.

Assign one staff member to approach the client regularly and interact with the client. Rationale: Assigning one staff member to approach and interact with the client regularly provides continuity and demonstrates to the client that the nursing staff is concerned; frequent contact should also reduce the client's need to call the staff for reassurance.

The nurse is changing the dressing of a postoperative client. Another client has fallen near the nursing station and is unconscious. Which is the priority nursing action in this situation? Attend to the client who lost consciousness. Delegate the dressing change to the nursing assistant. Delegate the care of the unconscious client to the nursing assistant. Complete the dressing, because the open wound may increase infection risk.

Attend to the client who lost consciousness. Rationale: Loss of consciousness may pose a threat to the client's safety and survival and is a high-priority need. The nurse would attend to the unconscious client. The nursing assistant may not have the required knowledge and skills to perform a dressing change. The care of an unconscious client may need critical nursing assessments and clinical decision-making and should not be delegated to the nursing assistant. Risk of infection is not a threat to survival and is considered an intermediate need.

What are levels of critical thinking in nursing?

Basic, Complex, Commitment

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. Which nursing intervention is correct to assist the client with taking the medication?

Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Rationale: The client does not require 24-hour supervision because the client is in the onset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

While assessing the vital signs of an alcoholic older adult client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. Which other findings would the nurse expect to observe? Select all that apply. Body temperature of 84.2°F/29°C Body temperature of 100.6°F/38.1°C Blood pressure of 88/62 mm Hg Respiratory rate of 11 breaths/minute Respiratory rate of 16 breaths/minute

Body temperature of 84.2°F/29°C Blood pressure of 88/62 mm Hg Respiratory rate of 11 breaths/minute Rationale: Alcohol acts as a vasodilator in the body; therefore it causes dilation of surface blood vessels and results in hypothermia due to loss of body heat. However, the skin of the alcoholic client gives a false sensation of warmth, even while the client shows symptoms of hypothermia. The nurse finds the body temperature of the client is less than 86°F. Cardiovascular collapse can result in clients with severe hypothermia. During severe hypothermic conditions, the blood pressure of the client decreases. Hypothermia lowers the respiratory rate; therefore the client may have a respiratory rate of 12 breaths/minute. Because the client does not have hyperthermia, the body temperature would not be 100.6°F. The normal respiratory rate for older adult clients is in the range of 12 to 18 breaths per minute. Individuals with hypothermia may not have a normal respiratory rate of 16 breaths/minute.

The nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. Which physical principle causes the sterile field to become contaminated? Dialysis Osmosis Diffusion Capillarity

Capillarity Rationale: When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration.

A client is diagnosed with a new disease. Which factor would the nurse consider when trying to promote effective learning by the client? Client's past experiences Client's personal resources Stress of the total situation Type of onset of the disease

Client's past experiences Rationale: Past experiences have the most meaningful influence on present learning. Although the client's personal resources, the stress of the total situation, and the type of onset of the disease affect learning, their influence is not as great as that of past experiences.

The nurse listens to and validates the feelings expressed by a confused older adult. Which elements would the nurse convey in this situation?

Respecting, Reassuring, Understanding Rationale: Validation therapy is used to communicate with a confused older adult. Recalling is related to reminiscence. Reinforcing is not related to validation.

The nurse completes an assessment and a care plan for each assigned client. Which element of decision-making is the nurse demonstrating? Authority Autonomy Responsibility Accountability

Responsibility Rationale: Responsibility refers to duties and activities that an individual is employed to perform. Authority refers to the legitimate power to give commands and make final decisions specific to a given issue. Autonomy refers to freedom of choices and the responsibility for the choices. Accountability refers to individuals being answerable for their actions.

While reviewing a client's prescriptions, the nurse finds that one of the prescribed medications is redundant and notifies the primary health care provider. Which attitude of critical thinking does the nurse exhibit? - Curiosity - Risk taking - Thinking independently - Responsibility and authority

Risk taking Rationale: If the nurse questions a health care provider's prescription by applying his or her knowledge, then this attitude is considered risk taking. If the nurse explores and learns more about a client to make appropriate judgments, then the attitude is curiosity. Thinking independently is indicated when the nurse reads nursing literature that provides multiple viewpoints on the same subject. The responsibility and authority of the nurse are shown by asking for help, reporting problems immediately, and following proper procedures.

In which position would the nurse place a sedated client recovering from general anesthesia? Supine Side-lying High Fowler Trendelenburg

Side-lying Rationale: Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state.

Which link to communication does the nurse know is important?

Social Rationale: Without some form of communication, there can be no socialization. People interact with animate things. Physical, materialistic, and environmental surroundings are inanimate.

Which component of hand washing would the nurse include that is the most effective for removing microorganisms?

Friction Rationale: Friction is necessary for the removal of microorganisms. Without friction, soap, time, and water have minimal value.

The spouse of a comatose client refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a durable power of attorney for health care (DPAHC). Which action by the nurse is correct? Institute the prescribed blood transfusion because the client's survival depends on volume replacement. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. Phone the primary health care provider for an administrative prescription to give the transfusion under these circumstances. Give the spouse a treatment refusal form to sign and notify the primary health care provider so legal action can be considered.

Give the spouse a treatment refusal form to sign and notify the primary health care provider so legal action can be considered. Rationale: The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the primary health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.

The nurse is providing colostomy care to a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? Select all that apply. One, some, or all responses may be correct. Gloves Gown Mask Goggles Shoe covers Hair bonnet

Gloves Gown Goggles Rationale: Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. A mask would be necessary if the client had MRSA of the nares. Shoe covers and hair bonnet are not required for the client care situation described.

Which action would the occupational health nurse take that supports secondary prevention efforts to reduce the risk for injury from exposure to contaminated air in the workplace? Conduct respirator fit tests to ensure proper fit. Implement annual (or more frequent) respiratory function tests. Provide training programs to all employees regarding appropriate actions to reduce risks. Perform compliance checks to ensure employees are wearing the proper protective equipment.

Implement annual (or more frequent) respiratory function tests. Rationale: Screening tests such as respiratory function tests are considered secondary prevention. Ensuring proper fit of respirators, training programs, and compliance checks all support primary prevention efforts.

A client with a disturbed state of mind is under observation. Which manifestation indicates that the client is suffering from dementia?

Difficulty making decisions Inability to complete purposeful work Rationale: Dementia affects thinking ability. Client with dementia may have apraxia, the inability to perform purposeful work. A client with dementia may not be able to recollect details of life. Their sleep/wake cycle may be fragmented, but in depression it is completely disturbed.

A client with hyperthyroidism has been treated with radioactive iodine to destroy overactive thyroid gland cells. To reduce radiation exposure, which would the nurse consider when providing care? Wearing a lead-shield apron at all times Limiting time with and increasing distance from the client Wearing a radiation meter to measure exposure Remaining at least 6 feet (1.8 m) away from the client at all times

Limiting time with and increasing distance from the client Rationale: When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure and are the first priorities.

A client reports abdominal cramping while undergoing a soapsuds enema. Which action would the nurse take?

Lower the height of the enema bag. Rationale: Abdominal cramping during a soapsuds enema could be due to too rapid administration of the enema. Lowering the height of the bag will allow the flow to slow and give the bowel time to distend without causing discomfort.

A postoperative client says to the nurse, "The person in the next room sings all night and keeps me awake." The client in the next room has dementia and is awaiting transfer to a nursing home. How can the nurse handle this situation? Tell the next door client to stop singing. Close the doors to both clients' rooms at night. Give the complaining client the prescribed as-needed sedative. Move the postoperative client to a room at the end of the hall.

Move the postoperative client to a room at the end of the hall. Rationale: Moving the postoperative client from the singing client's room diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because the clients need to be monitored. The use of a sedative should not be the initial intervention.

A client is admitted for surgery and appears apprehensive and withdrawn. Which is the nurse's best action? Orient the client to the unit environment. Have a copy of hospital regulations available. Explain that there is no reason to be concerned. Reassure the client that the staff is available if the client has questions.

Orient the client to the unit environment. Rationale: Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available and reassuring the client that the staff is available to answer questions are part of orienting the client to the unit. Explaining that there is no reason to be concerned may be false reassurance because no one can guarantee that there is no reason to be concerned.

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes needs. Which phase of the helping relationship is observed?

Orientation Phase Rationale: Orientation Phase - nurse assesses health status of the client and prioritizes needs Working Phase - the nurse encourages and helps the client to set treatment goals Termination Phase - nurse evaluates the achievement of treatment goals with the client Preinteraction Phase - nurse reviews the client's medical and nursing history and talks to the caregivers

When providing comfort to a client during the last hours of life, which would be the nurse's primary concern?

Pain, Respiratory Status Rationale: During the last hours of a client's life, assessments are limited to only those that are needed to determine comfort.

Which theory focuses on developing the interpersonal relationships between the nurse, client, and the client's family? Orem's theory Peplau's theory Leininger's theory Henderson's theory

Peplau's theory Rationale: Peplau's theory focuses on interpersonal relationships between the nurse, the client, and the client's family by developing the nurse-client relationship. Orem's theory focuses on the client's self-care needs. Leininger's theory recognizes the importance of culture and its influence on everything that involves the client and the providers of nursing care. Henderson's theory focuses on assisting the individual in the performance of activities that he or she can perform unaided that will contribute to health, recovery, or a peaceful death.

A client asks about the purpose of a pulse oximeter. Which measurement is a pulse oximeter used for? Respiratory rate Amount of oxygen in the blood Percentage of oxygen-carrying hemoglobin Amount of carbon dioxide in the blood

Percentage of oxygen-carrying hemoglobin Rationale: The pulse oximeter measures the oxygen saturation of blood by determining the percentage of oxygen-carrying hemoglobin.

A client's arterial blood gas report indicates the pH is 7.52, PCO 2 is 32 mm Hg, and HCO 3 is 24 mEq/L. Which does the nurse identify as a possible cause of these results? Airway obstruction Inadequate nutrition Prolonged gastric suction Excessive mechanical ventilation

Excessive mechanical ventilation Rationale: The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

Which assessments would the nurse perform while assisting an older adult with living arrangements?

Financial status, environmental hazards and support systems, access to public transportation and community activities. Rationale: When assisting with retirement, the nurse would assess the client's meaningful activities and long term plans.

A client with a terminal illness reaches the stage of acceptance. Which intervention would the nurse use to best assist the client in this stage? Acknowledge the client's crying. Encourage unrestricted family visits. Explain details of the care being given. Stay nearby without initiating conversation.

Stay nearby without initiating conversation. Rationale: The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy. Crying, part of depression, usually ceases when the individual reaches acceptance. During acceptance the client may decide not to have visitors, preferring time for reflection. Detached from the environment, the client may find that the details of various procedures lose significance.

Which clinical finding demonstrates to the nurse that the client can use a standard walker? Weak upper arm strength and impaired stamina Weight bearing as tolerated and unilateral paralysis Partial weight bearing on the affected extremity and kyphosis Strong upper arm strength and non-weight bearing on the affected extremity

Strong upper arm strength and non-weight bearing on the affected extremity Rationale: A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

The nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure? Droplet precautions Reverse isolation Surgical asepsis Medical asepsis

Surgical asepsis Rationale: Catheter insertion requires the procedure to be performed under sterile technique. Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

A family has undergone the emotional transition of accepting children into the family system. Which changes in the family's status are required to proceed developmentally?

Taking on parental roles Adjusting the marital system to make space for children

Which nursing interventions help prevent heat loss in newborns? Select all that apply. The nurse keeps the newborn covered in warm blankets. The nurse keeps the newborn under the radiant warmer. The nurse places the newborn on the mother's abdomen. The nurse measures the newborn's temperature regularly. The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

The nurse keeps the newborn covered in warm blankets. The nurse keeps the newborn under the radiant warmer. The nurse places the newborn on the mother's abdomen. Rationale: Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help prevent heat loss.

Which actions demonstrate the "analyticity" concept of a critical thinker? Select all that apply. One, some, or all responses may be correct. The nurse is organized and focused. The nurse trusts his or her own reasoning process. The nurse accepts multiple solutions to a problem. The nurse uses evidence-based knowledge for clinical decision-making. The nurse anticipates possible results or consequences in a given situation.

The nurse uses evidence-based knowledge for clinical decision-making. The nurse anticipates possible results or consequences in a given situation. Rationale: Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.

The nurse is caring for a client with a temperature of 104.5F (40.3C). The nurse applies a cooling blanket and administers an antipyretic medication. Which is the correct rationale for the nurse's interventions?

To reduce brain metabolism and limit hypoxia Rationale: Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen.

A client is receiving therapy that includes a radioactive sealed implant. Which nursing intervention would be implemented to protect against exposure to radiation? Wearing a dosimeter film badge at all times Limiting exposure to the client to 1 hour daily Using long-handled forceps to retrieve a dislodged implant Ensuring that visitors maintain a minimum distance of 3 feet from the client

Using long-handled forceps to retrieve a dislodged implant Rationale: Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.

The nurse reviews the medical record of a client who is eligible to receive hospice care. Which are the criteria for a client to receive this type of care? Select all that apply. When the death of the client is imminent When the expected death of the client is within 6 months When the client seeks no aggressive disease management When a family member has signed an informed consent form When the client has been issued a "do not resuscitate" order

When the expected death of the client is within 6 months When the client seeks no aggressive disease management When the client has been issued a "do not resuscitate" order

The nurse is caring for a client who had head and neck surgery. Which complication will the nurse try to prevent by positioning the client's head in functional alignment after surgery? Cervical trauma Laryngeal spasm Laryngeal edema Wound dehiscence

Wound dehiscence Rationale: Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? a. Maintain the head of the bed at 35 degrees or less. b. Use lift sheets to pull up, transfer, and position the client. c. Reposition the client at least every 2 hours and support the client with pillows. d. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

b. Use lift sheets to pull up, transfer, and position the client. Rationale: Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a draw sheet or when the client slides down in bed. With shearing, the skin adheres to the ned linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing tearing of the skin.

What are fine motor skills?

involve the smaller muscles of the fingers, toes, and eyes. specific and deliberate, such as picking up small objects

What are gross motor skills?

physical abilities involving large body movements, such as walking and jumping, an infant sitting up alone

Which infant is likely to need iron supplementation throughout the first year?

A 3 month old receiving formula Rationale: Formula is fortified with iron, but it is less readily absorbed than the iron in beast milk.

Which is the rationale for the nurse emptying the collection device frequently for a client with an ileal conduit? A full urine bag forces urine to back up into the kidneys. A full urine bag suppresses production of urine. A full urine bag causes the device to pull away from the skin. A full urine bag tears the ileal conduit.

A full urine bag causes the device to pull away from the skin. Rationale: If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

Which technique would the nurse use to maintain surgical asepsis? Change the sterile field after sterile water is spilled on it. Put on sterile gloves before opening a container of sterile saline. Place a sterile dressing no more than half an inch from the edge of the sterile field. Clean the surgical area with a circular motion, moving from the outer edge toward the center.

Change the sterile field after sterile water is spilled on it. Rationale: A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field.

Which principle of teaching would the nurse consider when providing instructions to an older client recently diagnosed with diabetes mellitus? Knowledge reduces general anxiety. Capacity to learn decreases with age. Continued reinforcement is important. Readiness of the learner precedes instruction.

Continued reinforcement is important. Rationale: Neurological aging causes forgetfulness and a slower response time; repetition increases learning. Continued reinforcement is an example of repetition. The facts that knowledge reduces general anxiety and that the readiness of the learner precedes instruction reflect principles that are applicable to learning regardless of the client's age. Capacity to learn does not decrease with age.