EAQ Fundamentals of Nursing (Level 2)

Normal serum calcium concentration?

9-10.5

Medical condition where there is too much/too little fluid in the blood

Hypervolemia / Hypovolemia

infections that can be defined as those occurring within 48 hours of hospital admission, 3 days of discharge or 30 days of an operation. They affect 1 in 10 patients admitted to hospital.

Nosocomial infections

Solid mass of fibrous tissue, palpable

Papule

Blockage of an artery in the lungs

Pulmonary embolus

The absence of viable pathogenic organisms

Surgical asepsis

Normal blood urea nitrogen (BUN)?

5-20 mg/dl

Coarse rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways.

Rhonchi

Clients on warfarin (Coumadin), what is a normal international normalized ratio (IRN)?

2-3

type of drug that reduces the body's ability to form clots in the blood

Anticoagulants

Examination of the sigmoid colon by means of a flexible tube inserted through the anus.

Sigmoidoscopy

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? a) Anger b) Denial c) Bargaining d) Depression

b) Denial Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

What is the priority nursing intervention for a client during the immediate postoperative period? a) Monitoring vital signs b) Observing for hemorrhage c) Maintaining a patent airway d) Recording the intake and output

c) Maintaining a patent airway Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output is important; however, a patent airway is the priority.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? a) Alkalosis b) Renal failure c) Hypervolemia d) Pulmonary edema

d) Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

Lesion filled with purulent drainage

pustule

Which of the following is unsafe to administer which medication as an IV bolus (IV Push)? (Why??) Saline flush Potassium chloride Naloxone (Narcan) Adenosine (Adenocard)

Potassium chloride given as an IV bolus can cause cardiac arrest. It should never be administered intravenously without being diluted and infused slowly through an IV infusion pump. Saline flush, naloxone (Narcan), and adenosine (Adenocard) are appropriate to be given as IV bolus undiluted.

Small blisterlike elevation on the skin containing serous fluid, usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy.

Vesicle

Breath sounds that are high-pitched, creaking, and accentuated on expiration

Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and COPD. Wheezes are produced as air flows through narrowed passageways.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? a) Keeps the area free of microorganisms b) Confines microorganisms to the surgical site c) Protects self from microorganisms in the wound d) Reduces the risk for growing opportunistic microorganisms

a) Keeps the area free of microorganisms Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound applies to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

When considering Erikson's psychosocial developmental tasks, a nurse should focus care for middle-aged adults around their need to be: a) Productive b) Controlling c) Independent d) Autonomous

a) Productive A psychosocial task for middle adulthood according to Erikson is generativity; this task is concerned with the sense of productivity and accomplishment. Controlling, being independent, and being autonomous are not involved in any task of middle adulthood identified by Erikson.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be appropriate to include in the instructions? a) "You do not need to wear them while you are awake but it is important to wear them at night." b) "You will need to apply them in the morning before you lower your legs from the bed to the floor." c) "If they bother you, you can roll them down to your knees while you are resting or sitting down." d) "You can apply them either in the morning or at bedtime but only after the legs are lowered to the floor."

b) "You will need to apply them in the morning before you lower your legs from the bed to the floor." Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor prevents excessive blood from collecting and being trapped in the lower extremities as a result of the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi, especially in clients who have had surgery or who have limited mobility, by applying constant compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at night, rolled down, or applied after the legs are lowered to the floor.

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, the nurse is aware that: a) The drainage system will be disconnected from the chest tube. b) A chest x-ray will be performed to determine lung re-expansion. c) An arterial blood gas will be obtained to determine oxygenation status. d) The client will be sedated 30 minutes before the procedure.

b) A chest x-ray will be performed to determine lung re-expansion. A chest x-ray should be performed to ensure and to document that the lung is re-expanded and has remained expanded. The drainage system should not be disconnected from the actual chest tube while still in the client because this may cause a pneumothorax to recur. An arterial blood gas may be performed prior to removal but is not necessary. An oxygen saturation reading with a pulse oximeter is usually sufficient to determine oxygenation level. The client may be given pain medication before the procedure but not sedation, as this may decrease the oxygen status.

Which nursing intervention is most appropriate for a client in skeletal traction? a) Add and remove weights as the client desires. b) Assess the pin sites at least every shift and as needed. c) Ensure that the knots in the rope are tied to the pulley. d) Perform range of motion to joints proximal and distal to the fracture at least once a day.

b) Assess the pin sites at least every shift and as needed. Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, the nurse should: a) Assess the strength of the affected leg. b) Explain the transfer procedure step by step. c) Instruct the client to bear weight evenly on both legs. d) Encourage the client to keep the affected leg elevated.

b) Explain the transfer procedure step by step. The client should understand the steps in the transfer to assist appropriately and avoid injury. Assessing strength in the affected leg is not advisable because it may disrupt the repair of the affected hip; also, weight bearing initially is not permitted on the operative leg. Bearing weight on the affected leg is contraindicated initially. The client may touch the floor with the foot of the affected leg but may not bear weight on the affected leg. Elevating the leg will cause hip flexion, which is contraindicated initially because it may precipitate hip dislocation.

A nurse receives a shift report on four adult clients that are between the ages of 25 and 55. Which client should the nurse assess first? a) Male client with a hemoglobin of 15.9 b) Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 c) Female client taking daily calcium supplements with a serum calcium level of 9.4 d) Male client with a blood urea nitrogen (BUN) of 20 and a creatinine of 1.1

b) Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse, because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the physician and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14-18 g/dL; serum calcium is 9.0-10.5 mg/dL ; BUN is 5-20 mg/dL and creatinine is 0.7-1.5 mg/dL.

An acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy is: a) Sepsis b) Hemorrhage c) Renal failure d) Paralytic ileus

b) Hemorrhage The kidney, an extremely vascular organ, receives a large percentage of the blood flow, and hemorrhage from the operative site can occur. Sepsis and renal failure may occur later in the postoperative period. Paralytic ileus can occur, but it is not life threatening.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? a) Limit the client's fluid intake. b) Teach the client how to exercise the legs. c) Encourage use of the incentive spirometer. d) Maintain the knee gatch position at an angle.

b) Teach the client how to exercise the legs. The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

a) Arrangements will be made by the client and the client's family. b) The plan is formulated and implemented early in the client's care. c) The rehabilitation is minimal and short term because the client will return to former activities. d) Arrangements will be made for long-term care because the client is no longer capable of self-care.

b) The plan is formulated and implemented early in the client's care. To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the health care system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.

The nurse recognizes that the reason the faucet handles on the sinks in a client's room are considered contaminated is because: a) They are not in sterile areas. b) They are touched by dirty hands when turning the water on. c) There are large numbers of people who use them each day. d) Water encourages bacterial growth.

b) They are touched by dirty hands when turning the water on. Unwashed hands are considered contaminated and are used to turn on sink faucets. Recontamination of washed hands may be prevented by using foot pedals or a paper towel barrier when closing the faucets. They are not considered contaminated because they are not in sterile areas; areas cannot be sterile. It is unrelated to the number of people but rather to being touched by contaminated hands. Although bacterial growth is facilitated in moist environments, this is not why sink faucets are considered contaminated.

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) feces. blood. semen. urine. sweat. tears.

blood. semen. HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other body secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? a) Place the client in a left side-lying position. b) Apply oxygen via non-rebreather mask. c) Apply a petroleum gauze dressing over the site. d) Prepare to reinsert a new chest tube.

c) Apply a petroleum gauze dressing over the site. A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The physician should immediately be notified and the client assessed for signs of respiratory distress.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? a) Erosions b) Macules c) Papules d) Vesicles

c) Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

A client has just spent five minutes complaining to the nurse about numerous aspects of the client's hospital stay. Which is the best initial response by the nurse? a) Attempt to explain the purpose of different hospital routines to the client b) Explain to the client that becoming so upset dangerously blocks the client's need for rest c) Refocus the conversation on the client's fears, frustrations, and anger about the client's condition d) Permit the client to release feelings and then promptly leave to allow the client to regain composure

c) Refocus the conversation on the client's fears, frustrations, and anger about the client's condition Refocusing the conversation on the client's fears, frustrations, and anger about the client's condition provides the opportunity for the client to verbalize the feelings underlying behavior. Attempting to explain the purpose of different hospital routines to the client has no effect on decreasing the client's anxiety or allowing ventilation. Explaining to the client that becoming so upset dangerously blocks the need for rest will not decrease anxiety so that the client can rest. Although allowing release of feelings is therapeutic, leaving immediately denies the client the opportunity for verbalization and discussion.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? a) Stop the heparin, flush the line, and administer the vancomycin. b) Use a piggyback setup to administer the vancomycin into the heparin. c) Start another IV line for the vancomycin and continue the heparin as prescribed. d) Hold the vancomycin and tell the health care provider that the drug is incompatible with heparin.

c) Start another IV line for the vancomycin and continue the heparin as prescribed. The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the health care provider's, to administer them safely.

Several recently licensed registered nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? a) "If you have liability insurance, you are more likely to be sued." b) "Your employer provides you with the liability insurance you will need." c) "Liability insurance is not available for nursing professionals working in a hospital." d) "Personal liability insurance offers representation if the State Board of Nursing files charges against you."

d) "Personal liability insurance offers representation if the State Board of Nursing files charges against you." Personal liability insurance will represent a nurse before the State Board of Nursing, whereas employee liability insurance will not. A nurse can be sued whether or not the nurse has liability insurance. Employer liability insurance will represent the nurse in charges related to employment, not charges brought by the State Board of Nursing. Liability insurance is available for all nurses.

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: a) "The body's fluid needs decrease with age because of tissue changes." b) "Access to fluid may be insufficient to meet the daily needs of the older adult." c) "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." d) "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

d) "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? a) Explain why there is a need to increase activity. b) Emphasize that with a prosthesis, there will be a return to the previous lifestyle. c) Appear cheerful and noncritical regardless of the client's response to attempts at intervention. d) Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving.

d) Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve ; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention.

A nurse advises a client to give someone the authority to make medical decisions for the client in the event that the client is unable to do so. What is the specific document that allows for this? a) Advance directive b) Living will c) Client rights proxy d) Durable power of attorney for health care

d) Durable power of attorney for health care A durable power of attorney for health care is a document that authorizes the client to name the person who will make the day-to-day and end-of-life decisions when the client becomes unable to do so. A durable power of attorney is part of an advance directive or living will document. An advance directive, also sometimes called a living will, is a legal document in which the client asks not to be kept alive by extraordinary medical effort when unable to make a decision. The document allows a client to make his or her wishes known through execution of a formal, legally binding document. Client rights proxy is not a term associated with medical decisions.

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? a) Place the client in a semi-Fowler's position. b) Stand behind the client during the transfer. c) Turn the chair so it faces away from the bed. d) Instruct the client to dangle the legs.

d) Instruct the client to dangle the legs. The nurse should place the client in high Fowler's position and then assist the client to the side of the bed. Next the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed.

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are: a) Ready for discharge and therefore in need of preparation b) At the peak of mental anguish and therefore open to change c) Less angry and therefore more compliant and more receptive d) Less anxious and more aware of reality and therefore ready to learn

d) Less anxious and more aware of reality and therefore ready to learn Anxiety or anger associated with other stages of coping interfere with learning. This is too late to start preparation for discharge and teaching. Many factors influence readiness for learning; planning for teaching must begin on the day of admission. The anxiety associated with mental anguish will interfere with the ability to process new information; mental anguish is associated with an earlier stage. Although clients in the acceptance or adaptation phase are less angry, the reason teaching is most effective is not because of their compliance but because new information can be processed more easily.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: a) Tropia b) Myopia c) Hyperopia d) Presbyopia

d) Presbyopia Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

Which task is most appropriate for a nurse to delegate to unlicensed assistive personnel? a) Emptying a portable wound drainage device b) Instructing a client to use an incentive spirometer c) Monitoring the rate of infusion of intravenous fluids d) Taking the blood pressure of a client before physical therapy

d) Taking the blood pressure of a client before physical therapy Taking vital signs is an appropriate task to delegate to unlicensed assistive personnel; it is within their job description because it is a task that has manageable parameters. Emptying a portable wound drainage device involves surgical asepsis; it is not an appropriate task to delegate to unlicensed assistive personnel.

. A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? a) A system of rewards and punishment is being used to motivate the client. b) Leaving the client alone allows time for the nurse to think of other strategies. c) This behavior indicates the client's desire for solitude that the nurse is respecting. d) This threat is considered assault, and the nurse should not have reacted in this manner.

d) This threat is considered assault, and the nurse should not have reacted in this manner. This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

Erosion into the dermis

Excoriation or ulcer

Normal hemoblobin levels for men and women?

Men -14-18 Women - 12 -16

An excessively alkaline condition (high bases) of the body fluids or tissues that may cause weakness or cramps

Alkalosis

There are two types of pneumonia.

Lobar pneumonia affects one or more sections, or lobes, of the lungs. Bronchopneumonia affects both lungs and the bronchi. Bronchopneumonia can be mild or severe. Viral bronchopneumonia is less severe usually.

An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action? a) Obtain a medication history from the client b) Check the blood pressure c) Instruct the client to avoid picking the nose d) Check the pulse

Nosebleeds can be indicative of high blood pressure in an adult. Of the choices provided, the first action of the nurse should be to check the client's blood pressure. If elevated, the nurse can initiate measures to decrease the blood pressure. The other options are appropriate but not the highest priority. A medication history is critical to determine if the client is on any anticoagulation therapy. After assessment and care, client teaching might include instruction not to pick the nose. After the blood pressure is measured, checking the pulse rate would be performed as part of the general vital signs assessment.

Inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization

Phlebitis

An abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle

Pleural friction rub

What is the Z-track method of injections used for?

The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. When the volume of medication is large, it should be administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not increase the likelihood that medication will remain in the muscle without flowing back up the needle track.

Battery means -

Touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? a) It provides rewards and punishment. b) The child's development is supported. c) It reflects the mores of a larger society. d) It is where child's identity and roles are learned.

d) Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society. Although important, providing rewards and punishments, supporting the child's development, and reflecting the mores of society are just one aspect of the family's influence and are not as important as identity and roles in relation to emotional development.