Final

List the six 'Cs' of a caring nurse

1. Compassion 2. competence 3. confidence 4. conscience 5. commitment 6. comportment

List three ways that a nurse can demonstrate 'caring' to patients.

1.Know your patient. 2. Maintain a trusting nurse-patient relationship 3. Be compassionate 4. Empower your patient 5. Demonstrate your competence

The opening of a non-moldable ostomy wafer should be this much larger than the stoma

1/8th inch

At approximately this month an infant can grasp a rattle by its handle

10 months

Young adults usually complete physical growth by this age

20 years old

This is how much water a client should drink every day

2000 - 3000 mL

Children like to pretend and try out new roles at this age

3 to 6 years

Medications should be given_______minutes before scheduled time but no later than_______minutes after scheduled time

30 minutes

Administering an intradermal injection should be given at this angle

5-15 degrees

•How many mL of water is equivalent to 1 lb?

500 mL

Total Braden scale score ranges from

6 to 23

•Which patient is at greatest risk for impaired wound healing after surgery?

75-year-old patient with poorly controlled diabetes mellitus

•When teaching an elderly patient how to prevent constipation, which instruction should the nurse include?

"Be sure to get regular exercise."

A patient with chest pain is being admitted to the Emergency Department. When asked about next of kin the patient states, "Don't bother calling my daughter, she is always to busy." What is the best response by the nurse?

"Is there someone else you would like me to call for you?"

The nurse is caring for a confused patient with a diagnosis of dementia of the Alzheimer's type. What should the nurse say when assisting the patient to eat?

"Please eat your meat."

A nurse is providing an end-of-shift report for a client with chronic obstructive pulmonary disease. Which interventions would be appropriate to include? Select all that apply.

- Administer low-flow oxygen as needed. - Encourage alternating client activity with rest periods. - Teach diaphragmatic, pursed-lip breathing.

When working as a team, which nursing duties would the nurse delegate to the LPN? Select all that apply.

- Administer morphine sulfate 30 mg IM every 4 hours as needed. - Place a nasogastric tube for gastric decompression. - Calculate output every 8 hours and report to the health care provider. - Insert a 14-French indwelling catheter.

Which recommendation should a nurse make when counseling a client who is experiencing insomnia? Select all that apply.

- Eliminate substances such as caffeine and chocolate. - Use progressive muscle relaxation skills before bed - Keep a sleep diary. - If insomnia continues, a referral can be made to a sleep disorder specialist

A nurse is teaching a client with left leg weakness to walk with a cane. Which nursing points about safe cane use would be included in the client teaching? Select all that apply.

- Hold the cane on the uninvolved side of the body - Avoid leaning on the cane to get in and out of a chair. - Adjust the cane so that the handle is level with the hip bone.

A nurse is caring for a client who states abdominal and sternal pain after eating and when lying down. Which instructions would the nurse recommend when teaching this client? Select all that apply.

- Maintain a normal body weight. - Sleep with the upper body elevated - Avoid constrictive clothing. - Decrease the intake of caffeine and spicy foods.

A nurse receives orders to apply a vest restraint and bilateral soft wrist restraints. Which nursing actions would be appropriate in carrying out this order? Select all that apply.

- Perform a face-to-face behavior evaluation every hour. - Tie the restraints in quick-release knots. - Document the client's condition. - Document alternate methods used before the restraints were applied.

A nurse is reviewing the advanced health-care directive of a recently admitted hospitalized client. Which content should the nurse expect to see on the directive? Select all that apply.

- Preference for health-care treatment - Preference for hospitalization - Do-not-resuscitate orders - Durable power of attorney for health care

Which duties can be assigned to the unlicensed assistive person? Select all that apply.

- Repositioning a client on complete bed rest - Changing the linen of a client on a pressure-releasing mattress. - Transferring a client from the bed to the chair using a mechanical lift. - Totaling the intake and output for the entire unit

A client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life. My doctor said I am not a candidate for a transplant." Which responses are appropriate? Select all that apply.

- Take a seat next to the client and sit quietly to reflect on what was said. - Say to the client, "You're feeling upset about the news you got about the transplant."

What is the standard time of 1:00 am when converted to the 24-hour or military time

0100

Client says good-bye to significant others and gets financial and legal affairs in order. The client states, "I feel ready. At least, I'm more at peace now."

Acceptance

The nurse is preparing the room for a client diagnosed with varicella. Which sign would the nurse place on the room door?

Airborne precautions

•What plasma protein aids in maintaining fluid and electrolyte balance?

Albumen

What lab data would the health care provider most likely order for a client with a nutritional problem? Name 2

Albumin Pre-albumin Transferrin Hemoglobin Hematocrit BUN

•An 82-year-old male patient with Parkinson's disease is frequently incontinent of urine. Which intervention should be done first?

Apply a condom catheter

The nurse and UAP are caring for clients. Which intervention should the nurse delegate to the UAP? a. Take the oral acetaminophen to a client with a headache. b. Apply an ice pack to the left knee of a client who had an arthroscopy. c. Check the client 30 minutes after the nurse administered pain medication. d. Explain how to use the PCA pump to the client returned from surgery.

Apply an ice pack to the left knee of a client who had an arthroscopy

Which action should a nurse plan when caring for four clients of varying religious beliefs who are near death?

Arranging for an uninterrupted time for male family members to wash the body of a male client of Muslim faith

A nurse is admitting a client who is in labor with her first child. The client states that she was born in Somalia. When performing a cultural assessment, what should be the nurse's first action?

Ask the client about any religious beliefs that could impact care

The daughter of an 82-year-old client with Alzheimer's disease contacts a clinic because the client has been unwilling to drink any fluids for over 24 hours. Which instruction by the nurse is most appropriate?

Ask the daughter about the presence of other symptoms

A client who does not speak or understand English has an interpreter at the bedside assisting a nurse with an admission interview and assessment. Which action is most appropriate for the nurse while utilizing the interpreter?

Asking the questions directly to the client

Which is the highest priority performed by the nurse prior to completing this nursing action? (image= testing pH)

Assess stomach residual

A nurse takes a client's blood pressure with an automatic blood pressure machine. The blood pressure is 86/56 mm Hg with a pulse rate of 64 beats per minute. Which action should the nurse do next?

Assess the client for dizziness and assess the skin on the extremities for warmth

What should a nurse do first when a hospitalized client tells the nurse about feeling a strong shock when turning on an electric hairdryer?

Assess the client's apical pulse

In this stage the child begins to make choices, understanding that parents/society have expectations about these choices.

Autonomy vs Sense of Shame and Doubt

Clients tries to make 'deals' with caregivers'. The client states, "Please, God, just let me live long enough to see my grandchild graduate."

Bargaining

BP: False-low Reading

Bladder or cuff too wide Arm above heart level

•The body's main source of energy is________________________.

Carbohydrates

A nurse is caring for a client who has a magnesium deficiency resulting from alcoholism. Which system should be a nurse's first priority when assessing this client?

Cardiovascular system

Identify two risks associated with parenteral nutrition

Catheter infection Hyperglycemia Hypoglycemia Electrolyte imbalances

•Which technique will maintain surgical asepsis?

Change the sterile field after sterile water is spilled on it

To ensure safe medication administration, which action should be performed first?

Check for patient allergies

A nurse is caring for a client who has 0.9% NaCl infusing intravenously. An order had been written the previous day to change the IV solution to 0.9% NaCl with 10 mEq KCL. Which action should the nurse initiate first?

Check the client's serum potassium level

A nurse is using a tympanic thermometer to measure an adult client's temperature. When using a tympanic thermometer, the nurse should complete which of the following actions?

Check the setting of the thermometer

A patient with hematuria has a three-way indwelling urinary catheter with continuous bladder irrigation (CBI) and is complaining of lower abdominal pain. What should be the nurse's first action?

Check urine flow to the drainage bag

This cultural group regards death as a negative life event; no concept of life after death. They also believe the body should remain intact; autopsy and organ donation are uncommon

Chinese culture

•An elderly patient has a sore on the inside of his ankle that he says won't heal. After noting varicosities and coarse discoloration around the sore, the nurse should suspect which finding?

Chronic venous insufficiency

This nurse founded the organization now known as the American Red Cross

Clara Barton

•A nursing assistant will be changing the soiled bed linens of a patient with a draining pressure ulcer. Which protective equipment should the nursing assistant wear?

Clean gloves

The nurse is preparing a client for surgery. Which intervention is priority for the nurse?

Complete the preoperative checklist

Name two warning signs of dysphagia

Cough during eating, change in voice tone or quality after swallowing, abnormal movements of the mouth, tongue, or lips, slow, weak uncoordinated speech, abnormal gag reflex, delayed swallowing, pocketing, and/or regurgitation

Client is diagnosed with terminal lung cancer but continues to smoke two packs of cigarettes daily. The client states, "This can't be happening to me."

Denial

The client refuses to admit to anger, even though the situation warrants it and the client's voice indicates anger. This behavior is called

Denial

A client withdraws and isolates himself from friends. The client states, "Go away. I just want to lie here in bed. What's the use?"

Depression

A nurse is transferring a patient from a bed to a wheelchair. What should the nurse do to quickly assess this patient's tolerance to the change in position?

Determine if the patient feels dizzy

A husband who is angry at his wife yells at the family dog rather than dealing directly with the anger. This behavior is known as

Displacement

•A patient complains of severe burning on urination. Which instruction is best to give the patient?

Drink 2500 to 3000 mL water every day

A hospitalized client diagnosed with end-stage cancer has suddenly decided to discontinue treatment. The client requests no additional treatment. When acting as the client's advocate, which action should a nurse take?

Encourage the client to share the decision with the family and the client's physician

This nurse established the first nursing philosophy based on health maintenance and restoration

Florence Nightingale

In this stage the adult focuses on supporting future generations through mentoring, teaching, and community involvement.

Generativity vs Self-Absorption and Stagnation

This law states that clients have a right to protect their health information

HIPAA - Health Insurance Portability and Accountability Act

A client who is recovering from orthopedic surgery demonstrates the use of a walker to ambulate with partial weight-bearing. Which observation should lead the nurse to conclude that the client is using the correct technique?

Has elbows bent at a 30-degree angle

Which intervention would be the nurse's priority when treating a client currently experiencing chest pain while walking?

Have the client sit down

A nurse is preparing a sterile field for a dressing change using surgical aseptic technique. The nurse gathers the supplies and prepares the sterile field using a packaged sterile drape. Which option correctly describes how the nurse should set up the sterile field?

Holding items 6 inches above the field and dropping them on the sterile field inside the 1-inch border along the edge of the drape

Which electrolyte imbalance should be the priority concern for a nurse when assessing a 10-year-old client diagnosed with acute renal failure?

Hyperkalemia

This communication method allows nurses and other healthcare providers to share information about a client

I-SBAR

•What should you do if you suspect a client is aspirating?

If you suspect that patient is aspirating, stop feeding immediately and suction airway

IV site found to have blanching around the site, swelling, and coolness to the touch. Lab results include a WBC of 8000. Based on the progress note, what condition has most likely occurred?

Infiltration

An adolescent takes on all the values and styles of an admired teacher. What behavior is the adolescent exhibiting?

Introjection

This nurse fought for licensing exams and registration to protect the public from incompetent nursing care

Isabel Hampton Robb

This nurse founded the Henry Street Settlement on the lower east side of New York City

Lillian Wald

A nurse is caring for a client who is unable to perform oral hygiene. The client has upper and lower denture plates. Which technique should the nurse use to correctly perform oral hygiene for this client?

Loosen the upper plate by grasping the front teeth with a piece of gauze.

This nurse established the first organized midwifery program in the United States

Mary Breckenridge

This charting system includes problems that are prioritized and numbered

PIE charting

The nurse and unlicensed assistive personnel (UAP) are working on a surgical unit. Which intervention should the nurse delegate to the UAP?

Place a surgical gown and cap on the client, and request the client to void.

A young adult says, "I'm not attracted to him, my best friend is." What defense mechanism is the adult using?

Projection

•A patient complains of the inability to sleep while on the medical unit. Which intervention should be performed first?

Question the patient about sleeping habits

A client brings gifts to a nurse with whom he is really angry. This behavior is called

Reaction formation

A child starts to suck his thumb when admitted to the hospital. This behavior is known as

Regression

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours?

Remove the restraints and assess skin and circulation

A teenager, seeing his best friend killed in a car crash, becomes amnesic about the circumstances surrounding the crash. Identify the defense mechanism

Repression

A nurse is setting up supplies to complete a dressing change at 8pm on a client's stump following a below-the-knee amputation of the right leg. The client looks away and angrily says, "I don't want to look at that thing. Can't you come back later?" Which is the best action by the nurse?

Restating to the client, "You don't want to look at your leg?"

Which assessment findings should prompt a nurse to conclude that interventions have been ineffective for a client with hypernatremia?

Restlessness and agitation

•A nurse obtains 250 mL of tube feeding prior to administering medications. Should the nurse return the feeding to the stomach?

Return the stomach residual volumes of 250 mL or less to avoid loss of nutrients, fluid, and electrolytes

The client in the preoperative holding area is wearing an amulet. Which is the most appropriate intervention for the nurse to implement?

See that the amulet is pinned to the client's pillow in the operating room

A nurse is caring for a client who is hypotensive. Which electrolytes should be closely monitored by the nurse?

Sodium, potassium, chloride

Droplet isolation examples

Streptococcal pharyngitis or pneumonia, scarlet fever, rubella, mumps, meningococcal pneumonia

A young man deals with aggression by playing football. What term would be used to identify this coping mechanism?

Sublimation

A student nurse decides not to think about a family problem in order to study for an upcoming examination. The term used for this behavior is called

Suppression

A client leaves the nurse a flower rather than directly saying she cares about the nurse. This behavior is called

Symbolization

The charge nurse on a 20-bed surgical unit has one RN, two LPNs, and two unlicensed assistive personnel (UAPs) for a 12-hour shift. Which task would be an appropriate delegation of assignments? a. The RN will perform the shift assessments. b. The LPN should administer all IVP medications. c. The LPN will complete all the morning care. d. The UAP will monitor laboratory values

The RN will perform the shift assessments.

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed upon the client's lap for safe transport

The nurse has received the morning shift report on a surgical unit. Which client should the nurse assess first?

The elderly client diagnosed with a left fractured hip who is crying and is frightened about the surgery

•In a patient with diarrhea, which outcome indicates that fluid resuscitation is successful?

The patient exhibits firm skin turgor

The charge nurse on a surgical floor is making shift assignments. Which client should be assigned to the leased experienced registered nurse? a. The client who has undergone an irrigation for sinusitis who has a severe headache. b. The pediatric client scheduled for a tonsillectomy who will not swallow medication. c. The client who had surgical drainage of the sinuses and has purulent drainage on the drip pad. d. The elderly client with a peritonsillar abscess who has a feeling of tightness in the throat.

The pediatric client scheduled for a tonsillectomy who will not swallow medication

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the following action?

To clear secretions from the tubing

Which of these foods would be a great source for potassium? A. Tomatoes B. Cottage cheese C. Egg yolk D. Canned white tuna

Tomatoes

Decreased levels of carbohydrates can lead to tissue breakdown leading to ketosis and metabolic acidosis. (T/F)

True

In this stage, a nurse uses anticipatory guidance to help parents cope with the hospitalization of an infant

Trust vs Mistrust

•Which intervention is performed first when changing a dressing or giving wound care?

Wash hands thoroughly

Which of the following tasks may be delegated to an LPN/LVN? a. Initiation of packed red blood cells b. Wet-to-dry dressing changes c. Administration of chemotherapy d.Mixing IV solutions

Wet-to-dry dressing changes

Contact isolation examples

Wound infections, herpes simplex, scabies, enteric diseases

A nurse calls a physician regarding a change in a client's condition. The physician gives orders over the telephone for arterial blood gases (ABGs) to be drawn stat. Which is the most important safety consideration when obtaining the order?

Writing the order down and reading it back to the physician

•The most reliable method for verifying the correct placement of small-bore feeding tubes is___________.

X-ray

Lower score indicates

a higher risk for pressure ulcer development

This type of loss refers to an amputation of a body part or loss of a job

actual

This type of wound usually heals within days to weeks and has a low risk of infection

acute wound

This stage commonly includes rapid growth spurts with the development of secondary sex characteristics

adolescence

This domain of learning deals with expression of feelings and acceptance of attitudes, opinions, or values

affective

Adolescents with this medical condition have an intense fear of gaining weight and refuse to maintain body weight at the minimal normal weight for their age and height

anorexia nervosa

This phase of the nursing process includes collecting, validating, organizing, interpreting, and documenting client data

assessment

A client has a nursing diagnosis of fluid volume deficit. Which vital sign, if decreased, supports this nursing diagnosis?

blood pressure

The greatest risk for home accidents that result in severe injury and death is found in this developmental age

children younger than 5 years of age

Side affects of opioids

constipation orthostatic hypotension urinary retention nausea/ vomiting sedation respiratory depression

This term is used to describe the process of identifying client strengths and weaknesses

data clustering

A patient says to the healthcare provider, "There must be some mistake. I want a second opinion about my prognosis."

denial

This mental health disorder most frequently has an onset between the ages of 25 and 44

depression

This condition is described as liquid stool, > 3 times/day, with urgency, discomfort, and possible incontinence

diarrhea

The boss gets angry; shouts at the employee. The employee goes home and kicks the dog.

displacement

This pressure injury cannot be staged

eschar

This term describes the accumulation of gas in the intestines causing the walls to stretch

flatulence

This type of assessment is used to gather data about a specific client problem

focused

This is one of the most common events leading to a client's fall during hospitalization

going to the bathroom, especially during evening or night hours and when the room is dark

This term is used to describe a person's reading and mathematics skills, comprehension, and decision making and functioning skills about health care

health literacy

This type of application relaxes muscle spasms, softens exudates for easy removal, and hastens healing due to vasodilation

heat

This type of care focuses on quality rather than length of life

hospice

•Pre-albumin

indicator for acute conditions; responds quickly to nutritional intake

Albumin

indicator for chronic illness; maintains colloidal osmotic pressure; slow to respond to patient's recent increase in nutrients

This document specifies which treatments/procedures a patient expects if a Code Blue occurs

living will

What are you assessing when assessing pain?

location quality intensity, strength, severity timing setting

Hemoglobin

main component of erythrocytes; vehicle for transportation of oxygen and carbon dioxide; screens for anemia

Respiratory (airborne) isolation examples

measles, varicella tuberculosis

The changing of an active drug from its original form to an inactivated or new form is known as this

metabolism

The nurse uses these two identifiers prior to administering a medication

name and date of birth

In young adults, this major health problem is a risk factor for other health problems later in life

obesity

This is the first level of Maslow's Hierarchy of Needs

physiological needs

This is the initial treatment if the onset of a seizure was not witnessed and the nurse suspects that the client fell and struck their head

place a cervical collar on the client before attempting to turn or reposition

Sleep disturbances are common for this age group including trouble falling asleep and nightmares

preschoolers

The attribution of one's own undesired traits or impulses onto someone else

projection

PASS

pull the pin aim at base of fire squeeze handle sweep side to side

"The test had too many trick questions; the instructor was out to get me."

rationalization

A client brings gifts to the nurse with whom he/she is really angry

reaction formation

This action is required by a nurse after receiving a telephone prescription from a healthcare provider

read-back

A communication technique that makes an older adult more aware of time, place, and person

reality orientation

A middle-aged person is playing with his child's toy blocks. He says, "This is really relaxing after a hard day at the office." •

regression

Older adults interpret their lives as a meaningful whole or experience this

regret because of goals not achieved

•Transferrin

regulates iron absorption; transport protein; synthesized by the liver; iron needed for production of hemoglobin; increased in iron-deficiency anemia; decreased in protein deficiency or malnutrition, chronic infection

RACE

rescue alarm confirm extinguish

These are the 6 rights of medication administration

right medication, dose, client, route, time, and documentation

The body stiffens 2-4 hours after death as a result of muscle contraction

rigor mortis

This type of nursing diagnosis identifies a client's vulnerability or a problem not yet present

risk diagnosis

This nursing diagnosis is defined as 'vulnerable to entry of GI secretions, oropharyngeal secretions, solids, of fluids to the tracheobronchial passages, which may compromise health

risk for aspiration

If patient complains of increased ear pain during irrigation what might be the reason?

rupture of eardrum may have occurred - Stop irrigations immediately and notify health care provider

Greatest danger with ear irrigation

rupture of tympanic membrane - forcing liquid into ear canal

This term refers to middle adults who begin to help aging parents while being responsible for their own children

sandwich generation

Burns, pressure ulcers, and severe lacerations heal by this method

secondary intention

This term refers to a person's perceived ability to successfully complete a task

self-efficacy

Braden scale assessment categories

sensory moisture activity mobility friction and shear

The Braden Scale for predicting pressure sore risk measures these five categories

sensory perception, moisture, activity, mobility, nutrition, and friction and shear

The standard bowel diversion creates this opening

stoma

This data is provided only by the client

subjective data

This process focuses on a patient's learning needs and ability to learn

teaching process

A big concern for this age group is toileting and learning to talk

toddler

Picture books, simple words, and playing with equipment and bandages are the best methods for teaching this age group

toddlers

Liquid used for irrigation should be warmed to body temperature to avoid

vertigo or nausea

•Which vitamin is activated by sunlight and is synthesized in the skin?

vitamin D

BP: false-high reading

•Bladder or cuff too narrow or too short •Cuff wrapped too loosely or unevenly •Arm below level of heart

List two clinical signs of poor nutrition

•Cachectic appearance •Dry, brittle hair •Flaccid muscles •Dry, scaly lips •Brittle nails •Scarlet, beefy tongue •Bleeding, receding gums •Sagging posture

•What diet would be most appropriate for a client who has gum disease and wears dentures?

•Clear liquids •Full liquids •Pureed •Mechanical Soft •Soft/low residue •High fiber •Low sodium •Low cholesterol •Diabetic •Regular

Hypoxemia: Late signs

•Confusion and stupor •Cyanotic skin and mucous membranes •Bradypnea •Bradycardia •Hypotension •Cardiac dysrhythmias

False-low systolic & False-high diastolic

•Deflating cuff too quickly •Stethoscope that fits poorly or impairment of examiner's hearing causing sounds to be muffled

False-high diastolic

•Deflating cuff too slowly •Inflating too slowly

Name two adverse effects of tube feedings

•High gastric residuals •Nausea •Cramping •Vomiting •Diarrhea •Aspiration

False-low systolic

•Inadequate inflation level

•Alcohol ingestion can result in which metabolic state?

•Metabolic acidosis

False-high systolic & False-low diastolic

•Multiple examiners using different sounds for diastolic readings

•A client has a BMI of 27. Is this client within an acceptable weight, overweight, or obese?

•Overweight (25-30)

False-high systolic

•Repeating assessments too quickly

False-low diastolic

•Stethoscope applied too firmly against antecubital fossa

Hypoxemia: early signs

•Tachypnea •Tachycardia •Restlessness •Pale skin and mucous membranes •Elevated blood pressure Respiratory distress symptoms