Foundation of Professional Nursing Practice
Which dietary guidelines are important for nurse Oliver to implement in caring for the client with burns?
High protein and high carb A positive nitrogen balance is important for meeting metabolic needs, tissue repair, and resistance to infection. Caloric goals may be as high as 5000 calories per day.
Is characterized by a reduced number of leukocytes (leucopenia) and neutrophils (neutropenia) in the blood.
Agranulocytosis
means that a test is measuring what it purports to measure Reliability Validity Specificity Sensitivity
Validity
108 F convert to Celsius
108 - 32 x 5/9 76 x 5 / 9 380/9 Answer: 42.222 C Formula: (32°F − 32) × 5/9 = 0°C
A normal platelet count in adults ranges from
150,000 - 450,000 platelets/microliter of blood
The physician orders DS 500 cc with KCl 10 mEq/liter at 30 cc/hr. The nurse in-charge is going to hang a 500 cc bag. KCl is supplied 20 mEq/10 cc. How many cc's of KCl will be added to the IV solution? .5 cc 1.5 cc 5 cc 2.5 cc
2.5 cc is to be added, because only a 500 cc bag of solution is being medicated instead of a 1 liter.
To prevent bacterial growth, feeding containers for TPN should be changed every
8-12 hours (per shift technically)
Nurse May is aware that the main advantage of using a floor stock system is: A. The system reinforces accurate calculations. B. The system minimizes transcription errors. C. The nurse can implement medication orders quickly. D. The nurse receives input from the pharmacist.
A floor stock system enables the nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.
Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital? A. Signs of severe dehydration B Cough for more than 30 days C High grade fever D. Inability to drink
A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken.
Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures? I.V. fluids B Diuretic agents C Acetaminophen (Tylenol) for pain D Antihypertensive agents
A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren't necessary. Diuretic wouldn't be used unless fluid overload resulted.
The maximum transfusion time for a unit of packed red blood cells (RBCs) is: 2 hours 3 hours 6 hours 4 hours
A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.
Nurse Amy has an order to obtain a urinalysis from a male client with an indwelling urinary catheter. The nurse avoids which of the following, which contaminate the specimen? Clamping the tubing of the drainage bag. Obtaining the specimen from the urinary drainage bag. Aspirating a sample from the port on the drainage bag. Wiping the port with an alcohol swab before inserting the syringe.
A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening the system.
Nurse Amy is aware that the following is true about functional nursing Provides continuous, coordinated and comprehensive nursing services. Concentrates on tasks and activities. One-to-one nurse patient ratio. Emphasize the use of group collaboration.
A. Functional nursing is focused on tasks and activities and not on the care of the patients.
A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: A Urinary output 90 cc in 2 hours. Absent patellar reflexes. C Rapid rise in blood pressure. D Rapid respiratory rate above 40/min.
Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
Standard use to determine if nurse was negligent is:
Actions of a reasonably prudent nurse with similar education and experience Standard of care is determined by - average degree of skill, care, and diligence by nurses in similar circumstances
When walking with clients, the nurse should stand on __________ side and grasp the security belt in the ________ area of the small of the back. The nurse should position the free hand at the shoulder area so that the client can be pulled toward the nurse in the event that there is a forward fall. The client is instructed to look up and outward rather than at his or her feet.
Affected side Midspine
Ronald plans to conduct a research on the use of a new method of pain assessment scale. Which of the following is the second step in the conceptualizing phase of the research process? Review related literature Design the theoretical and conceptual framework Formulating and delimiting the research problem Formulating the research hypothesis
After formulating and delimiting the research problem, the researcher conducts a review of related literature to determine the extent of what has been done on the study by previous researchers.
The physician inserts a chest tube into a female client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse in-charge can prevent chest tube air leaks by: Checking patency of the chest tube. Keeping the head of the bed slightly elevated. Checking and taping all connections. Keeping the chest drainage system below the level of the chest.
Air leaks commonly occur if the system isn't secure. Checking all connections and taping them will prevent air leaks. The chest drainage system is kept lower to promote drainage - not to prevent leaks
Nurse Oliver must apply an elastic bandage to a client's ankle and calf. He should apply the bandage beginning at the client's: A. Ankle B. Foot C. Lower thigh
An elastic bandage should be applied form the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee does not promote venous return
A male client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit? It's the smallest measurement in the apothecary system. It's a common measurement in the metric system. It's the basis for solids in the avoirdupois system. It's a measure of effect, not a standard measure of weight or quantity.
An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity.
Convert 32 C to Fahrenheit
Answer: 89.6 Formula: (0°C × 9/5) + 32 = 32°F 32 x 9 / 5 + 32 278 / 5 + 32 55. 6 + 32 89.6
The nurse is aware that the most important nursing action when a client returns from surgery is: Assess the Foley catheter for patency and urine output Assess the client for presence of pain. Assess the IV for type of fluid and rate of flow. Assess the dressing for drainage
Assessing the client for pain is a very important measure. Postoperative pain is an indication of complication. The nurse should also assess the client for pain to provide for the client's comfort.
The correct order of assessment for examining the abdomen is
Auscultation, percussion, palpation The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation.
Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for A. Lifetime B. 1 year C 5 years D 3 years
B. The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection.
Which of the following is the most prominent feature of public health nursing? A It involves providing home care to sick people who are not confined in the hospital. Public health nursing focuses on preventive, not curative, services. C Services are provided free of charge to people within the catchments area. The public health nurse functions as part of a team providing a public health nursing services.
B. The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services
Nurse Hazel will administer a unit of whole blood, which priority information should the nurse have about the client? Height and weight. Hgb and Hct levels. Blood pressure and pulse rate. Calcium and potassium levels
BP and PR The baseline must be established to recognize the signs of an anaphylactic or hemolytic reaction to the transfusion.
A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for: Early in the morning B After the child has been bathe Just before bedtime D Any time during the day
Based on the nurse's knowledge of microbiology, the specimen should be collected early in the morning. The rationale for this timing is that, because the female worm lays eggs at night around the perineal area, the first bowel movement of the day will yield the best results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test.
Which nursing intervention takes highest priority when caring for a newly admitted client who's receiving a blood transfusion? Documenting blood administration in the client care record. Assessing the client's vital signs when the transfusion ends. Instructing the client to report any itching, swelling, or dyspnea. Informing the client that the transfusion usually take 1 ½ to 2 hours.
Because administration of blood or blood products may cause serious adverse effects such as allergic reactions, the nurse must monitor the client for these effects. Signs and symptoms of life-threatening allergic reactions include itching, swelling, and dyspnea. Although the nurse should inform the client of the duration of the transfusion and should document its administration, these actions are less critical to the client's immediate health. The nurse should assess vital signs at least hourly during the transfusion.
She finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibit most likely? Communicates downward to staffs. Allows decision making among subordinates. Gives economic and ego awards. Have condescending trust and confidence in their subordinates.
Benevolent-authoritative managers pretentiously show their trust and confidence to their followers.
Terbutaline drug class
Beta 2 adrenergic agonist
Terbutaline can be used in what type of diseases
COPD, asthma
In a mothers' class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct? A Chicken pox vaccine is best given when there is an impending outbreak in the community. The older one gets, the more susceptible he becomes to the complications of chicken pox. To prevent an outbreak in the community, quarantine may be imposed by health authorities. D A single attack of chicken pox will prevent future episodes, including conditions such as shingles.
Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults.
Which are common side effects and adverse effects of terbutaline A. Tremors B. Angina C. Headache D. Increased heart rate E. Hypertension F. Nervousness G. Arrhythmia
Common side effects: Tremors, headache, increased HR, nervousness Adverse: AHA Angina, hypertension, arrhythmia
Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is: A Community survey Contact tracing C Interview of suspects Mass screening tests
Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases.
Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating? Crutches Single straight-legged cane Quad cane Walker
Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.
Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is: Decreased urine output Increased respiratory rate C Hyperreflexia D Anemia
Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels.
The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to: A Wash the area vigorously with each diaper change. B Decrease the infant's fluid intake to decrease saturating diapers. C Apply talc powder with diaper changes. Change the diaper more often.
Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation
Patient's refusal to divulge information is a limitation because it is beyond the control of Tifanny". What type of research is appropriate for this study? Quasi-experiment Historical Descriptive- correlational Experiment
Descriptive- correlational study is the most appropriate for this study because it studies the variables that could be the antecedents of the increased incidence of nosocomial infection
Nurse Michelle hears the alarm sound on the telemetry monitor. The nurse quickly looks at the monitor and notes that a client is in a ventricular tachycardia. The nurse rushes to the client's room. Upon reaching the client's bedside, the nurse would take which action first? Check the client's level of consciousness Prepare to defibrillate the client Prepare for cardioversion Call a code
Determining unresponsiveness is the first step assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, checking the unresponsiveness ensures whether the client is affected by the decreased cardiac output.
Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need? A 3 1 2 D The RHU does not need any more midwife item.
Each rural health midwife is given a population assignment of about 5,000.
When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating Efficiency B Appropriateness Adequacy D Effectiveness
Efficiency is determining whether the goals were attained at the least possible cost.
Nursing care for a female client includes removing elastic stockings once per day. The Nurse Betty is aware that the rationale for this intervention? To observe the lower extremities To permit veins in the legs to fill with blood. To allow the leg muscles to stretch and relax To increase blood flow to
Elastic stockings are used to promote venous return. The nurse needs to remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood.
Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is:
Endocardial cushion defect
The nurse is assessing a 48-year-old client who has come to the physician's office for his annual physical exam. One of the first physical signs of aging is: Failing eyesight, especially close vision. Increasing loss of muscle tone. Accepting limitations while developing assets. Having more
Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).
True or False: Complaints of abdominal discomfort and nausea are serious effects that can lead to complications in clients receiving tube feedings
False. This is common for patients receiving TPN. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Feedings are normally given at room temperature to minimize abdominal cramping. To prevent aspiration during feeding, the head of the client's bed should be elevated at least 30 degrees. Also, to prevent bacterial growth, feeding containers should be routinely changed every 8 to 12 hours
Which type of evaluation occurs continuously throughout the teaching and learning process? Informative Retrospective Summative Formativ
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative is not a type of evaluation
Contact precautions require the use of _________ if direct client contact is anticipated. Goggles are not necessary unless the nurse anticipates the splashes of blood, body fluids, secretions, or excretions may occur. Shoe protectors are not necessary.
Gowns and gloves
is based on the study of Elton Mayo and company about the effect of an intervention done to improve the working conditions of the workers on their productivity. It resulted to an increased productivity but not due to the intervention but due to the psychological effects of being observed. They performed differently because they were under observation.
Hawthorne effect
Nurse Len is administering sublingual nitrglycerin (Nitrostat) to the newly admitted client. Immediately afterward, the client may experience: Nervousness or paresthesia. Tinnitus or diplopia. Drowsiness or blurred vision. Throbbing headache or dizziness
Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops tolerance
If a central venous catheter becomes disconnected accidentally, what should the nurse in-charge do immediately? Call another nurse Apply a dry sterile dressing to the site. Clamp the catheter Call the physician
If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn't available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension and restart the infusion.
The nurse prepares to administer a cleansing enema. What is the most common client position used for this procedure? A. Sims' left lateral B. Supine C. Prone D. Lithotomy
The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. If the client can't assume this position nor has poor sphincter control, the dorsal recumbent or right lateral position may be used. The supine and prone positions are inappropriate and uncomfortable for the client.
A 10 year old child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? Hypernatremia Hyperphosphatemia Hypokalemia Hypercalcemia
Insulin administration causes glucose and potassium to move into the cells, causing hypokalemia
sampling involves including samples according to the knowledge of the investigator about the participants in the study.
Judgement
The student nurse is aware that the pathognomonic sign of measles is Koplik's spot and you may see Koplik's spot by inspecting the: A Skin on neck Buccal mucosa C Nasal mucosa D Skin on the abdomen
Kop-LIK = LICK = TONGUE = MOUTH (buccal mucosa) Koplik's spot may be seen on the mucosa of the mouth or the throat.
John plans to use a Likert Scale to his study to determine the: Degree of acceptance Degree of agreement and disagreement Level of satisfaction Compliance to expected standards
Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study
Nurse John develops methods for data gathering. Which of the following criteria of a good instrument refers to the ability of the instrument to yield the same results upon its repeated administration? Reliability Validity Specificity Sensitivity
Reliability is consistency of the research instrument. It refers to the repeatability of the instrument in extracting the same responses upon its repeated administration
A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse? A. Notify the physician. B. Place the client in high-Fowlers position. C. Place the client on the left side in the Trendelenburg position. D. Stop the total parenteral nutrition.
Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration. Lying on the left side in Trendelenburg position is sometimes recommended for suspected air embolism during Total Parenteral Nutrition (TPN) administration. This position is believed to trap air in the right atrium, preventing it from traveling to the pulmonary artery and causing a blockage. However, the use of Trendelenburg position for air embolism is debated, and current guidelines may vary. It's essential to follow specific medical protocols and consult healthcare professionals for the most accurate and up-to-date information. The Trendelenburg position involves placing the body on its back with the lower half elevated higher than the head. This position is thought to encourage air bubbles to rise and collect in the right atrium, preventing them from traveling to the pulmonary artery and causing a blockage.
The nursing theorist who developed transcultural nursing theory is:
Madeleine Leininger
Nurse Monique is monitoring the effectiveness of a client's drug therapy. When should the nurse Monique obtain a blood sample to measure the trough drug level? 1 hour before administering the next dose. 30 minutes after administering the next dose. Immediately before administering the next dose. Immediately after administering the next dose.
Measuring the blood drug concentration helps determine whether the dosing has achieved the therapeutic goal. For measurement of the trough, or lowest, blood level of a drug, the nurse draws a blood sample immediately before administering the next dose. Depending on the drug's duration of action and half-life, peak blood drug levels typically are drawn after administering the next dose.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: Fresh orange slices Ice cream Steamed broccoli Ground beef patties
Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers.Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.
A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? A Cover his eyes while receiving oxygen. B Humidify the oxygen. Monitor partial pressure of oxygen (Pao2) levels. D Keep her body temperature low.
Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated.
is a symptom of impending myocardial infarction (MI) and should be assessed immediately so that treatment can be instituted and further damage to the heart is avoided.
Nausea
Abnormal or normal finding: Bowel sounds occurring every 10 seconds. Dullness over the liver. Shifting dullness over abdomen Vascular sounds in renal arteries
Normal Normal Abnormal Normal
A 65 years old male client requests his medication at 9 p.m. instead of 10 p.m. so that he can go to sleep earlier. Which type of nursing intervention is required? Independent Intradependent Interdependent Dependent
Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already-prescribed drug on time is a dependent intervention. An intradependent nursing intervention doesn't exist.
Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? External fetal monitoring B Amniocentesis Ultrasound D Digital or speculum exam
Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldn't be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring won't detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation.
Monica is aware that there are times when only manipulation of study variables is possible and the elements of control or randomization are not attendant. Which type of research is referred to this? Field study Solomon-Four group design Post-test only design Quasi-experiment
Quasi-experiment is done when randomization and control of the variables are not possible.
Nurse Myrna is aware that the Board of Nursing has quasi-judicial power. An example of this power is: The Board prepares the board examinations The Board can visit a school applying for a permit in collaboration with CHED The Board can issue rules and regulations that will govern the practice of nursing The Board can investigate violations of the nursing law and code of ethics
Quasi-judicial power means that the Board of Nursing has the authority to investigate violations of the nursing law and can issue summons, subpoena or subpoena duces tecum as needed.
literally means the thing speaks for itself. This means in operational terms that the injury caused is the proof that there was a negligent act.
Res ipsa loquitor
refers to a test's ability to designate an individual with disease as positive Reliability Validity Specificity Sensitivity
Sensitivity
refers to the number of workers who report directly to a manager.
Span of control
of a test is its ability to designate an individual who does not have a disease as negative. Reliability Validity Specificity Sensitivity
Specificity
Nurse Janah is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Nurse Janah plans to implement which intervention to obtain the specimen? A. Use a sterile plastic container for obtaining the specimen. B. Ask the client to expectorate a small amount of sputum into the emesis basin. C. Ask the client to obtain the specimen after breakfast. D. Provide tissues for expectoration and obtaining the specimen.
Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid.
developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode.
Sr. Callista Roy
What type of order is this. "Administer acetaminophen 500 mg orally every 6 hours as needed for pain."
Standing order
Terbutaline mechanism of action
Stimulates beta 2 receptors in bronchial smooth muscles to produce bronchodilation and relaxation > bronchodilator, relieves bronchospasm and improves air flow
Which finding might be seen in baby James a neonate suspected of having an infection? A. Decreased temperature B. Increased temperature C Flushed cheeks D Increased activity level
Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The neonate's color often changes with an infection process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy.
Nurse Reese is teaching a female client with peripheral vascular disease about foot care; Nurse Reese should include which instruction? Avoid using a nail clipper to cut toenails. Avoid wearing cotton socks. Avoid wearing canvas shoes. Avoid using cornstarch on feet.
The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.
A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client? Encourage family and friends to visit. Encourage the client to take frequent rest periods. Place client on reverse isolation. Admit the client into a private room.
The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation.
Which of the following item is considered the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person's needs? Physical examination History of present illness Biographical date Diagnostic test results
The history of present illness is the single most important factor in assisting the health professional in arriving at a diagnosis or determining the person's needs.
Tony is aware the Chairman of the Municipal Health Board is: A Municipal Health Officer Mayor C Any qualified physician D Public Health Nurse
The local executive serves as the chairman of the Municipal Health Board.
Nurse Marian is preparing to administer a blood transfusion. Which action should the nurse take first? Compare the client's identification wristband with the tag on the unit of blood. Measure the client's vital signs. Arrange for typing and cross matching of the client's blood. Start an I.V. infusion of normal saline solution.
The nurse first arranges for typing and cross matching of the client's blood to ensure compatibility with donor blood. The other options,although appropriate when preparing to administer a blood transfusion, come later.
Nurse Betty is assessing tactile fremitus in a client with pneumonia. For this examination, nurse Betty should use the: Ulnar surface of the hand Dorsal surface of the hand Finger pads Fingertips
The nurse uses the ulnar surface, or ball, of the hand to asses tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface best feels warmth
Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" Stat order Standard written order Standing order Single order
This is a standard written order. Prescribers write a single order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. A standing order, also known as a protocol, establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give.
Low platelet count is called
Thrombocytopenia
A male client with a right pleural effusion noted on a chest X-ray is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. To provide a safe environment, the nurse assists the client to which position for the procedure? Sims' position with the head of the bed flat. Left side-lying with the head of the bed elevated 45 degrees. Prone with head turned toward the side supported by a pillow. Right side-lying with the head of the bed elevated 45 degrees.
To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees.
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? Instructing the client about the importance of perineal (kegel) exercises. Instructing the client to use two or more peripads to cushion the area. C Applying cold to limit edema during the first 12 to 24 hours. D Instructing the client on the use of sitz baths if ordered.
Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.
The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires: A More oxygen, and the newborn's metabolic rate increases. B More oxygen, and the newborn's metabolic rate decreases. C Less oxygen, and the newborn's metabolic rate increases. D Less oxygen, and the newborn's metabolic rate decreases.
When a newborn gets too cool, their body has to work harder to stay warm. This extra effort increases the baby's metabolism, which means they need more oxygen to keep up with the energy demand. So, option A is the right choice.
A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first? A "Do you have any allergies?" B "Do you have any chronic illnesses?" "What is your expected due date?" D "Who will be with you during labor?"
When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons.
When the method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulations, the wound healing is termed Primary intention healing Second intention healing First intention healing Third intention healing
When wounds dehisce, they will allowed to heal by secondary intention
Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution? 2 hours B 8 hours C At the end of the day 4 hours
While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning.
Nurse Trish is caring for a female client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The female client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hr. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, Nurse Trish should avoid which route? I.V Oral I.M S.C
With a platelet count of 22,000/μl, the clients tends to bleed easily. Therefore, the nurse should avoid using the I.M. route because the area is a highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop.
A 45 year old client, has no family history of breast cancer or other risk factors for this disease. Nurse John should instruct her to have mammogram how often? Once, to establish baseline Once per year Every 2 years Twice per year
Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks, such as family history, genetic tendency, or past breast cancer, exist, more frequent examinations may be necessary.
RA 9173 sec. 24 states that for equity and justice:
a revoked license maybe re-issued provided that the following conditions are met: a) the cause for revocation of license has already been corrected or removed; and, b) at least four years has elapsed since the license has been revoked
Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy? 5 skin lesions, positive slit skin smear B 3 skin lesions, positive slit skin smear C 3 skin lesions, negative slit skin smear D 5 skin lesions, negative slit skin smear
multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions
Curling's ulcer
occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers.
In preventing the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use: Footboard Trochanter roll extending from the crest of the ileum to the midthigh. Pillows under the lower legs. Hip-abductor pillow
trochanter roll, properly placed, provides resistance to the external rotation of the hip
