Fundamentals Exam 1

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"Give the client choices regarding their bathing preferences to encourage them to bathe."

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

Care of Dentures

** place a paper towel or washcloth in the sink to prevent dentures from breaking if dropped. do not place dentures in sink ** holding the dentures securely, brush the dentures with toothpaste and a toothbrush **Store in a half filled container with water

WHY ARE FALLS DANGEROUS?

*30-35% of falls result in injury (hip/leg fractures, head trauma) *Among older adults, falls are especially dangerous because of their increased causation of morbidity and mortality.

Nursing Process: Diagnosis • Common patient problems associated with hygiene: include

- Activity intolerance - Bathing self-care deficit - Dressing self-care deficit - Impaired physical mobility - Impaired oral mucous membrane - Ineffective health maintenance - Potential for infection

Walkers

- Lift all 4 legs at one time -Advance 6-8", then walk up to walk

Oral Medication Considerations

- Oral route is the most convenient, costs less, and is typically a safer route of medication administration. -Client can self-administer & Painless -Assess the client's level of consciousness and ability to swallow. If they're NPO Enteric-coated- Medications that are formulated to be dissolved and released in the small intestines for a slower release and can be administered less frequently during the day. Sustained-release- Tablets designed to release medication slowly over an extended period. Know if the medication should be administered on an empty stomach or with foods. In addition, the nurse should identify whether specific foods may decrease or enhance absorption. -Assist the client to a position that will prevent aspiration, such as elevating the head of the bed to semi-Fowler's or high-Fowler's position as the client's prescribed activity level permits. -Offer water or a beverage

Factors that could contribute to a fall:

- Physical disorders - Cognitive influences - Environmental factors - Medication - Age - Staffing levels - Bathroom frequency

Musculoskeletal changes due to prolonged bed rest

- sarcopenia (loss of lean muscle mass) -Joint contractures (An abnormal fixation of a joint due to changes in muscles and connective tissue.) - Foot drop (A type of joint contracture that results in the foot and toes permanently pointing downward.) -Disuse osteoporosis- occurs when bones have become thinner and weaker

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (Select all that apply.) -A client's visitor falls in the hallway. -A nurse forgets their computer password. -A client develops an unexpected reaction to a medication. -A client's dentures are lost. -An antibiotic was administered to a client 30 min after the scheduled time.

-A client's visitor falls in the hallway. -A client develops an unexpected reaction to a medication. -A client's dentures are lost.

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.) A fluoride mouthwash should be used to promote oral health. The teeth should be brushed twice daily for 2 min. Poor oral hygiene can lead to gingivitis. Teeth should be flossed every other day Use a soft-bristled toothbrush for brushing the teeth.

-A fluoride mouthwash should be used to promote oral health. -The teeth should be brushed twice daily for 2 min. -Poor oral hygiene can lead to gingivitis. -Teeth should be flossed every other day. -Use a soft-bristled toothbrush for brushing the teeth.

Culture of Safety to prevent harm includes:

-Acknowledgement of high-risk nature of activities -Blame-free environment -Collaboration across all levels/disciplines -Commitment of resources to address concerns

What to keep in mind when helping a pt walk

-Assessment (strength, coordination, vitals, environment for safety) -Non-skid shoes/socks -Assist to sitting, dangle legs for 1-2 minutes -GAIT BELT -Assisting with falls/syncope -Use of assistive devices as neede

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (Select all that apply.) -Blood transfusion incompatibility -Wrong site surgery -Ineffective insulin usage -Dysphagia following a stroke -Dehydration due to diarrhea

-Blood transfusion incompatibility -Wrong site surgery -Ineffective insulin usage

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? (Select all that apply.) -Influenza infection -Catheter-associated urinary tract infection -Mycobacterium tuberculosis infection -Central line-associated bloodstream infection -Surgical site infection

-Catheter-associated urinary tract infection -Central line-associated bloodstream infection -Surgical site infection

Elements of Therapeutic Communication

-Compassionate, Caring, Empathetic -Techniques: silence, active listening, open-ended questions, accepting, giving recognition, restating, summarizing, reflecting -Avoid: not listening, rejecting client's views, being critical/judgmental, giving advice, dismissing concerns

Pathological influences on body alignment and mobility:

-Congenital defects (OI/Scoliosis) -Disorders of bones, joints, and muscles (Osteoporosis) -Inflammatory joint diseases (Arthritis) -Central nervous system damage (TBI, Spinal cord Injury) -Musculoskeletal trauma (Bone fx) -Any equipment or devices to protect (IV line, Oxygenation equipment ect.)

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for fire to occur? (Select all that apply.) -Carbon dioxide -Nitrogen -Cooking oil -Oxygen -Heat

-Cooking oil -Oxygen -Heat

Principles of Transfer when Pt IS UNABLE to assist

-Dividing balanced activity between arms and legs reduces the risk of back injury -Leverage, rolling, turning, or pivoting requires less work than lifting -When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it

Assessment of Mobility-Activities of Daily Living (ADL's)

-Essential skills that a person does independently everyday and related to personal care -Unsupervised-bathing, toileting, feeding -Support to continue to provide these ADL's-achieves high quality of life and independence -Assistive equipment-assist with independence and reduce physical strain on a client

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? (Select all that apply.) -Fall history -Medical diagnosis -Use of assistive devices -Mental status -Do-not-resuscitate status

-Fall history -Medical diagnosis -Use of assistive devices -Mental status

Enteral Tube Medication Administration

-Flush with 30-60mL of water before and after, 15mL-30mL between meds -NEVER mix medications

Enteral Tube Administration (through nose not GI)

-For pts who can't shallow/ chew -Higher risk of infection -Flush with 30-60mL of water before and after, 15mL-30mL between meds -NEVER mix medications

safety?

-Freedom from psychological and physical injury. -Safety refers to the prevention of patient injury caused by health care errors.

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply.) -Locks the brakes on the client's bed -Checks the maximum weight of the lift before using it -Places the client on the edge of the sling -Uses the lift without assistance from another team member -Performs a safety check before lifting the client

-Locks the brakes on the client's bed -Checks the maximum weight of the lift before using it -Performs a safety check before lifting the client

Principles of Safe Patient Transfer and Positioning when pt can assist

-Mechanical lifts and lift teams essential when pt. unable to assist -When pt. CAN assist: *Wider the base of support, the greater stability of nurse *The lower of center of gravity, the greater stability of nurse *Facing the direction of mvmt prevents abnormal twisting of spine

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (Select all that apply.)

-Place the client on round-the-clock surveillance. -Remove objects from the room that the client could use to harm themselves. -Search items brought into the client's room by visitors. -Screen the client for suicidal ideation.

Bath guidelines are?

-Provide privacy. -Maintain safety. -Maintain warmth. -Promote independence. -Anticipate needs.

Restraint Documentation

-Restraint alternatives utilized -Pt. behaviors/LOC prior to application -Any education provided to pt./family -Purpose, type, location, time applied/DC'd -Any physical assessment data-Pt. behaviors/LOC after application -Exact times patient was assessed/monitore

Oral Administration disadvantage

-Slow onset of action -Subject to first-pass effect -May have an unpleasant taste -Not appropriate for unconscious clients -Not appropriate for clients with excessive vomiting and/or diarrhea

A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority? -The client reports dizziness when standing -The client has not had a bowel movement in 3 days -The client has non-pitting edema in the lower extremities -The client has several scratch marks on their abdomen

-The client reports dizziness when standing

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint? -Synovial joints contain sensory receptors that trigger flexion. -The contraction of a muscle results in flexion of a joint. -Neurotransmitters coordinate with cartilage to initiate flexion. -Ligaments extend to enable flexion of a joint.

-The contraction of a muscle results in flexion of a joint.

A nurse is providing education on priority setting frameworks to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?

-This framework assigns the highest priority to the situation that poses a threat to the client's physical well-being. -The safety and risk reduction priority setting framework assigns the highest priority to the factor or situation that will cause the greatest harm to the client's physical well-being.

Urinary Elimination Changes

-Urinary Retention (give fluids to get them to urinate and position in semi fowlers) - Renal calculi (kidney stones)

Safe Patient Handling Best Practices

-Use Standardized Assessment Tools (Banner Mobility Assessment Tool) -Environment should be assessed for ergonomics -Algorithms/assessments to select the appropriate lift devices, equipment, and support needed -Safety huddles -Minimize lifting when possible -Importance of early mobility

Hygiene Assessment

-Usual hygiene care practices (HYGIENE IS NEVER ROUTINE) -Skin and hair -Eyes, ears, nose -Oral cavity -Nails and feet -Perineal area -Cultural influences -Self-care ability -Use of sensory aids

bowel elimination changes

-Will end with constipation (end up with dry and hard stools) give the pt as much fluid as they can handle, medications like stool softeners/ have the pt sit up in bed -Gastroesphageal reflux

Intramuscular (IM) injection

-injection into a muscle -often have a faster absorption rate than subcutaneous injections due to the large blood vessels found in the muscles. -faster than oral & enteral route

Factors Influencing Hygiene

-social practices -body image -health beliefs and motivation -developmental stage -personal preferences -socioeconomic status -cultural variables -physical condition

How to identify a patient

1. Have them state their name and DOB 2. check their bracelet 3. Bar Scan when giving medication

Crutches measurement

2-3 inches below axilla, tips 4-6 inches in front of shoes, elbow flexed 15-30 degrees

Tanner's Clinical Judgment Model

1. Noticing 2. Interpreting 3. Responding 4. Reflection

Factors Influencing Activity Tolerance

1. Physiologic Factors: -Skeletal/Muscular abnormalities -Metabolic illnesses -Cardiac/Respiratory Function -Endurance/Physical Stability -Pain -Sleep/fatigue 2. Emotional Factors: - Anxiety, Depression -Addictions -Motivation 3. Developmental Factors (Age/Sex) 4. Pregnancy

Steps to lift heavy object

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and the lower back straight 3.Look straight ahead with shoulders raised up 4. Bend hips slightly and squat is the fourth step. 5.Push up from the knees when lifting the object is the fifth step.

hand washing steps

1. Wet hands with warm water 2. Apply the amount of soap recommended by the manufacturer 3. Rub hands together vigorously for at least 15 seconds 4. Rinse hands with water 5. Use a disposable towel to dry 6. Use a towel to turn off the faucet

Sublingual medications

Administered by placing medication under the tongue (i.e. nitroglycerin) Instruct the client not to swallow or chew the medication. Remain with the client until the medication has dissolved.

Buccal medications

Administered by placing the medication between the cheek and gum (i.e. anesthetic benzocaine) Instruct the client not to swallow or chew the medication. Remain with the client until the medication has dissolved.

drug metabolism

changed to prepare for excretion

A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first? -A client who reports a possible sprained wrist and is walking around -A client who has an open forearm fracture without visible drainage -A client who has a respiratory rate of 6/min and no pupil response -A client who has an abdominal wound that is actively bleeding

A client who has an abdominal wound that is actively bleeding requires immediate intervention for survival; therefore, when using the survival approach to client care, the nurse should recommend this client for first transport to a health care facility. A client who is hemorrhaging has an immediate threat to life.

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? -A client who is receiving a blood transfusion and reports urticaria -A client who has back pain and is requesting a muscle relaxant medication -A client who has an ankle sprain and requests toileting assistance -A client who has chronic migraines and reports a headache

A client who is receiving a blood transfusion and reports urticaria is unstable because this is a manifestation of anaphylaxis; therefore, the nurse should plan to see this client first. Anaphylaxis is a life-threatening condition that requires immediate attention.

A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care? -A client who received digoxin and has a heart rate of 48/min -A client who received pain medication and has a respiratory rate of 14/min -A client who has a urinary tract infection and temperature of 37.9° C (100.2° F) -A client who has anemia and a blood pressure of 118/78 mm Hg

A client who received digoxin and has a heart rate of 48/min is unstable; therefore, the nurse should identify this client as the priority for care. This heart rate is below the expected reference range. The nurse should report this finding to the provider and check for manifestations of decreased cardiac output.

Which of the following patients is at greatest risk for experiencing a fall? a) A confused patient with a history of a previous fall b) A patient who ambulates by holding onto furniture c) A recently admitted patient d) A patient who wears glasses to read

A confused patient with a history of a previous fall

sequential compression device (SCD)

A device that continually inflates and deflates compression hose on the legs to stimulate circulation in the legs.

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? -Near-miss event -Client safety event -Adverse event -Sentinel event

A near-miss event is an error that could have harmed the client which almost occurs, but was caught and avoided. The nurse noted the client had an allergy to the medication prior to administering it, avoiding harm to the client.

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? -Extinguish the fire. -Close the windows in the client's room. -Close the client's door. -Activate the fire alarm.

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next?

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? A stable center of gravity increases stability and balance. A wide base lowers the center of gravity. Proper body alignment involves tightening the abdomen. Leaning slightly back while carrying an object equalizes the center of gravity. Bending at the waist when picking up objects stabilizes the spine.

A stable center of gravity increases stability and balance. A wide base lowers the center of gravity. Proper body alignment involves tightening the abdomen.

What is a patient fall?

A sudden, unintentional change in position, coming to rest on the ground or other lower level, is among the most commonly reported adverse hospital events Factors: sleep deprivation, new environment, change in medications, decreased strength

AIDET stands for

Acknowledge Introduce Duration Explain Thank you

The nurse has applied extremity restraints on a patient. What should the nurse assess on a regular basis? (Select all that apply.) a) Skin integrity and ROM b) Pulse and temperature of the restrained body part c) Ability of the patient to breathe without restriction d) Readiness for discontinuation of the restraint e) Frequency of the patient's visitors f) Therapy (e.g., IV catheters, drainage tubes) remains uninterrupted

All of the above

transdermal

Allow for the medication to be absorbed slowly, providing prolonged medication release lasting for several days. Generally applied to the upper torso, chest, upper arms, or back, or behind the ears. The medication released by these patches is absorbed through the skin for systemic distribution for a prescribed amount of time. Examples of types of medication delivered via transdermal patches include opioids, antidepressants, contraceptives, nicotine, and antinausea medications.

Idiosyncratic (paradoxical) reaction

An abnormal and unexpected response to a medication, other than an allergic reaction, that is peculiar to an individual patient.

physical restraint

Any manual method, physical or mechanical device, or material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs or head freely.

Medication Errors

Any preventable adverse drug events involving inappropriate medication use by a patient or health care professional; they may or may not cause the patient harm. • Report all medication errors • Patient safety is top priority when an error occurs • Documentation is required. • The nurse is responsible for preparing a written occurrence/ incident report: an accurate, factual description of what occurred and what was done.

Topical

Applied directly to the skin or mucous membranes of the eyes, nose, respiratory tract, vagina, rectum, and urinary tract. Such medications can be used for local effects (i.e., for treatment of a specific body part) or for a systemic effect, in which the whole body is affected once the medication is absorbed through the skin.

Nursing Process

Assessment Diagnosis Analysis Planning Implementation Evaluation

Plateau

Blood serum concentration is reached and maintained

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include? -Muscles store calcium and magnesium. -Muscles produce red blood cells and platelets. -Muscles assist with thermoregulation in the body. -Muscles provide protection of internal organs.

Contracting muscles generate heat that assists in maintaining body temperature. Shivering is an example of the muscles working to produce heat.

Restraint Alternative

Devices or techniques employed to avoid the use of restraints. Depending on the intent and how it is used, it can be an alternative or a restraint.

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion? Enamel protects the teeth from pathogens. Enamel is a substance that cannot be dissolved. Enamel is a soft material that protects the teeth. Enamel covers the pulp.

Enamel protects the teeth from pathogens. Enamel protects the teeth from pathogens by providing a coating that covers the teeth.

Therapeutic effect

Expected or predicted physiological response

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop occurs when the joint of the foot becomes contracted and results in the inability to perform dorsiflexion, or pulling the toes upward. This is due to nerve damage that causes shortening of the muscle. The foot is left with the toes pointing downward and in a dropped position.

A nurse is planning to use the identity, situation, background, assessment, recommendation, read back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? -The client's admitting diagnosis -The client's medical history -The client's laboratory test results -The client's response to treatment

General client impression and significant findings such as diagnostic tests, laboratory results, and vital signs are included in the assessment component of the ISBARR communication tool.

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

Health promotion programs emphasize encouraging the client to take control of improving their overall health.

Elements of Musculoskeletal Assessment

History -Past medical history -Family history -Current medications -Lifestyle behaviors -Occupation -Social environment -Problem-based history Symptoms Associated with Altered Mobility -Pain -Reduced joint movement -Reduced sensation or loss of sensation -Falls Fatigue -Altered gait or imbalance -Reduced functional ability

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? -Kyphosis is when the upper back extends posteriorly to the lower back. -Kyphosis is an inward curvature of the lower back. -Kyphosis is a sideways curvature of the spine. -Kyphosis is a rounded upper back with the pelvis tilted forward.

Kyphosis is when the upper back is abnormally rounded with the pelvis tilted forward.

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include? The skin contains Langerhans cells that kill pathogens. The skin is the smallest organ of the body. The skin is the second line of defense against micro-organisms. The dermis is the outermost layer of the skin.

Langerhans cells within the skin sense the presence of disease-causing pathogens and destroy them, decreasing the risk of developing infection in the body.

When using this framework, the nurse will encourage the client to have social relationships through group interaction.

Maslow's Hierarchy of Needs includes client love and belonging needs, which can be met by encouraging social relationships and group interactions with personal friends and work connections.

enteral route

Medications administered via the mouth, stomach or intestines. Provides for a much slower rate of absorption. The mucous membranes of the gastrointestinal (GI) tract delay medication movement. Oral and enteral medications must pass through these GI membranes to reach the circulatory system.

chemical restraint

Medications used to manage a patient's behavior that are NOT a standard treatment for their condition

Drug Trough

Minimum blood serum concentration before next scheduled dose

Now

Needed right away but not STAT (30 to 60 minutes)

Atelectasis

Partial collapse of the alveoli. If pt is immobilized they don't have the best breathing. You want good fluid intake bc if the pt has secretions the liquids can help thin them out and they can cough it out.

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational Therapist

Restraint ordering

Orders must be: -Clinically justified -Based on face-to-face assessment -Current -Detailed (include type of restraint, duration, circumstance, etc.) -Renewed as indicated (cannot be PRN)

Maslow's Hierarchy of Needs

Physiological needs are the highest priority. Physiological needs take priority over other needs because they are essential for survival. The nurse should not address any other needs until physiological needs have been met. Safety needs are the second level of priority. Once physiological needs have been met, the nurse should plan to meet safety needs. Love and belonging are the are the third level of priority. After physiological and safety needs have been met, the nurse should address love and belonging. Esteem needs are the fourth level of needs in Maslow's Hierarchy of Needs. The nurse should focus on esteem needs once the client has satisfied the need for love and belonging. Self-actualization is the fifth level of needs. Only after all other needs have been satisfied will an individual be ready to turn their attention to self-actualization. The nurse should recognize that self-actualization is the lowest priority of need.

Integumentary changes

Pressure injuries can happen. So assess, do frequent turning at least every 2 hours, and use pillows.

Brushing: Unconscious Patient

Prevent aspiration 1. Positioning—lateral position with head turned to the side or side-lying. Position back of head on a pillow so that the face tips forward and fluid/ secretions will flow out of the mouth, not back into the throat. 2. Place a bulb syringe or suction machine with suction equipment nearby. Yankuer end on suction device.

subcutaneous injection

Subcutaneous injections are delivered into the fat layer found immediately under the dermis. The absorption rate with this route of administration may be slower than with an intramuscular injection due to smaller size of blood vessels found in this fat layer. has a faster rate of absorption than oral or enteral route.

Fire Safety: PASS

Pull, Aim, Squeeze, Sweep

Fire Safety: RACE

R-rescue: protect/evacuate clients in danger A-alarm: activate alarm/report the fire C-contain: close doors/windows E-Extinguish: use the correct extinguisher to eliminate the fire

Clinical Judgement Model

Recognize cues Analyze cues & prioritize hypotheses Generate solutions Take action Evaluate outcomes

Rights of Medication Administration

Right medication Right patient Right dosage Right route Right time Right reason Right assessment data Right documentation Right response Right to education Right to refuse

A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment? -Acute vs. chronic -ABCDE -Least restrictive/least invasive -Survival potential

Since this client is experiencing manifestations in multiple body systems, the nurse should use the ABCDE framework to prioritize which assessment to perform first. The ABCDE method prioritizes the client's airway first, followed by breathing, circulation, disability, and exposure, so the first assessment the nurse should make is to ensure the client has an adequate airway.

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min -Level 1 most severe -Level 4 needs no assistance

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture? -Center of gravity -Bones -Muscles -Synovial joints

Skeletal muscles are attached to the skeleton. They maintain body posture and position.

Pharmacokinetics

Study of the absorption, metabolism, distribution, and excretion of drugs in the human body. (what happens to the drug when its in the body)

-Cartilage is always remodeling and changing. -Tendons connect muscle to bone. -Ligaments are flexible connective tissue that coat bony areas. -Synovial joints attach to the skeleton to maintain posture.

Tendons and ligaments are both made of fibrous connective tissue. Tendons attach muscle to bone while ligaments attach bones to other bones.

The nurse and NAP are applying extremity restraints to a patient. Which action, if made by the NAP, would require correction? a) The NAP inserted two fingers under the secured restraint. b) The NAP used a quick-release tie. c) The NAP placed the patient in functional alignment. d) The NAP attached the restraint to the side rail of the bed.

The NAP attached the restraint to the side rail of the bed.

A nurse is planning to implement the Transforming Care at the Beside plan on a medical-surgical unit. Which of the following interventions should the nurse include in the plan? -Require nurses to spend 50% of their time at the bedside of clients. -Perform change-of-shift report at the nurses' station. -Complete client rounds every 4 hr. -Use a standardized communication tool.

The Transforming Care at the Bedside plan recommends using a standardized communication tool, such as the Identity, Situation, Background, Assessment, Recommendation, and Readback (ISBARR) tool. Using a standardized communication tool enhances communication, which results in improved client outcomes.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? -The hand grips of the crutches are at the level of the client's umbilicus. -The client's elbows are bent 45° when holding the crutches. -The client places their weight on their axilla when using the crutches. -The client has the crutches resting 5 cm (2 in) below their axilla.

The client has the crutches resting 5 cm (2 in) below their axilla.

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

The cuticle of the nail forms a barrier to prevent infections.

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (Select all that apply.)

The date the medication was mixed The dose of the mixed medication The time the medication was mixed

A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first? -Develop nursing diagnoses -Perform a physical assessment -Administer prescribed medications -Develop goals and outcomes

The first action the nurse should take when using the nursing process is to assess the client. Assessment of the client includes a physical examination, client interview, review of the medical records, and general observation. A registered nurse uses a five-step sequential nursing process, which includes assessment, analysis, planning, implementation, and evaluation.

A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care? -Chronic -Minimal -Urgent -Expectant

The nurse should categorize this client's condition as urgent. Conditions in the urgent category have a greater probability of poor outcomes if prompt actions are not taken. Abdominal pain can be caused by non-life-threatening problems such as gas and constipation but can also be a manifestation of more significant illnesses such as bowel obstruction or appendicitis. The nurse should assess the client further to determine the cause of the abdominal pain.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take?

The nurse should have the client shower to remove the chemical toxin from their skin, hair, and eyes to reduce the effects of exposure.

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system? -Increased curvature of the thoracic spine -Reduced depth perception -Narrower stance when standing -Quick steps when ambulating

The nurse should identify that an increased curvature of the thoracic spine, along with protrusion of the neck, indicates an age-related change to the client's musculoskeletal system. This occurs due to bone loss and degeneration of vertebral discs. This can cause the client to lean forward when standing and have an unsteady gait when walking.

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions? -Deep vein thrombosis -Asthma -Hernia -Hypertension

The nurse should identify that the client is at risk for developing deep vein thrombosis. Blood clots can develop when a client is immobile due to an increase in blood viscosity and atrophy of the muscles. This can then result in decreased blood circulation, which can lead to blood clots and deep vein thrombosis.

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage? -Deep damage through the skin and tissue -Damage beyond the skin layer -Damage into the skin layer -Damage with the skin intact

The nurse should identify that the client's wound indicates damage into the skin layer. In this stage, the wound can be lighter in color than the client's skin tone, along with temperature differences and an intact or open blister.

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL? -Toileting -Writing -Ambulating -Talking

The nurse should include that toileting is an ADL that the AP can assist the client to perform. Other ADLs include dressing, bathing, and feeding.

This framework uses the least restrictive measures first as long as the client's safety is maintained

The nurse should inform the newly licensed nurses that the least restrictive/least invasive priority setting framework gives priority to nursing actions that are the least restrictive, or least invasive while still maintaining the safety of the client.

When using this framework, clients are prioritized using a color-coded system.

The nurse should inform the newly licensed nurses that the survival potential priority setting framework, used during mass casualty situations, uses a color-coded system to prioritize clients for treatment based on potential for survival. This priority framework seeks to provide the most good to the most clients with the resources available.

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? -An extension cord is secured under a rug. -The edges of stairs are marked with brightly colored tape. -A toaster is plugged in when not in use. -The water heater is set to 55° C (131° F).

The nurse should instruct the client to mark edges of stairs with brightly colored tape to alert the client of the steps and reduce the risk of fall.

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics? -Twisting the torso when transferring the client -Bending at the waist when transferring the client -Placing the bed in the high position before transferring the client -Looking at the client face-to-face when transferring the client

The nurse should look at the client face-to-face when transferring. This prevents twisting or turning of the torso, which can cause back injuries.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? -Record the time and length of the seizure. -Restrain the client's extremities. -Place the client in the prone position. -Monitor the client's hemoglobin level.

The nurse should monitor the length of time of the seizure to evaluate the type of seizure and determine treatment required.

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

The nurse should place the client in Fowler's position to promote lung expansion and prevent atelectasis, which is the partial or complete collapse of a lung. In this position, the client is seated in a semi-sitting position and can have their knees bent or straight.

A nurse is caring for a client who reports feeling inferior and states that they are not good enough. The nurse should recognize that these feelings fall under which of the following categories of Maslow's Hierarchy of Needs? -Love and belonging -Self-actualization -Safety -Self-esteem

The nurse should recognize that self-esteem needs are motivated by the need to feel good about one's self and have the respect of others. If self-esteem needs are unfilled, the client may experience a feeling of inferiority.

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? -Reposition the client every 2 hr while in bed. -Remind the client to use the incentive spirometer. -Obtain the client's weight daily. -Encourage the client to eat foods that are high in fiber.

The nurse should remind the client who is at risk for developing atelectasis to use the incentive spirometer. Using the incentive spirometer prevents atelectasis from occurring because the client takes slow, deep breaths to promote lung expansion.

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? (Select all that apply.) -Tie the restraints to the siderails on the client's bed. -Remove the restraints with each vital sign check. -Use a square knot to secure the restraints. -Make sure one finger can fit under the restraints.

The nurse should remove the restraints and check the client's skin and circulation with each vital sign and at least every 2 hr to monitor for client injury.

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing? -Sarcopenia -Disuse osteoporosis -Atrophy -Joint contracture

The nurse should suspect the client is experiencing atrophy of their muscles. Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged immobility or disuse of a limb.

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use? -Pivot disc -Mechanical lift -Sit-to-stand lift -Gait belt

The nurse should use a mechanical lift, along with assistance from two or more health care staff, to transfer a client who is unable to assist. The use of a mechanical lift decreases the risk of injury to both the staff and the client.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.) -The nurse's hands become visibly soiled. -The nurse removes the meal tray of a client who has infectious diarrhea. -The nurse moves the cell phone of a client who has pneumococcal pneumonia from the bedside table. -The nurse empties the urinal of a client who has Clostridium difficile. -The nurse is preparing to insert an intravenous catheter.

The nurse's hands become visibly soiled. The nurse removes the meal tray of a client who has infectious diarrhea. The nurse empties the urinal of a client who has Clostridium difficile.

A standard toothbrush is more effective than a battery-operated toothbrush in decreasing plaque. Clean the tongue with the toothbrush or tongue scraper during oral hygiene. Floss the teeth at least three times each day. Have the client use mouthwash after brushing their teeth.

The tongue should be cleaned during oral hygiene to remove bacteria that can be found on the tongue.

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include? The top of the walker should be at the level of your wrist. When using the stairs, place the walker before taking a step. When holding the walker, bend your elbows 30° Take a step first before moving the walker.

The top of the walker should be at the level of your wrist.

Metabolic changes with an immobilized long term pt

Their nutritional needs will change. Pts will need their meals to be nutritionally dense. So no empty calories. Be mindful of weight gain and BMI. Reduction in overall muscle mass and metabolism. Hypercalcemia (high calcium in the blood) when pts are immobilized and are not doing weight lifting actives their bones can become a lot more brittle. -Pathological factors decrease in ↓GI motility -Constipation -Fecal impactions w/ pseudodiarrhea

Peak

Time at which a medication reaches its highest effective concentration

Onset

Time it takes for a medication to produce a response

When can restraints be used?

To ensure patient safety, when other methods are unsuccessful, and only when an order is obtained

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make? -Soak the feet prior to washing the feet. -Use hot water when performing foot care. -Use a towel to completely dry between the toes. -File the nail edges straight across with a file.

Use a towel to completely dry between the toes.

Implementation/ interventions

Use caring to reduce anxiety, promote comfort. Administer meds for symptoms before hygiene. Be alert for patient's anxiety or fear. Assist and prepare patients to perform hygiene as independently as possible. Teach techniques and signs of problems. Inform patients about community resources.

Ascending stairs with crutches

Using the railing when climbing stairs with crutches is the safest method. Strong leg should be next to railing Strong leg first then affected leg

descending stairs with crutches

Using the railing when descending stairs with crutches is the safest method. Affected leg should be next to railing Affected leg first then unaffected leg

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Washing the client in bed is less effective than taking a shower.

The nurse should perform personal hygiene tasks for the client. The client has a minor loss of strength on the right side of the body. The nurse should have the client remove clothing from the unaffected side first. Oral care is much easier for the client to perform than bathing.

When assisting the client with dressing, the unaffected arm is used first to place clothing on the affected side. When undressing, the clothing is removed from the unaffected side first, then the affected side.

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.) -Observe the client's lower extremities for indications of deep vein thrombosis. -Obtain a respiratory rate for one full minute. (breathing component) -Measure the client's temperature. -Check the client for bruising. -Obtain a blood pressure measurement. (circulation)

When completing the exposure component of the ABCDE priority setting method, the nurse should observe the client from head-to-toe for abnormalities. This includes the client's lower extremities for indications of deep vein thrombosis such as pain, edema, and erythema of the calf area. -An elevated temperature might indicate that the client has a current infection or other inflammatory process. -The nurse should monitor the client for manifestations of bleeding such as bruising or abdominal distention in the exposure component of the ABCDE priority setting method.

A nurse at a provider's office is reviewing the records of several clients. Which of the following clients should the nurse recommend as the priority for treatment? -A client who has a history of hypertension and requires a yearly checkup -A client who reports new chest pain -A client who reports increased joint stiffness due to arthritis -A client who has diabetes mellitus and needs dietary instruction

When using the acute vs chronic approach to client care, the nurse should recommend a client who reports new chest pain as the priority for treatment. The client might be experiencing a myocardial infarction, which could result in poor outcomes if not identified and treated immediately.

A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first? -Apply soft limb restraints to the client's wrists. -Administer an antianxiety medication to the client intramuscularly. -Cover the IV site with an elastic bandage. -Request a prescription for a central venous catheter.

When using the least restrictive/least invasive priority setting framework, the nurse should use the least restrictive or least invasive intervention before other more invasive or restrictive ones. Therefore, the first action the nurse should take is to cover the IV with elastic bandage in an attempt to prevent the client from pulling the IV out. An elastic bandage will hide the IV from the client's vision while at the same time allowing the nurse easy access to the site.

A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? -A client who is scheduled for an abdominal ultrasound -A client who needs a urine specimen sent to the lab -A client who has audible wheezing during respirations -A client who requests their routine pain medication

When using the urgent vs. nonurgent approach to client care, the nurse should determine that they should first see a client who has audible wheezing during respiration. This client's airway is partly compromised, and their condition could worsen quickly without urgent intervention.

side effect

an unwanted physical or mental effect caused by a drug Unintended, secondary effect

adverse effect

any undesirable effects that are a direct response to one or more drugs. more harmful & unexpected than side effects

Topical medications

applied directly to the area being treated (e.g., skin, eye, ear, nose), as are transdermal patches. In both cases, the medication is absorbed through the mucous membranes or skin in the area of application and moves into the blood through the capillaries in that area. -painless, caution with abrasions -provides local effects -short duration -check skin integrity

PRN

as needed

barrier restraint

barriers that limit movement

Anticoagulation

commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood to discourage thrombosis

drug action

describes how a drug produces changes within the body

drug absorption

entrance of a drug into the bloodstream from its site of administration

STAT

give immediately (within 30 minutes)

Number one way to prevent the spread of infection.

hand hygiene

Excretion

how the drug exits the body

Allergic reaction

hypersensitivity reaction develops when the body perceives a medication as a foreign substance (allergen), which then stimulates an immune response. a type of adverse drug event.

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage? -Lateral -Supine -Prone -Fowlers

in the prone position to promote postural drainage. -lateral to reduce pressure injuries - supine allows most comfort - fowler's for lung expansion

synergistic effect

interaction of two or more medicines that results in a greater effect than when the medicines are taken alone EX-BP medication along with diuretics and vasodilators work together to control bp when one medication isn't enough.

Intravenous route (IV)

most rapid rate of absorption because the medication is directly injected into the circulatory system through the client's vein. intravenous medications are not affected by the same factors that affect absorption of medications administered through the other routes.

drug distribution

passage of a drug from the blood to the tissues and organs of the body

seclusion aa a restraint

placing the client by themselves to prevent harm to self or others

Mobility

the ability to move freely, easily, rhythmically, and purposefully in the environment, is an essential part of living.

A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's airway and breathing status. Which of the following assessments should the nurse perform next? -Body temperature (exposure) -Abdominal contour (exposure) -Skin integrity (exposure) -Blood pressure

the nurse should determine to next assess the client's circulatory status after airway and breathing status. Indicators of circulatory function can include taking a blood pressure, checking peripheral pulses, and measuring capillary refill time.

Duration

the period of time for which the medication maintains its therapeutic effects.

half life

the time it takes for the medication to fall to half its strength through excretion

toxic effect

when the body is unable to metabolize and excrete a medication. The remaining medication may reach toxic levels and cause deleterious and sometimes irreversible damage to organs. Older adults and those with impaired cardiac, liver, and kidney function are at high risk for developing medication toxicities.

Fall Assessment Tools

• Assessment of a patient's risk factors for falling is essential in determining specific needs and developing targeted interventions to prevent falls. -Morse Fall Scale: used at Community Hospital and IU Health Hospitals -Hendricks II Fall Risk Scale -John Hopkins Fall Risk Scale -Humpty Dumpty in Pediatric Patients

Bathing Order/Technique

• Bathe using distal to proximal strokes - promotes venous return • Order: 1. face (starting with eyes) 2. arms from distal to proximal 3. hands/fingers 4. Chest/Abdomen 5. legs from distal to proximal 6. feet/toes 7. Perineal care 8. Back 9. Buttocks

Purpose of Bathing

• Cleansing the skin • Stimulation of circulation • Improve self-image • Reduction of body odors • Promotion of Range of Motion

Safety Guidelines

• Communicate clearly with team members. • Incorporate patient's priorities. • Move from the cleanest to less clean areas. (perineal care/ eye care) • Use clean gloves for contact with nonintact skin, mucous membranes, secretions, excretions, or blood. • Test the temperature of water or solutions. • Use principles of body mechanics and safe patient handling. • Be sensitive to the invasion of privacy.

Evaluation

• Evaluate during and after each intervention .• Observe for changes in patient's behavior. • Consider the patient's perspective. • Often it takes time, repeated measures, and a combination of interventions for improvement. • Expected outcomes met? • Patient's expectations met?

Hospital Acquired Conditions include:

• Foreign body retained • Air embolism • Blood incompatibility • Stage 3 & 4 pressure injuries • Falls/Trauma • CAUTI • CLABSI • Poor glycemic control • Surgical site infections

Nursing Process: Planning

• Goals and outcomes -Partner with the patient and family -Measurable, achievable, individualized • Set priorities based on assistance required, extent of problems, nature of diagnoses • Teamwork and collaboration -Health care team members -Family -Community agencies

hygiene

• Hygiene impacts patients' comfort, safety, and well-being • Hygiene includes cleaning/grooming activities to maintain cleanliness and appearance • It is the nurses' responsibility to provide the patient with the opportunity for hygiene

Oral Hygiene: Unconscious Patient

• Keeping the mouth open 1.Use a padded tongue blade to open the patient's mouth and separate the upper and lower teeth 2.Never place your hand in the patient's mouth or open with your fingers. Oral stimulation often causes the biting -down reflex and serious injuries can occur.

Patient Problems related to medication administration

• Knowledge deficit regarding drug therapy due to unfamiliarity with information resources • Noncompliance regarding drug therapy due to limited economic resources (or health beliefs) • In effective management of therapeutic regimen due to complexity of drug therapy (or knowledge deficit). • Impaired swallowing due to neuromuscular impairment

Types of Physical Restraints

• Less Restrictive -Self-release lap belt -Posey Bed • More Restrictive -Lap belt patient cannot release -soft wrist restraints

Linen Care

• Only use what you need • Avoid shaking used linen • Keep used linen away from your uniform • Do not place linens on the floor • Dispose of used linens in the appropriate receptacle

Things to keep in mind with restraints as they require on-going monitoring?

• Patient Comfort (minimum q2hr) - Food - Hydration - Toileting - ROM • Patient Safety/Signs of Injury (minimum q15minutes) - Vital Signs - Circulation Checks - Skin Integrity- Correct Application •Continuation/Discontinuation - Mental Status - Cognitive Functioning - Level of Distress/Agitation

Criteria to Discontinue Restraints

•Able to follow directions •Able to participate in care •Able to participate in program •Behavior improves/changes •Lines tubes discontinued •Positive response to medication intervention

back injuries causes

•Improper lifting/bending •Increase force/stress •Repetitive Motion/twisting •Poor posture• Poor job design •Deconditioned/poor physical fitness

Fall Prevention Methods

•Key is to individualize. Examples include: -Rounding -Wrist-bands/socks -Bed low/wheels locked -Gait belts -BSC -Assess condition/correct use of ambulatory aids -Assess environment

clinical judgement

•OUTCOME of critical thinking and clinical decision making •Requires several steps to make decisions related to care based on the best available evidence Both (clinical judgement and critical thinking) are required for safe patient care, evidence-based practice, and are required for all patient interactions!

critical thinking

•Systematic and Logical •Cognitive Process •Involves analysis and interpretation of data

presentation for back injuries

•Use good ergonomics to prevent injury - Ex: Raise patient bed to working height •Lift Teams/Mobility Devices •Encourage the patient to help as much as possible •Bend at knees, stand close to the object to be moved •Refrain from twisting motions and bending at the waist •Push, don't pull •Self- care: Sleep, Nutrition, Exercise