NURS 3632 EXAM 2
A medication order reads: "K-Dur, 20mEq PO BID" When and how does the nurse correctly give this drug? 1. Daily at bedtime by subcutaneous route 2. Every other day by mouth 3. Twice a day by the oral route 4. Once a week by transdermal patch
Twice a day by the oral route
A client with a new ileal conduit asks the nurse when he needs to wear his appliance. What should the nurse tell the client? a) "The appliance must be worn after your meals." b) "You need to wear your appliance after you irrigate." c) "It is only necessary to wear your appliance at night." d) "You need to wear your appliance all the time."
"You need to wear your appliance all the time."
Diagnostic Statement/Analysis
(NANDA) the statement identifies areas of concern where nursing practice has the chance to assist the client to attain improved or increased wellness
Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation? a) Moderate amount of serous drainage on the surgical dressing b) Blood pressure of 100/70 mm Hg c) Temperature of 37.6°C (99.7°F) d) Urinary output of 20 mL/hr over 2 hours
Urinary output of 20 mL/hr over 2 hours
Evaluate
What was the result or response Use measurement in goal statement • Goal met? (Yes, No, or Partially) • Goal appropriate? • Goal continued (or modified)?
Nursing Intervention
carefully selected observations & actions to be applied under the scope and supervision of the R.N
The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure?(select all that apply) A: crush the enteric coated pill for mixing in a liquid B: flush open the tube with 60 mL of very warm water C: use the recommended procedure for checking tube placement in the stomach or intestine D: give each medication separately and flush with water between each drug E: lower the head of the bed to prevent reflux F: adjust the amount of water used if patient's fluid intake is restricted
use the recommended procedure for checking tube placement in the stomach or intestine give each medication separately and flush with water between each drug adjust the amount of water used if patient's fluid intake is restricted
Nursing Process from student perspective
• A - What do I find? • D - What do I think? • P - What do I want? • I - What do I do? • E - What worked (or didn't)?
Maslow's Hierarchy of Needs - Physiological Needs
• Airway • Breathing • Circulation • Nutrition & Hydration
Prioritization Strategies
• Airway - Breathing - Circulation • Safety - Infection, Physical, Injury • Pain • Education • Feelings • Which option is closest to Airway?
Maslow's Hierarchy of Needs - Safety and Comfort
• Protection from injury • Relief of Pain
Nursing Process
Assess first, diagnose, plan, implement, evaluation
Maslow's Hierarchy of Needs - Esteem
Autonomy
Maslow's Hierarchy of Needs - Self-actualization
Fulfillment
Evaluation
a reassessment of client response to intervention is necessary to determine the effectiveness of the plan
The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. "The enema will be given while I am sitting on the toilet." 2. "I should try and hold the fluid as long as possible after it isinstilled." 3. "I know that there will be some cramping after the enema administration." 4. "I should tell the nurse if cramping occurs during the instillation of the fluid."
"The enema will be given while I am sitting on the toilet." The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying (Sims') position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible since this will promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.
A clear liquid diet has been prescribed for a client. The nurse offers which item to the client? 1. Apple juice 2. Orange juice 3. Tomato juice 4. Ice cream without nuts
Apple juice A clear liquid diet consists of foods that are relatively transparent. The food items in options 2, 3,and 4 would be included in a full liquid diet Eliminate options 2, 3, and 4 because they are comparable or alike and are items allowed on a full liquid diet. Remember that a clear liquid diet consists of foods that are relatively transparent. Option 1 is the only food item that is transparent. Review food items allowed on a clear liquid diet and full liquid diet and the various test-taking strategies if you had difficulty with this question
A client with a colostomy asks the nurse about types of foods that may help to control diarrhea and cause leakage into the pouch. In order to avoid leakage, the nurse should instruct the client to consume: 1. Asparagus, beans, eggs, onions 2. Applesauce, bananas, rice, tapioca, yogurt 3. Fried foods, highly spiced foods, raw fruits and vegetables 4. Carbonated drinks, fruit juices, greasy and pureed foods
Applesauce, bananas, rice, tapioca, yogurt The foods that thicken stools are in option 2. The foods in option 1 produce odor. Food in options 3 and 4 loosen stool
The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? 1. Withdraw the catheter slightly and reinflate the balloon. 2. Remove the catheter and reinsert a new one that is 1size smaller. 3. Finish inflating the balloon; the discomfort is normal and temporary. 4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
Aspirate the fluid, advance the catheter farther, and reinflate the balloon. If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid should be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter should not be withdrawn slightly because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon should not continue to be inflated because the pain is not normal and will not go away. Note the strategic word, immediate. To answer this question accurately, it is necessary to know the proper procedure for inserting an indwelling urinary catheter. Visualizing the procedure will assist in eliminating options 1 and 3first. Choose correctly between the remaining two options, knowing that the balloon, not the catheter size, is causing the problem
Identify the purposes of a health care record.(Select all that apply). 1. Communication 2. Legal documentation 3. Reimbursement 4. Education 5. Research 6. Nursing process
Communication Legal documentation Reimbursement Education Research The primary purpose of the patient record is to help health care professionals from different disciplines (who interact with the patient at different times) communicate with one another. Communication fosters continuity of care. The records also provide information for other professionals, related to accreditation, credentialing, legal, regulatory and legislative, reimbursement, research, and quality activities
A client with a urinary catheter in place complains of discomfort in the bladder and urethra. What should the nurse do first? 1. Notify the physician 2. Milk the tubing gently 3. Check the patency of the catheter and tubing 4. Irrigate the catheter with prescribed solutions
Check the patency of the catheter and tubing This ensures drainage and prevents bladder distention and other complications. Patency of the catheter should be established before notifying the physician. Option 1:Assessment is necessary before consultation with the physician. Option 2: Patency of the catheter should be assessed first. This may be necessary if the catheter is clogged. This usually is required when the drainage is viscous rather than liquid. Option 4: Irrigation is avoided if possible because of the associated risk for infection
The nurse is assessing the urine of a client with a urinary tract infection. Which of these characteristics should the nurse assess for a patient with a UTI? 1. Clarity 2. Viscosity 3. Specific gravity 4. Glucose and acetone
Clarity Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Option 2,viscosity, is a subjective characteristic that is not measurable. Option 3, specific gravity, is measured in a lab and yields information related to fluid balance. Option 4, urine glucose and acetone levels, are not affected by urinary tract infections.
Assessment is the act of
Clinical Judgment
A nurse is teaching the client taking medications by inhalation about the advantages of a spacer device. The nurse tells the client that the spacer: 1. Disperses medication more deeply and uniformly 2. Reduces the frequency of medication use to only once per day 3. Requires coordinating timing between pressing the inhaler and inhaling 4. Totally eliminates the chance of developing a yeastinfection in the mouth
Disperses medication more deeply and uniformly
After abdominal surgery a client complains of pain. What action should the nurse take first? 1. Reposition the client. 2. Monitor the vital signs. 3. Administer the ordered analgesic. 4. Determine the characteristics of the pain
Determine the characteristics of the pain The exact nature of the pain must be determined to distinguish whether this is pain caused by the surgery or is from some other cause. • 1-3 This should be done later, but the first action would be to determine the nature of the pain. (Assess: first step in nursing process)
A nurse is caring for patients with a variety of nutrition related problems. Which problem eventually may require a patient to have a nasogastric feeding tube inserted? 1. Malabsorption syndrome 2. Difficulty swallowing 3. Nausea and vomiting 4. Stomatitis
Difficulty swallowing If a patient with difficulty swallowing does not respond to dysphagia diet (soft, blended, or pureed), there may be a need for the insertion of an NG tube. Enteral feeding can be administered to meet nutritional needs and minimize the risk of aspiration. It is contraindicated in option 3.Stomatitis, an inflammation of mouth usually is a temporary problem that responds to meds. Tube feed is not necessary
The nurse is beginning to administer oral medications to a client. The client states, 'I haven't taken that pill before. Are you sure it's correct?" The nurse rechecks the MAR and finds that the medication is scheduled to be administered. Which response is most appropriate? 1. It wouldn't be listed on this MAR if it wasn't prescribed for you 2. It's listed here on the MAR so you should take it 3. Go ahead and take it, and I'll check with your primary care provider about it 4. Don't take that pill yet. I will verify that the medication was ordered by your primary care provider
Don't take that pill yet. I will verify that the medication was ordered by your primary care provider
An elderly bedridden client reports being constipated but cannot understand why. What instruction should the nurse give to assist the client? 1. Decrease fluid intake before bedtime 2. Encourage bland and low-residue foods 3. Avoid beverages with caffeine 4. Drink hot liquids and increase intake of water and fruit juices
Drink hot liquids and increase intake of water and fruit juices Because of limited mobility, the client is already at risk for constipation. To promote bowel function, instruct the client to drink plenty of liquids, including fruit juices such as apple and prune The critical phrases are bedridden client and constipation. Use nursing knowledge of the common complications of immobility to allow you to select the teaching points and further prevent this complication of immobility
Maslow's Hierarchy of Needs Prioritization
From the base upwards 1. Physiological Needs 2. Safety and Comfort 3. Love and belonging 4. Esteem 5. Self-actualization
What is evidence based practice?
Gather and use information, and research (EVIDENCE) to perform actions that assist the client (PRACTICE)
The nurse teaches a client measures to avoid complications associated with urinary elimination. Which of the following indicates to the nurse that the expected outcome is achieved? The client: 1. Identifies symptoms of and measures to prevent urinary tract infection 2. Is able to perform perineal care by self 3. Maintains proper disposal of urinary output 4. Takes regular baths and appropriate personal hygiene measures
Identifies symptoms of and measures to prevent urinary tract infection Symptoms and ways of preventing an infection are crucial for a client to understand. Performance of perineal care independently and disposal of urinary output are not appropriate outcomes. Tub baths are to be avoided, especially in females, as they may increase the possibility of developing a lower UTI. Nursing Process - Evaluation involves assessing the attainment of goals. Teaching must always be evaluated. Recall that infections may be prevented by increasing consumption of cranberry juice, voiding frequently, and cleansing from front to back
A 30-year-old client arrives at the clinic for a diagnostic work-up related to chronic right hip pain. The nurse teaching the client about chronic pain would include which of the following items? 1. It is an unusual occurrence for younger adults. 2. It lasts longer than 12 months in duration. 3. It can be difficult to treat effectively. 4. It is often associated with nerve damage
It can be difficult to treat effectively. Chronic pain may be difficult to treat. It persists for 6 months or longer 6 months or longer and can affect adults of all age groups. Etiology is often difficult to determine; nerve damage is one of many causes
A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops four times a day. The nurse should administer the medication by gently dropping the medication onto which of the following areas? 1. Center of the cornea 2. Sclera by the inner canthus 3. Sclera by the outer canthus 4. Lower conjunctival sac
Lower conjunctival sac Eye drops are placed in the lower conjunctival sac to prevent damage to the cornea and to facilitate coating the eye with the medication. The drop are not applied directly to the cornea or to the sclera near either the inner or outer canthus
Charting by exception is used by a hospital for documentation. Using this format, how would the nurse document routine morning care in the narrative notes? 1. Morning care completed 2. Morning care completed. Client tolerated well 3. Morning care completed by client 4. Not necessary to document morning care if uneventful
Not necessary to document morning care if uneventful Charting by exception is a form of documentation in which notations are made if there was an exception to the standard of care or the client's response to care. All other options are normal and are therefore not necessary to include in documentation using this format
The nurse determines that when a female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound, and is informed that she demonstrates signs of breast malignancy, the client is at risk for experiencing sensory... a. Overload b. Stimulation c. Adaptation d. Deprivation
Overload When the reticular activating system (RAS) is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action
The plan of care for a client exhibiting signs of sensory deprivation includes incorporating tactile stimulation. Which nursing intervention will provide tactile simulation? a. Providing a back rub with morning and evening care. b. Delivering meticulous oral care. c. Orienting the client to his environment. d. Placing a calendar and clock on the client's bedside table
Providing a back rub with morning and evening care. Tactile stimulation includes back rubs, foot soaks, turning and repositioning, passive range-of-motion exercises, hugs, and touching. Orienting a client to his environment is cognitive input. Placing a calendar and clock on the client's bedside table is visual stimulation. Oral care is gustatory and olfactory stimulation
A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action? 1. Quickly insert the tube. 2. Notify the physician immediately. 3. Remove the tube and reinsert when the respiratory distress subsides. 4. Pull back on the tube and wait until the respiratory distress subsides
Pull back on the tube and wait until the respiratory distress subsides During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, excessive coughing, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options 2 and 3 are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may belikely that the tube has entered the bronchus
A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a a. Report b. Record c. Consultation d. Referral
Report Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient's record or chart is a confidential, permanent legal document consisting of information relevant to his or her healthcare. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider)
A client has had chest surgery and is using patient-controlled analgesia (PCA) with morphine to manage the pain. The nurse determines that it is most important to intervene if observing which of the following signs? 1. Respiratory rate 24 breaths per minute. 2. Respiratory rate 8 breaths per minute. 3. Sleeping, but arousable. 4. Comfortable when reading a book but uncomfortable when ambulating to the bathroom
Respiratory rate 8 breaths per minute The patient who is breathing 8 breaths/minute is experiencing a potentially life-potentially life-threatening side effect of the analgesia. This is the highest priority for the nurse: ABCs. A RR of 24 may indicate pain and pt may need additional teaching about PCA use, but this is a lesser priority than the low RR. It is anticipated that pt may have more pain with ambulation. Sleeping but arousable is an expected response
The nurse is providing instructions to a nursing assistant regarding care of an older client with hearing loss. The nurse tells the assistant that clients with a hearing loss: 1. Are often distracted. 2. Have middle ear changes. 3. Respond to low-pitched tones. 4. Develop moist cerumen production
Respond to low-pitched tones Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options 1, 2, and 4 are not accurate.
How to make nursing intervention?
Show what action you will take Avoid monitor Use active verbs - assist, feed, bathe, examine, measure, record, demonstrate, collaborate, teach, encourage, listen, etc
A client is scheduled for a colonoscopy and the physician orders a tap water enema. In which position should the nurse place the client? 1. Sims' position 2. Back-lying position 3. Prone 4. Mid-Fowler's position
Sims' position To take advantage of the anatomic position of the sigmoid colon and the effect of gravity, the client should be placed in a left Sims' or left side-lying position for the enema. Options 2, 3, 4: These positions does not facilitate the flow of fluid into the sigmoid colon by gravity
Planning SMART Goal
Specific - what does the pt want to achieve Measure - how will you measure success, evidenced by Attainable - action oriented, will do what for how many times Realistic - can this happen, can it be completed on schedule Time - exact time and date to evaluate
How to build a nursing diagnosis?
State the need: What is the highest priority nursing problem? State the evidence: What are the signs and symptoms from assessment?
Maslow's Hierarchy of Needs - Love and belonging
Support systems
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a) Take a stool softener such as docusate sodium daily. b) Take a mild laxative such as magnesium citrate when necessary. c) Administer a tap-water enema weekly. d) Administer a phospho-soda enema when necessary
Take a stool softener such as docusate sodium daily
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reviews the patient's medical record. b. The student nurse reads the patient's plan of care. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient
The student nurse shares patient information with a friend.
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching focusing on foods high in which vitamin that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E
Vitamin B12 Vegans do not consume any animal products. Vitamin B12 is found in animal products and therefore would most likely be lacking in a vegan diet Vitamins A, C, and E are found in fresh fruits and vegetables, which are consumed in a vegan diet
What observation should the nurse instruct the client with an ileostomy to report immediately? a) absence of drainage from the ileostomy for 6 or more hours b) temperature of 99.8° F (37.7° C) c) passage of liquid stool from the stoma d) occasional presence of undigested food in the effluent
absence of drainage from the ileostomy for 6 or more hours
The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine? a) an orange, raisin bran and milk, and wheat toast with butter b) orange juice, breakfast pastries (doughnut and Danish), and coffee c) corn flakes with sliced banana, milk, and English muffin and jelly d) eggs and bacon, buttered white toast, orange juice, and coffee
an orange, raisin bran and milk, and wheat toast with butter
At what point should the nurse perform the first of the three checks of medication administration? 1. after retrieving the drug from the drawer of a drug cart 2. when reviewing the client's medication administration record 3. as the nurse reaches for the drug package or container 4. at the beginning of the shift
as the nurse reaches for the drug package or container
A nurse is administering a pain medication to a patient, Mr. Brown. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identity by performing which action? 1. asking the patient his name and birthdate 2. reading the patient's name on the sign over the bed 3. asking the patient's roommate to verify his name 4. asking "Are you Mr. Brown?"
asking the patient his name and birthdate
A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube? 1. avoid crushing sustained release pellets 2. add medications to the formula 3. use cold water when mixing powdered medications 4. mix all the medications together in 15 mL of water
avoid crushing sustained release pellets
Mrs. Hall has an order for acetaminophen, 650 mg, q 6hours PRN for pain. The nurse notes that according to Mrs. Hall's chart, she is allergic to acetaminophen. The order for the medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? 1. administer the medication; the doctor is responsible for medication administration 2. call Dr. Long and ask that the medication be changed 3. ask the supervisor to administer the medication 4. ask the pharmacist to provide a medication to take theplace of acetaminophen
call Dr. Long and ask that the medication be changed
A nurse discovers that a medication error occurred. What should be the nurse's first response? 1. record the error on the medication chart 2. notify the physician regarding course of action 3. check the patient's condition to note any possible effect of the error 4. complete an incident report, explaining how the mistake was made
check the patient's condition to note any possible effect of the error
ADPIE - Diagnose
choose from the list of NANDA problems
Which nursing intervention for catheter careshould have the highest priority? a) irrigating the catheter with several milliliters of normal saline solution b) cleaning the area around the urethral meatus c) changing the location where the catheter is taped to the client's leg d) clamping the catheter periodically to maintain muscle tone
cleaning the area around the urethral meatus
ADPIE - Assess
collect data & analyze it for patterns
ADPIE - Implement
deliver the care, based on evidence
A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer the medication? 1. during the post-operative period 2. doses administered as needed for pain relief 3. one dose administered immediately 4. doses routinely administered as a standingorder
doses administered as needed for pain relief
SMART Goal
each goal contributes to improve the client experience and must include SMART criteria (Specific, Measurable, Attainable, Relevant/Realistic, and Time-based) to allow the student to analyze effectiveness of interventions
ADPIE - Plan
make a SMART Goal & a plan to intervene
ADPIE - Evaluate
measure progress towards the goal
A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case? 1. inform the charge nurse about the client's absence 2. leave the medication at the client's bedside table 3. return the medication to the medication cart or medication room 4. inform the physician about the client's absence
return the medication to the medication cart or medication room
The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? 1. standing 2. single 3. stat 4. PRN
standing
A client has been admitted to the health care facility with an asthmatic attack. The medication order for the client indicates that the nurse administer the prescribed medication immediately. Which standard abbreviation indicates immediate medication? 1. t.i.d. 2. q.d. 3. stat 4. q4h
stat
Assessment Data
subjective & objective data from the nursing assessment is clustered to identify patterns in the client experience
When the nurse administers the morning dose of medication during the evening, which of the rights of medication administration has she failed to follow? 1. medication 2. client 3. dose 4. time
time
A client with COPD has been prescribed an inhaled bronchodilator. Which technique should the nurse implement in order to ensure safe and complete delivery of the prescribed medication? 1. provide oxygen therapy 30 minutes prior toadministration 2. place inhaler as deeply into the client's mouth as is comfortable 3. provide multiple puffs of the medication in rapid sequence 4. use a spacer or extender with the MDI
use a spacer or extender with the MDI
