nursing

The nurse is educating a client with primary adrenal insufficiency (Addison's disease) on diet and nutrition changes needed to manage the client's disease. Which statement by the client would indicate that the nurse's instructions have been effective?

"I should increase sodium and fluids, but limit potassium." Addison's disease develops when the adrenal glands are damaged. They don't make enough of the hormones cortisol and aldosterone. Besides corticosteroid medications, dietary changes include increased sodium, decreased potassium, and adequate fluid intake.

After a high school athlete sustains a fractured femur during a competition, a full leg plaster cast is applied. When the nurse provides discharge instructions to the athlete and their parents six hours later, which statement by the athlete indicates a need for further education?

"I should walk around on my cast as soon as I get home." Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions include: 1 Keep the limb raised on a soft surface, such as a pillow, for as long as possible in the first few days. This will help any swelling to go down. 2. Keep the cast dry. If the plaster gets wet, it weakens and is unable to support the bone. 3. Do not put anything into the cast to relieve itching. This can damage the skin and cause an infection. A hair dryer set on cool or an ice pack over the itchy area can help. 4. Immediately report any pain, tingling, or numbness, or if the toes turn blue or white.

The nurse is educating a client with a new diagnosis of bursitis of the elbow (olecranon bursitis). Which statement by the client would indicate an understanding of proper treatment?

"I'll apply moist heat three times a day." Bursitis is a painful condition that affects the small fluid-filled sacs (bursae) that cushion bones, tendons, and muscles near the joints. The most common locations for bursitis are the shoulder, elbow, and hip. The olecranon bursa is a thin fluid-filled sac located at the bony tip of the elbow (the olecranon). Moist heat dilates the blood vessels and decreases inflammation. The client should be instructed to apply the heat for 20 minutes tid. Treatment also involves taking NSAIDs and resting the joint by eliminating movements or exercise that can irritate the bursa. Resting elbows on a hard surface can cause bursitis. While ice can be used for the first 48 hours, dry ice is never used on a body surface.

The nurse prepares a 5-year-old girl for a pre-operative IV insertion. Which statement is most appropriate to reduce the child's anxiety?

"Tell me if this feels more like a pinch or a bug bite." Like all clients, children should be prepared for procedures. Educate them, but don't suggest that there will be pain. Allow them to decide if there is discomfort. Ignoring an explanation or trying to distract the child is rude and interferes with the child's sense of trust.

Oral temp.

-(blue) -Not considered "Core" -Affected by hot and cold -liquids and smoking. -Patient must be able to co-operate -Contraindicated in patients who have had oral surgery, breathe through their mouth, or are confused or unconscious!

Factors affecting Temp.

-Circadian Rhythms -Developmental level -Sex -Environmental temperature -Exercise -Emotions and stress -Drugs and Disease

Oral temperature is approximately:

1 higher than axillary, and 1 lower than rectal.

A client with end-stage renal disease has opted for an arteriovenous (AV) fistula for long-term treatment with hemodialysis. Following the surgical creation of the AV fistula, when will the client be able to use it for hemodialysis? A. 2-3 weeks B. 4-6 weeks C. 2-3 months D. 4-6 months

2-3 months An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis

What is the smallest IV catheter that can be used to give a blood transfusion?

20- gauge, an 18- gauge is the preferred size for transfusion.

Which lab value indicates hypokalemia? A. 3.6 mEq/L B. 5.6 mEq/L C. 4.2 mEq/L D. 3.2 mEq/L

3.2 mEq/L The normal serum potassium (K) range is 3.5-5.0 mEq/L. For this question, the only correct option is 3.2 mEq/L. Hypokalemia is associated with an increased risk of cardiac arrhythmias. The nurse should report this result immediately and be prepared to administer a potassium supplement.

A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client's intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client's intake?

540 mL Intake is considered any food that is liquid at room temperature. The client's intake is 8+6+4=18 fluid ounces. 1 fluid ounce = 30 mL, so 18 ounces = 540 mL. Pudding is not included, because it is not a liquid at room temperature. Liquids include coffee, tea, milk, soft drinks, water, gelatin (jello), broth, ice cream, popsicles, sorbet, and nutritional supplement drinks, such as Ensure. Note: Ice chips melt to half their volume. For example, if the client receives 8 oz. of ice chips, record the intake as 4 oz.

Normal body temperature

96.8F - 100.4F 36C - 38C

After emptying a Jackson-Pratt drainage bulb, how does the nurse reestablish negative pressure in the system?

A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This causes fluid around the surgical site to flow into the drain.

When instructing a patient with Addison's disease about nutrition, the healthcare provider should NOT recommend which of the following dietary modifications? A. A high-protein diet B. A diet with adequate caloric intake C. A restricted-sodium diet D. A diet high in grains

A restricted-sodium diet A patient with Addison's disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss. The patient should be instructed to maintain adequate caloric intake with a diet high in protein and complex carbohydrates, including grains.

The nurse is educating the parents of a young child with a recent diagnosis of cystic fibrosis. The nurse tells the parents that the child will be at risk for which vitamin deficiencies?

A, D, and K People with cystic fibrosis have trouble absorbing fats, which means they also have trouble absorbing vitamins that need fat to be absorbed — A, D, E, and K. These fat-soluble vitamins are critical to normal growth and good nutrition. B-complex, C, folic acid, biotin, and pantothenic acid are water soluble and easily absorbed.

Which meal best promotes healing for a patient recovering from a burn injury? A.Chicken breast, strawberries, milk B. Peanut butter and jelly sandwich, banana, tea C. Pasta marinara, garlic bread, ginger ale D. Pork chop, fried potatoes, coffee

A. Chicken breast, strawberries, and milk The meal with the best nutrition for wound-healing includes protein and vitamin C. Foods that have low nutritional value, such as sugar or those with low or no calories, are not beneficial.

A nurse is giving discharge instructions to a 45-year-old male who has been hospitalized for chronic pancreatitis. Which of these statements should be a critical part of the dietary counseling for this patient? A. avoid alcohol entirely B. do not take multivitamins or calcium supplements C. eat foods high in fat and cholesterol D. drink plenty of fruit juices

A. avoid alcohol completely

The nurse is planning care for a client with status-post CVA and limited mobility. The client is scheduled for occupational therapy at 10:00 a.m. and physical therapy at 2:00 p.m. What times are most appropriate for nursing care? AM care at 0800, PM care at 1600 AM care at 0900, PM care at 1600 AM care at 0800, PM care at 1500 AM care at 0900, PM care at 1500

AM care at 0800, PM care at 1600 Clients who are recovering from a serious condition and have limited mobility require extra time. Not only do they need more time to prepare and to move but they also need more time to rest before and after therapy sessions. The only correct option is to provide AM care at 0800 and PM care at 1600.

Before administering a soap suds enema, which position is appropriate for the client?

Sims To receive an enema, the client should be in the Sims position. The client lies on their left side, with the right leg flexed forward. This position facilitates the flow of the enema solution into the rectum and colon. Supine position is lying horizontally with the face and torso facing up. Prone position is lying horizontally with the torso down and the head turned to the side. Lithotomy position is lying on the back with hips and legs flexed 90 degrees.

Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate?

Administer the bolus as prescribed. Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. According to current American Society for Parenteral and Enteral Nutrition, enteral feedings can be administered with a residual up to 500 mL; however, individual HCP orders should be followed. signs of feeding intolerance include abdominal distention and/or pain, constipation, nausea, vomiting, and sense of fullness.

After your patient dies, the patient's family gathers at the bedside and asks you to step out while their clergy performs a religious rite for the deceased. As the patient's nurse, what is your most appropriate course of action?

Allow the ceremony and step out of the room. The nurse should honor the family's wishes and culture and leave the room. Most hospitals do not have a policy that prohibits religious rites or ceremonies at the time of death. Remaining in the room shows disrespect and lack of trust at a time of grieving.

The nurse is instructing a client with a new sigmoid colostomy about caring for the colostomy. The nurse explains that to best regulate the bowel, the client should perform colostomy irrigation at the same time every day. What is the optimal time for doing this?

An hour after a meal Colostomy irrigation is a way to regulate bowel movements by emptying the colon at a scheduled time. It distends the bowel to stimulate peristalsis and promote evacuation. Patients who had a permanent colostomy made in the descending or sigmoid portion of the colon and had regular bowel function before having the colostomy are good candidates for irrigation. It's most effective when performed about an hour after a meal, when the colon is most likely to be full.

An unconscious trauma patient is admitted to the ICU. The health care provider (HCP) prescribes enteral feedings via the nasogastric (NG) tube. Before the nurse administers a formula feeding, which finding by the nurse requires IMMEDIATE action?

Breath sounds are decreased in the right lower lobe. A major risk associated with enteral feedings is aspiration, resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the most common site. Clients should be positioned at a minimum of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should verify tube placement before each feeding, or every four to eight hours if the client is receiving a continuous feeding. Residual volumes of up to 100 mL are acceptable. Urine output of less than 30 mL/hr should be reported to the HCP. Decreased bowel sounds should be monitored but are not an immediate concern.

Fahrenheit to Celsius conversion

C = (F - 32) x 5/9

What is the difference between cardioversion and defibrillation?

Cardioversion is 50-200 joules and Defibrillation is 200-360 joules

One of the nurse's patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient?

Check the area where the tape is applied qd. The nurse should change the tape at the patient's nose every day and assess the skin for breakdown. Tubing and feeding items are replaced every 24 hours. The NG tube is flushed with warm water to avoid burning the patient or causing discomfort. The bed is placed in the high Fowler's position for tube feedings.

A pediatric patient has been diagnosed with right lower lobe pneumonia. Upon auscultation of this lung field, the healthcare provider should expect to hear which breath sounds?

Crackles Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound that is seen in airway constriction that can lead to complete closure. Rhonchi are heard in mixed-issue airway constriction and secretions.

Which of these typically does not factor into a patient's perception of and response to pain? A. support system B.past experience with pain C. fatigue D. gender

D. Gender

To measure an adult client's apical heart rate, where does the nurse place the stethoscope? Second left intercostal space at midclavicular line Fourth left intercostal space at midclavicular line Third left intercostal space at midclavicular line Fifth left intercostal space at midclavicular line

Fifth left intercostal space at midclavicular line FILM = Fifth Intercostal Midclavicular Line. The apical pulse is auscultated with a stethoscope over the chest where the heart's mitral valve is best heard. For adults, the point of maximum pulse is the fifth left intercostal space at the midclavicular line. In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line.

Despite frequent turning and skin assessment, occasional urinary incontinence has caused a bedridden resident to develop a reddened and tender area on the coccyx. The resident weighs 192 pounds. Which pressure-relieving device should be used for the client?

For clients who weigh less than 250 pounds, an alternating pressure overlay is the best choice because it is liquid resistant. It has compartments that alternately inflate and deflate to relieve pressure. Foam and sheepskin surfaces are not appropriate for clients with urinary incontinence. A low air loss bed is ideal but expensive, and it can cause hypothermia if not carefully monitored.

A patient with a total hip replacement requires certain equipment for recovery. Which of the following will assist the patient with activities of daily living (ADL)? A. Recliner B. TENS unit C. Abduction pillow D. High-seat commode

High-seat commode A high-seat commode keeps the hip higher than the knee. A recliner is helpful because it prevents 90° flexion, but it is not necessary for activities of daily living (ADL). A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management, and an abduction pillow is used to prevent hip adduction and possibly dislocation of the prosthesis, but neither are part of ADL.

A nurse working at a community health fair is administering intramuscular injections of influenza vaccine. Which injection technique will avoid leakage into subcutaneous tissue? I.

Injection by the Z-track method The Z-track injection method avoids leakage into subcutaneous tissue. Pull the client's skin downward or upward, and inject the vaccination (or medication) at a 90-degree angle before releasing the skin. Aspiration is done to assure that the injection is not going into a vein or artery. Massaging the injection site can introduce the material into subcutaneous tissue. A 45-degree angle is incorrect.

A client comes to the clinic, complaining of severe gastrointestinal distress. Which abdominal physical assessment step does the nurse do first? Palpation Inspection Percussion Auscultation

Inspection The correct sequence for physical assessment of the abdomen is as follows: 1. Inspect. 2. Auscultate. 3. Percuss. 4. Palpate. Remember this sequence with the phrase "I Am a People Person." The order is different from the physical assessment of the body systems, for which you inspect, then palpate, percuss, and auscultate.

A primigravida client comes to the prenatal clinic after missing three periods. After her pregnancy has been confirmed, the client tells the nurse that her last period started on June 10. Using Naegele's Rule, what is the client's estimated date of delivery (EDD)?

March 17 According to Naegele's Rule, the estimated date of delivery (EDD) is calculated by subtracting 3 months from the first day of the normal menstrual period (June 10 - 3 months = March 10) and then add 7 days. (March 10 + 7 days = March 17). The other dates are incorrect. NOTE: EDD replaces the former term, estimated date of confinement (EDC)

A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client? Apply a hydrocolloid dressing. Do a wet-to-dry dressing change. No dressing is necessary. Cover with sterile gauze.

No dressing is necessary. Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loss, it should remain in place. Unless the nurse is a certified wound specialist, removal or debridement of eschar should be performed by a health care provider (HCP). The other dressings are not indicated.

The nurse is educating a client who is scheduled for surgery for a descending colostomy. Which type of stool should the client expect after the surgery?

Semi-formed to formed The stool of a descending or sigmoid colostomy is semi-formed to formed, because much of the water has already been absorbed. The stool is firmer than that of a transverse colostomy and does not contain caustic enzymes. Elimination may occur at regular, predictable intervals after a certain amount of stool has collected in the bowel above the colostomy. Spilling can happen between bowel movements, because there is no anus to hold it back. Many people choose to wear a lightweight, disposable pouch for security.

Which of the following assessment findings is consistent with an extracellular fluid volume deficit?

Oliguria Oliguria is a sign of an extracellular fluid volume deficit. Extracellular fluid is the body fluid not contained within individual cells. It constitutes about 20% of our body weight and includes blood plasma, lymph, spinal cord fluid, and the fluid between cells. Importantly, this fluid isn't just water; it contains electrolytes and other essential solutes. Common causes of oliguria are blood loss, vomiting and diarrhea, polyuria, excessive sweating, and burns. The other answer options are not related to fluid deficit or hypovolemia

Of the following positions, which one facilitates maximum air exchange? A. othropneic B. High fowler's C. trendelenburg D. Lithotomy

Orthopneic- allows for the most lung expansion. High Fowler's can help, but it isn't as effective as the orthopneic position. Trendelenburg is used for hypotension or low cardiac output. Lithotomy is used for vaginal examinations and childbirth.

During assessment, the home health nurse learns that the client has a fecal impaction. Before proceeding to manually remove the stool, what is the nurse's PRIORITY? Advise the family to increase the client's fluid and fiber intake. Give an analgesic or sedative to make the client comfortable. Teach family members to perform the disimpaction process. Recall that cardiac dysrhythmias are a possibility.

Recall that cardiac dysrhythmias are a possibility. A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time. Treatment of a fecal impaction includes administrating an enema to soften the stool to produce a bowel movement, or manually removing the impaction. With a lubricated glove, insert the index finger into the rectum to break up the hardened stool with a circular motion. Cardiac dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation.

when using the PQRST method of pain assessment what does S stand for?

S stands for the severity of pain felt by the patient. Try using a scale from 1-10 to help them describe how much pain they are in.

A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer?

Stage II. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed.

The nurse is providing discharge instructions to parents of a 3-year-old who was hospitalized for severe croup. In the event of a future croup attack, what non-pharmacological intervention can the parents do at home?

Take the child into a steamy bathroom. If their child develops croup at home, the parents should make steam by running a hot bath or shower in a closed bathroom. They can then take the child into the steamy room and let the child breathe the moist, humid air. This will liquefy and mobilize secretions. The parent should hold the child in an upright position and reassure the child. A dry room does not help loosen secretions. Crying can irritate and contribute to hypoxia.

A 10-year-old boy is admitted to the pediatric unit with a diagnosis of viral meningitis. He is experiencing a severe headache, a stiff neck, vomiting, photophobia, and drowsiness. The nurse can make him more comfortable by?

The first action should be to alleviate the photophobia by darkening the room. This may alleviate the child's headache also. Deep breathing can be useful but will not eliminate the discomfort of meningitis symptoms. Fluid balance is important but not the first priority. A large, soft pillow may place the neck in an awkward position and exacerbate the child's discomfort by stretching the meninges.

A client returns to the unit after abdominal surgery. While monitoring the client, the nurse observes a moderate amount of red blood on the dressing. The nurse will document this type of wound drainage as

The nurse will document this drainage as Sanguineous. The word comes from the Latin, meaning "blood." Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be cultured. The amount of drainage is generally documented as absent, scant, minimal, moderate, large, or copious. The presence and degree of odor can be documented as absent, mild, or foul. Foul odors can be indicative of an infection.

A client with chronic renal failure (CRF) is learning to perform peritoneal dialysis at home. The nurse instructs the client to warm the dialyzing solution to 37 degrees Celsius so that it will?

The rationale for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by preventing cold sensations, but this is a secondary reason for warming the solution. The other options are incorrect.

When taking the blood pressure of a client who is seated, which position must the client change so that the nurse can get an accurate measurement? A. Lean the head back. B. Sit up straight. C. Uncross the legs. D. Put down the phone.

Uncross the legs. The nurse should ask the client to uncross their legs because the position can compress blood vessels and affect the accuracy of the reading. The other positions do not affect circulation or the measurement.

A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of? constipation. bowel incontinence. diarrhea. fecal impaction.

fecal impaction. Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity

Contraindications for administering an enema include all of the following EXCEPT: A. suspected appendicitis. B. recent colon surgery. C. acute myocardial infarction. D. hypercalcemia treatment. .

hypercalcemia treatment. An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the treatment of hyperkalemia. Kayexalate can be administered either orally or as an enema. Sodium polystyrene sulfonate is not absorbed from the gastrointestinal tract. As the resin passes through the gastrointestinal tract, the resin removes the potassium ions by exchanging them for sodium ions. Recent colon surgery, acute myocardial infarction, and suspected appendicitis are contraindications for administering an enema. With elderly clients, enemas should be used with caution because of their higher risk of hyperphosphatemia, perforation, and sepsis.

The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site?

lower right quadrant

The Wong-Baker FACES® Pain Rating Scale can be used by all of the following EXCEPT

parents and caregivers

what are the four phases of pain in correct order?

transduction, transmission, modulation, and perception