Nursing Fundamentals -- Other

Assigning same nurse

Assigning the same nurses to a client should be encouraged to help promote and provide continuity of care and decrease client anxiety. It should be explained to the client that while this can be the goal, it cannot be guaranteed due to staffing considerations. A school-age client with a recent kidney transplant requests the same nurse every day. Which is the correct response by the nurse caring for the client? "This can be accomplished most days, but scheduling may make it difficult, depending on the length of your stay." This assures the client the request has been heard but that it may not be possible at all times. NOT: "The same nurse cannot care for you every day. This creates the opportunity to become too involved." This does not address the desire of the client to have a familiar face each day and may communicate a lack of care or concern. "It is more important for you to have a variety of nurses to ensure the best possible care." This does not address the desire of the client to have a familiar face each day, as well as not being a true statement regarding ensuring the quality of care. "Hospital policy requires that each day clients are assigned a new nurse to provide care." This does not address the desire of the client to have a familiar face each day, as well as not being a true statement, because hospitals do not have policies that call for different nurses caring for clients each day.

Hospice

Hospice care is end-of-life care provided to a client when the decision has been made that no further life-saving actions will be taken and when the provider has estimated that the client has fewer than six months to live. Hospice care is provided in 60- and 90-day periods of time and can be renewed if eligibility criteria continue to be met. Care is provided by RNs, social workers, chaplains, and volunteers. No treatment to extend life is provided. A home health nurse cares for an older adult client who has metastatic cancer. Which information provided by the family will exclude the client for hospice qualification? The client is using a cancer treatment that is still in clinical trials. Continuation of treatment aimed at extending life excludes a client from hospice care. Treatments to enhance quality of life can be continued. NOT: The client does not have an advanced directive for healthcare. It is not required that a client have an advanced directive for healthcare in order to qualify for hospice care. The client is prescribed narcotic pain medications for pain relief. Palliative care is provided in hospice, including pain medication. The client does not wish the family to know why hospice is needed. It is not required that a client inform the family of the reason for hospice in order to qualify.

Informed consent

Informed consent is the client providing agreement that a procedure has been fully explained to the individual, including risks, benefits, and alternative treatments, and that the client is willing to allow the procedure to occur. The provider is legally responsible to provide information to the client regarding the procedure in a language understood by the client. The provider who is responsible for performing the procedure is responsible for obtaining consent. Obtaining informed consent does not fall within the nursing duty; however, the nurse should be certain informed consent has been obtained prior to a procedure being performed. A nurse cares for a client who is scheduled for surgery. Which team member is responsible for obtaining informed consent for the procedure from the client? Provider performing the procedure The provider performing the procedure is responsible for explaining the procedure, with risks and benefits to the client, and obtaining informed consent. NOT: Anesthesiologist providing anesthesia The anesthesia team would be responsible for obtaining consent for the anesthesia portion of the procedure but not the procedure itself. Surgical first assistant for procedure The surgical assistant is not responsible or authorized to obtain informed consent. Circulating nurse in the operating room The nurse caring for the client is responsible for making sure informed consent has been obtained.

Transfers

In using a transfer board, the board serves as a bridge from one horizontal surface to another. This technique is reserved for clients who are not able to engage in bed mobility sufficient enough to move themselves. The team applies ergonomic and safety principles that minimize the risk for injury to self or client. Three or four team members should be involved in this type of transfer. https://www.youtube.com/watch?v=jaz80bqc150 The nurse uses a transfer board to move a client from a bed to a stretcher. The nurse includes what actions? Select All That Apply Position the client closest to the side of the bed where the stretcher will be placed. This prevents the need for the nurse or other team member to have to lean forward to reach the client, increasing the risk for back injury and reduces the distance the client must be moved. Placeboard halfway under side-lying client with a portion extending over the edge of bed. The slider board must be positioned under the client in a way that it serves as a bridge between the bed and the stretcher. Place a sheet on top of the sliding board, so it is between the board and client. A sheet is used to decrease friction between client and board. NOT: Place bed in lowest position to reduce injury to the client if a fall should occur. The bed should be placed at the ideal height for the team members doing the transfer. Putting it in a low position would increase the risk for back injury and complicate the transfer. Have two team members stand beside stretcher and pull the sheet toward the stretcher. The two team members should use the board to pull the client toward the stretcher, not the sheet. According to the Centers for Disease Control (CDC) healthcare workers experience some of the highest rates of musculoskeletal injuries from overexertion. Learning the principles of safe, ergonomically-sound techniques can protect the nurse, the client, and fellow healthcare team members. The nurse performs a client transfer. The nurse includes what principles to reduce musculoskeletal injury for self and other team members? Select All That Apply Have the person supporting client's heaviest weight coordinate the team's lifting effort. To avoid injury, the person with the heaviest load coordinates the efforts of team involved by counting to three prior to initiating the lift. Lift the client while maintaining a vertical position and avoiding twisting. Twisting increases risk of back injury and to avoid using back muscles the nurse keeps in a vertical position rather than bending at the waist. When preparing to lift, flex knees and keep about shoulder width or slightly wider. A broad base of support increases stability and prevents placing additional strain on the lower back. Flexed knees help the nurse apply leg muscles instead of the back. NOT: Instruct the client to lie still and let the healthcare team members do the work. The nurse should tell the client to assist where possible and offer specific instructions. This promotes client's independence while reducing the healthcare team members' workload. Position the client so that nurse's arms are extended fully when lifting the client. The nurse should position the client close to allow for flexion of the arms and assist in using the arm muscles rather than the back for lifting.

Red alert (Fire alarm)

The nurse knows the appropriate immediate actions should a fire occur on the unit. The acronym "RACE" can be used to help remember the steps: R—Rescue and remove. A—Activate the alarm. C—Confine the fire. E—Extinguish. The nurse takes which action first after noticing a small, contained fire in a client's trash can? Remove the client and others in danger. The priority is to reduce the risk of harm to the client and others. NOT: Pull the fire alarm to alert local fire authorities. Once emergency services have been activated and people are out of immediate danger, the nurse should attempt to extinguish the fire. Attempt to extinguish fire using proper equipment. The nurse should try to contain the fire as much as possible. The nurse should not enter the room if there is risk of injury. If deemed safe, closing doors and windows and turning off oxygen and electrical equipment should be done. If safe to do so, turn off oxygen, close room door. The alarm should be activated prior to trying to extinguish the fire. The order for care in cases of fire follows the mnemonic RACE: Rescue Alarm Confine Extinguish/Evacuate Rescue and remove all clients in immediate danger. Activate the alarm. Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Extinguish the fire using an appropriate extinguisher if the fire is small, or evacuate if the fire is too large. A nurse prepares to rescue clients after a fire outbreak. Which action does the nurse take first? Remove clients in immediate danger. The order for care in cases of fire is RACE. The first step is to rescue and remove all clients in immediate danger. NOT: Activate the hospital's fire alarm. The order for care in cases of fire is RACE. The second step is to activate the alarm. Confine the fire to a central location. The order for care in cases of fire is RACE. The third step is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment. Extinguish the fire if possible. The order for care in cases of fire is RACE. The fourth step is to extinguish the fire using an appropriate extinguisher if the fire is small, or evacuate if the fire is too large. The order for care in cases of fire is to use the mnemonic RACE: Rescue Alarm Confine Extinguish/Evacuate Rescue and remove all clients in immediate danger. Activate the alarm. Confine the fire by closing all doors and windows and turning off oxygen and electrical equipment. Extinguish the fire using an appropriate extinguisher if the fire is small, or evacuate if the fire is too large. A nurse is the team leader on a unit where a fire occurs. The nurse rescues clients in immediate danger and activates the alarm. Which action does the nurse take next? Close all doors on the unit. The next step is to confine the fire. Closing all doors on the unit will confine the fire. NOT: Extinguish the fire. Extinguishing the fire if it is small is the last step to be followed when a fire breaks out. Evacuate the hospital. Evacuation of the entire hospital is likely not required for a small fire. Evacuate the unit. Evacuation of the unit is the third step after confining the fire if the fire is too large to be extinguished. When a red alert (fire alarm) is called, the nurse assists in clearing the hallways of equipment or obstacles, including stretchers, so that if the fire is not contained, the hallway is clear if an evacuation becomes necessary. The nurse closes all client doors until an evacuation is ordered, because this helps prevent the fire from spreading. Remember RACE: Rescue: The nurse removes clients from immediate danger, but only if safe to do so. Alarm: In this case, the alarm has already been activated. Contain: The nurse closes doors and, in some cases, turns off oxygen at the source in a room if instructed to do so. Evacuate: The nurse removes clients to a safe location, bringing portable oxygen and an emergency medical supply bag. A nurse is working on a medical floor when the fire alarm goes off and a red alert is announced throughout the hospital. Which actions does the nurse perform? Select All That Apply Close all the clients' room doors and any others in the hallway. The nurse closes all client doors until an evacuation is ordered, because this helps prevent the fire from spreading. Remove all equipment from the hallway in the event that an evacuation is necessary. When a red alert (fire alarm) is called, the nurse assists in clearing the hallways of equipment or obstacles, such as stretchers, so that if the fire is not contained, the hallway is clear if an evacuation becomes necessary. NOT: Turn off the main oxygen supply to all the client rooms. Only the charge nurse or another nurse directed by the charge nurse may shut off the oxygen supply to a room or zone (though any RN may shut off the oxygen source at the wall), and only after an assessment of clients requiring oxygen in that area. This is not generally done unless the supply cannot be turned off at the source in the room or in cases where the fire department orders it. Complete documenting in the electronic medical record and then turn off the computer station. It is inappropriate for the nurse to continue charting in the electronic medical record. The nurse pauses or closes the client record immediately and begins closing doors and clearing the halls. Nurses never assume an alarm is a drill, because this places clients and hospital staff at risk if a fire is nearby and spreads. Turn off the lights and unplug equipment in the client rooms. It is unsafe to turn off the lights and unplug equipment in the client rooms. Evacuation in the dark would be more difficult and unsafe. Some equipment is life-saving and cannot be unplugged without battery backup.

Ergonomics

Ergonomics is the study of the way people work. Other ergonomic considerations include not overextending to reach; lifting an item through the legs, not pulling with the back; adjusting chairs to prevent back strain, and taking frequent computer breaks to reduce eye strain and hand cramping The nurse using a sliding board to move a client from one place to another is an example of what? Ergonomics To ergonomically transfer a client, have the client help as much as possible. If a transfer device is available, use it to move the client. Ask for help if needed. NOT: Standard precautions Standard precautions are a combination of rules to reduce the risk of disease transmission by means of moist body substances (blood, bodily fluids except sweat, nonintact skin, and mucous membranes). Personal protective equipment Personal protective equipment is any type of protective gear worn to guard against physical hazards. Universal precautions Universal precautions assume that all blood and body fluids are infected with bloodborne pathogens. The correct answer is: Keep the elbow of the arm using the mouse directly next to the body. People who perform repetitive tasks often develop work-related musculoskeletal disorders. Ergonomics is the science of workplace tools and equipment designed to reduce worker discomfort, strain, and fatigue to reduce workplace injuries. When using a computer, the upper arms and elbows should be close to the body. The mouse should be located directly next to the keyboard so that it can be used without reaching. The nurse follows which ergonomic rule when using a computer workstation in a client's examination room? Keep the elbow of the arm using the mouse directly next to the body. When using a computer, the upper arms and elbows should be close to the body. The mouse should be located directly next to the keyboard so that it can be used without reaching. NOT: Move the monitor to one side so both the client and monitor are in view. When using a computer, the monitor should be positioned directly in front of the body so as not to twist the head or neck. Move the top of the screen to above eye level. When using a computer, the top of the screen should be at eye level or below so that it can be read without bending the head or neck down and back. Lean forward in the chair toward the computer screen. When using a computer, the trunk should be perpendicular to the floor. The nurse may lean back into a backrest, but not forward toward the computer screen.

Nurse role

The nurse has direct and frequent contact with the family and will act as an advocate in making certain that client and family issues and concerns are addressed in the meeting. The nurse can help to be certain the client and family understand the plan of care and medical options that are discussed. The nurse can then help to coordinate with designated providers to be certain an agreed-upon plan is followed. An infant client with Down syndrome has inoperable cardiac defects. The healthcare team holds an interdisciplinary care conference. Why is the nurse involved in this discussion? Select All That Apply As a liason for the client and family in order to coordinate care The nurse can be responsible for coordination of the care planned in moving forward to meet client and family needs. As an advocate to communicate the specific needs of the client Nurses are advocates for both the client and the family, and in a team meeting they can communicate needs the client or family may not be able to communicate. NOT: As an expert regarding needs of a client with a terminal illness Nurses are generally not experts regarding terminal illness. As a witness to the meeting and discussion of care needs There is no need for a specific witness. Documentation of the meeting with all involved will be placed in the client's record. As a provider of comfort for the family during this difficult time The nurse may in fact provide comfort for the family, but that is not the role of the nurse in this type of meeting.

Alcohol withdrawal

• Other than padding the rails, the other interventions are used to treat withdrawal, plan care, or guide treatment - not prevent injury. • (CIWA) The client in alcohol withdrawal has a very sensitive central nervous system that is overexcitable, potentially leading to seizures. • The most direct way to prevent the client from injury is to pad the bed rails because sometimes nursing and medical interventions do not prevent seizures. A client is admitted to the medical-surgical unit for acute alcohol intoxication. What does the nurse include in the care plan to best reduce the risk for injury? Initiate seizure precautions with padded bed rails. The primary concern is that the client may have seizures, regardless of other interventions. Padding the bed rails reduces the risk of injury. NOT: Complete the withdrawal assessment scale. The nurse completes an alcohol withdrawal scale to determine the client's level of overall physiological risk and to intervene appropriately. This does not directly address the client's risk of injury. Monitor for level of consciousness changes. Monitoring for changes is a required intervention; however, the client may incur injury before the nurse notes the cognitive alterations. Give the scheduled benzodiazepine. Giving the benzodiazepine is helpful for this client, but does not necessarily work toward fall prevention. Benzodiazepines are considered to increase fall risk.

abbreviations

IU for international unit is on the Joint Commission's official "do not use" abbreviation list. It can be easily confused with IV or 10, leading to possible medication errors. The requirement is to write "international units" or to calculate the dose in micrograms or milligrams instead.Vitamins can be measured by international units and by micrograms. In this case, 600 international units of Vitamin D is equal to 15 mcg. Other unapproved abbreviations include U for unit, QD and QOD or any version of it, trailing zeros or lack of leading zeros, MS, which can mean magnesium sulfate or morphine sulfate, and MSO4 and MgSO4 which are easily confused for one another. The nurse reviews a prescription for a client being treated for depression. The prescription reads, "Vitamin D 600 IU PO once daily." For which reason does the nurse question this prescription? IU is not an accepted abbreviation. IU is not an accepted abbreviation by the Joint Commission. The prescription needs to be clarified and rewritten. NOT: The dose should read "6,000 units." 600 international units of vitamin D is equal to 15 mcg, which is the recommended daily allowance for adults and a common supplement dose. PO must be written out as orally. PO is a common and accepted abbreviation. The administration time is not specified. The prescription administration time is specific enough. "Once daily" is generally given in the morning unless otherwise indicated but allows personal discretion about administration time when it is not time-sensitive. The nurse should call the health care provider to clarify the term units and rewrite as a verbal prescription. The use of u for unit is on the Joint Commission's official list of "do not use" abbreviations. U could be mistaken for 4, O, or cc. The requirement is to write units.Other unapproved abbreviations include IU, QD, and QOD or any version of it; trailing zeros or lack of leading zeros; MS, which can mean "magnesium sulfate" or "morphine sulfate"; and MSO4 and MgSO4, which are easily confused for one another. The nurse plans discharge teaching for a client with Type 1 diabetes being treated for a pulmonary embolism. After reviewing the prescription that reads "heparin 5,000 u subcutaneously twice daily × one week," which action does the nurse take? Contact the health care provider to clarify the heparin dose. The use of u in the prescription makes the prescription invaild. The nurse should contact the health care provider to clarify the prescription and rewrite as a verbal prescription using the word units. NOT: Check the client's international normalized ratio. PT and INR are not used to monitor heparin effects; aPPT is used for heparin. Checking lab values is not a priority at this time. Provide instruction to the client on self-injection technique. This client already takes insulin injections, so this teaching may not be necessary. The nurse should observe the client's technique to ensure it is appropriate, but the first action is to clarify the heparin prescription. Provide teaching about signs of bleeding and what to report. It is important to teach the client about signs of bleeding and what to report, but the priority action is to clarify the prescription for heparin, an anticoagulant. Correct documentation in the client chart includes drug name, dose, route, time, and date. Documentation of medications prescribed PRN must include the reason given (severe pain, anxiety, constipation, etc). Trailing zeros and lack of leading zeros are included on the Joint Commission's official "do not use" list. They can easily cause confusion and be misread. 1.0 looks like 10, and .6 mg could be read as 6 mg. The new graduate nurse appropriately informs the nurse preceptor when which examples of incorrect documentation are found in the electronic medication administration record? Select All That Apply Omeprazole 20 mg given at 1130 on March 4, 2018, for gastroesophageal reflux disease. This documentation is incorrect, as the route of administration is missing. Omeprazole, an acid reducer, is most often given PO but may be given IV for critically ill clients and for treatment and prevention of ulcers. Hydromorphone .6 mg IV given PRN for breakthrough pain rated 8/10, given at 2300, March 9, 2018. This documentation is incorrect due to the lack of a leading zero on "hydromorphone .6 mg." Lack of leading zero is prohibited by the Joint Commission. This could be read as 6 mg instead of 0.6 mg, showing that ten times the prescribed dose was given. NOT: Propranolol 40 mg PO given at 0810 on March 3, 2018. This documentation is correctly written. Acetaminophen 650 mg PO given PRN for headache pain rated 6/10 at 1900, March 5, 2018. This documentation is correctly written. Insulin aspart 6 units by subcutaneous injection LUQ, given at 0800, March 3, 2018. This documentation is correctly written. This prescription is invalid due to the use of QOD. The nurse should call the health care provider to clarify the frequency and rewrite the prescription as a verbal prescription. Q.O.D., QOD, qod, Q.D., QD, q.d., and qd are all on the Joint Commission's official "do not use" abbreviation list.These abbreviations are easily mistaken for each other, and the periods after Qs were occasionally mistaken for 1s, causing confusion. The Joint Commission requirement is to write out "every other day" or "daily." Other unapproved abbreviations include MSO4, MgSO4, and MS, IU for international units, u for a unit and trailing zeros or lack of leading zeros. The nurse reviews admission orders for a client with constipation. Which action does the nurse take for a prescription that states, "Methylnaltrexone 8 mg subcutaneous injection QOD in the morning starting today"? Call the health care provider to clarify the frequency and rewrite the prescription. The nurse should call the health care provider to clarify that every other day was meant, then rewrite the verbal prescription using that terminology.The health care provider should co-sign the verbal prescription within 24 hours. NOT: Administer this medication now and every other day. The notation QOD means "every other day," but this abbreviation is prohibited by the Joint Commission, and the prescription should be clarified with the health care provider before the nurse administers the drug. Prepare to administer this medication daily in the morning. The notation QOD means "every other day," not "every day." QD means "every day," but the use of both QD and QOD are prohibited by the Joint Commission. Call the health care provider because the medication is contraindicated. This medication is appropriate for this client. Methylnaltrexone, an opioid antagonist, treats constipation caused by opioid use and is given subcutaneously every other day. MSO4, MgSO4, and MS are all on the Joint Commission's official "do not use" abbreviation list. They can be easily confused with one another and are not acceptable abbreviations. The health care provider should clarify and provide a new prescription.Other unapproved abbreviations include IU for international units, u for a unit, QD, and QOD or any version of it, and trailing zeros or lack of leading zeros.

SMART goals

A client-centered nursing goal needs to be SMART (Specific, Measurable, Attainable, Reasonable, and Time-oriented). A nurse establishes goals to meet discharge criteria. Which is the best example of an appropriate client-centered goal? The client walks to the nurses' station and back to bed before the end of the shift. This goal is specific, measurable, attainable, reasonable, and time‑oriented. NOT: The client walks to the cafeteria, to the nurses' station, and back to the room. This goal does not have a specific time frame associated with completion. The client eats and drinks an appropriate volume of food and fluids. This goal is not specific and measurable. The client reports pain is manageable when ambulating in hallway. This goal is not specific. A case manager's role is to ensure the client has the services and support they need at home or at the time of discharge from the hospital. Goals are set by a case manager to assess the client's progress towards independence. The case manager coordinates with other support services and ensures the client has any equipment they need to acheive their goals. A nurse case manager reviews a client's chart. The client has not met the goal to walk without assistance. What does the nurse do? Select All That Apply Rewrite the goals to something that the client will be able to achieve. A goal may have been unrealistic for the client to achieve, reviewing and reassessing is important to creating achievable client goals. Since goals are measurable and timed, perhaps the client will achieve independent ambulation if only the time is altered, for example. Evaluate any obstacles the client may have in achieving the goal. It is important to identify any obstacles the client has in order for the case manager to address them so the goals are being achieved. Ensure the client has any equipment needed to walk independently. A client may benefit from a cane or walker to assist in their independence and meeting goals. Meet with health care providers to understand why the client is not progressing. It is important to know why the client is not meeting goals. Are there more health issues or are they physically not capable? NOT: Rewrite the goal so that the client walks a greater distance at a future time. Goals must be achievable. Creating goal that is too challenging or is unrealistic for a client is not beneficial.

medication error

If this medication could result in immediate client harm, the nurse would first assess the client. An extra dose of acetaminophen has the potential to cause long-term harm (often related to existing liver failure) and will not cause immediate harm.All medication errors and near misses should be documented in an occurrence or incidence reporting system. This will let nursing leadership and pharmacy identify and resolve any processes that contribute to medication errors (e.g., poor labeling and packaging, inefficient workflows, and knowledge deficits).Medication incidents can be due to human error but are more often a result of faults within the medication administration process. Reporting errors is important to help make changes that will prevent others from making similar mistakes. The nurse gives a client two 500 mg acetaminophen tablets for a headache, then realizes that the prescription was for two 325 mg acetaminophen tablets. The nurse notifies the health care provider and the charge nurse of the error. Which step does the nurse take next? Submit a detailed occurrence or incident report. An occurrence or incident report should be filed as soon as possible after an error happens. The report should include client identification information, the location and time that the error occured, a truthful description of what occured, the actions taken, and the nurse's signature. NOT: Leave a note on the chart for the nurse on the next shift. Leaving a note on the chart is not a secure way to communicate client information to the next nurse. Write a thorough narrative note in the client's chart. The error should not be recorded anywhere else in the client's chart to legally protect the nurse and the health care facility. Comment in the medication administration record to hold the next dose. Commenting in the medication administration record to hold the next dose is not within the nurse's scope of practice. The decision to alter medication doses should only be made by the health care provider.

Latex Allergy

Natural rubber latex allergy involves a sensitivity to latex proteins. Symptoms range from contact dermatitis, urticaria, asthma, and even anaphylaxis. Avoidance of exposure is critical in susceptible individuals. A nurse working in the operating room cares for a client with a latex allergy. The nurse teaches a new nurse about which precaution? Removal of all latex products from the operating room All latex products should be removed from the room because latex particles may become airborne or come into contact with the client via another route and cause a reaction. NOT: Administration of diphenhydramine before the procedure Diphenhydramine, an antihistamine, does not need to be given prophylactically; it is sometimes given to mitigate an allergic reaction but is not indicated to prevent a reaction to latex. Avoidance of nitrile gloves when performing client care Nitrile gloves are latex-free and are an appropriate alternative when caring for clients with a latex allergy. Cleaning of rubber vial stoppers with alcohol before use Cleaning rubber vial stoppers with alcohol does not prevent a latex allergy. Medication rubber vial stoppers can contain latex, but cleaning them with alcohol does not prevent a latex allergy. Natural rubber latex allergy is caused by sensitivation to latex proteins, most often from latex gloves or other latex products. Symptoms range from contact dermatitis, urticaria, asthma, and even anaphylaxis. Avoidance of exposure is key in susceptible individuals. Clients with a latex allergy should carry self-injectable epinephrine (Epi-pen). Immunotherapy (allergy shots) may be effective in some individuals. Which is an appropriate intervention for the nurse to implement for a client with a latex allergy? Withdraw medications from single use vials. Medication vials often have rubber latex stoppers. Research has shown that the risk of exposure to latex increases when stoppers are pierced multiple times, so single-use vials are safest for clients with latex allergy. NOT: Avoid transparent film dressings, like Tegaderm. Transparent dressings such as Tegaderm do not contain latex. Place the client in a private room or area. It is not necessary to place clients with a latex allergy in a private room. Do not use nitrile or vinyl gloves for care. Nitrile and vinyl gloves do not contain latex, and so are safe for use on clients with a latex allergy.

pain

Pain is described as chronic or acute. Acute pain is generally of sudden onset and is associated with illness or injury of a specific nature. It may be tissue damage that has developed due to surgery or trauma. It is generally short-lived. Physical symptoms associated with acute pain include tachycardia, increased or decreased blood pressure, diaphoresis, tachypnea, and focusing on the pain. There are variations of intensity, frequency, and duration from one client to the next. Chronic pain, conversely, is longer-lasting, even lasting years. It is often accompanied by depression, social withdrawal, change in appetite, restricted activity, decreased concentration, and poor sleep. The nurse assesses a client for pain. Which findings indicate the client lives with chronic pain? Select All That Apply The client reports not accepting invitations for social gatherings. Clients suffering from chronic pain will often withdraw socially. The client takes frequent naps during the day. Clients suffering from chronic pain may take multiple naps during the day due to difficulty sleeping at night. The client has difficulty focusing during conversation. Clients suffering from chronic pain may have difficulty maintaining focus. NOT: The client states feeling rested after a night of sleep. Clients suffering from chronic pain often experience difficulty sleeping due to the continual discomfort. The client's heart rate is 146 beats/min upon auscultation. A client's suffering from chronic pain often does not manifest as an increased heart rate due to the client being accustomed to living with the pain. Pain beliefs can differ significantly between cultures. The nurse should assess the situation with the client and determine the reason for refusing pain medication. The nurse should ensure that if the client chooses no medication that it is due to the client's personal choice and that the options were explained fully. If, after discussion and explanation of the need to take this medication, the client continues to refuse, the nurse needs to notify the client's primary provider and seek an alternative treatment if indicated. A nurse cares for an adult client from Pakistan who has colon cancer and reports severe pain. The client refuses all pain medication. Which action should the nurse take next? Ask the client about the refusal to take medications. The nurse will need to get a full understanding of the client's refusal of the medication to determine whether it is cultural or a lack of understanding of medication use. NOT: Contact the client's primary care provider. The nurse will need to notify the primary care provider after seeking to determine the rationale behind the client's refusal to take medications. Ask for permission to speak with the family about the medication. It is a violation of the client's privacy to notify the family of the client's refusal without consent from the client to do so. Document the client's refusal to take medications. It is necessary to document the refusal, but the nurse first should explore the reasoning behind the refusal. Pain is an individual experience and is the most common reason people seek health care. Nurses need to recognize the subjective nature of pain and accept the client's description of pain. Cultural aspects including age, gender, education, diagnosis, and client knowledge can impact a nurse's perception of the client's pain. Biases and misconceptions about pain impact a client's comfort and care. The nurse cares for an older adult client admitted following surgery. The nurse discusses the client's pain management with a student nurse. Which statement by the student indicates further education is needed? "Pain is a natural outcome of the aging process." Older adults are at greater risk than younger adults for painful conditions. However, pain is not an inevitable result of aging. OK: "Pain can be present even if a client is sleeping." Older adult clients may believe showing pain is unacceptable and learn ways to cope with the pain, such as sleeping or other distraction techniques. "Older adults often underreport their pain." Older adults underreport pain for many reasons, including the following: believing that pain is expected with age, protecting loved ones, fearing loss of independence, and not wanting to bother caregivers. Older adults may also believe caregivers know they have pain and feel they do not need to report it. "Analgesics have a longer duration in older adults." Due to declined liver and renal function, older adults often have reduced metabolism and excretion of drugs. This results in a greater peak effect and longer duration of analgesics. Pain is a subjective concept, often measured by using a self-reported pain scale. In the non-verbal client, the nurse recognizes physical and emotional symptoms that indicate lack of comfort. In hospice care, the nurse often educates family members how to recognize and treat the client's pain. This education must be clear and appropriate to the family member's abilities. The spouse of a non-verbal client with metastatic cancer asks the hospice nurse, "How will I know when pain medication is needed? I'm afraid to give him too much of the liquid morphine." The nurse teaches the spouse to look for which signs that indicate pain? Select All That Apply Frowning or grimacing Facial grimacing is a symptom of pain. Acting restless Restless activity is a symptom of pain, indicating that the client cannot get comfortable. NOT: Eating less Decrease in appetite may be related to pain, but this requires additional assessment by the nurse. Eating less can be related to a number of factors. Shallow breathing Shallow breathing may be caused by opioid use, and requires assessment by the nurse. In the client with rib or abdominal pain, shallow, quick breathing may be noted. Awake more often Somnolent clients may become more alert when pain increases, but this needs more assessment and education by the nurse to avoid the spouse giving analgesia every time the client is awake. Ideally, narcotic doses allow the client to continue interacting with others and to have alert periods.

Requirements for Nurse Job

Passing the NCLEX is required for performing RN duties.A new graduate nurse must complete a unit and hospital orientation before working. This provides the nurse with knowledge about the policies and procedures of that particular hospital. A nurse applies to work on a cardiovascular unit at a local hospital. Which actions are necessary before the nurse can begin working? Select All That Apply Complete-unit specific and hospital orientation. Completion of unit-specific and hospital-required orientation is necessary before beginning work on a hospital unit. Verification of a passing score on the NCLEX-RN exam. Passing the NCLEX-RN is required for performing RN duties. NOT: Obtain two years of medical-surgical nursing experience. Some facilities may prefer 6 months to a year of Medical-surgical experience but it is not always required on a focused unit. Work as a nurse in a cardiologist's office for one year. Working in a cardiologist's office for one year may make a nurse a more appealing candidate but is not required. Earn a certification in cardiac-vascular nursing. Certification in cardiovascular nursing may make a nurse a more appealing candidate but is not required. To obtain advanced certification in a specialty area, several hours of experience and education contact hours are usually required.

spastic bladder

A spastic (overactive) bladder causes urinary incontinence in sudden, gushing voids. It is typically found in clients with neurologic problems affecting the upper motor neurons from stoke or high-level spinal cord injury. Sensory transmission fails, and the client is unable to sense a full bladder. The voiding reflex arc remains intact so the motor impulse associated with the distended bladder reacts causing incontinence. Retraining techniques, medications, and technological advances can be used to reduce the incidence of incontinence. The nurse discusses bladder retraining techniques with a client diagnosed with spastic bladder. Which technique does the nurse teach the client? Stroke the medial aspect of the thigh. Stroking the medial aspect of the thigh is a facilitating technique that helps to stimulate voiding in clients with an intact reflex arc. Additional techniques include pinching the area above the groin, massaging the penoscrotal area, pinching the posterior aspect of the glans penis, and digital anal stimulation. NOT: Schedule toileting every eight hours. Toileting schedules are effective in re-establishing urinary continence. Schedules can be established on a client's voiding pattern prior to injury. At a minimum, clients should toilet upon waking, before and after meals, before and after physical activity, and at bedtime. Every eight hours would not be sufficient. Implement the Credé maneuver. The Credé maneuver is a retraining technique taught to clients with flaccid bladders. Clients are taught to cup their hand directly over the bladder area of the abdomen and apply pressure inward and downward. This technique is not necessary for clients with spastic bladders as their reflex arc is intact. Implement the Valsava maneuver. The Valsalva maneuver is a retraining technique taught to clients with flaccid bladders. Clients are taught to hold their breath and bear down as if having a bowel movement. This technique is not necessary for clients with spastic bladders as their reflex arc is intact.

Advocacy

Advocacy is speaking for others in order to ensure needs are met. Nurses advocate for the health, safety, and rights of clients. Nurses develop relationships with clients, which provide a unique perspective to understand clients' point of view. The nurse who advocates for a client is standing up for the client and fighting for the client to have optimal health and excellent safety goals and ensure rights are not violated. A nurse cares for client who has advanced lung cancer and is on the transplant list. The health care provider discusses the client's situation with the nurse, stating the client will likely continue smoking even after receiving a transplant. How does the nurse advocate for the client? "Cessation of smoking may be a goal for the client, but it will require education and support." The nurse advocates for the client by acknowledging the ability to succeed if desired with support and education. NOT: "If the smoking continues, the client should not be considered for receiving a transplant." This is not an example of client advocacy but instead is working against the client. "The client cannot control the smoking as it is an addiction that has lasted more than ten years." It is incorrect to say that smoking cessation is not possible, but correct to acknowledge it is difficult instead. "Our best hope for the client is that there will be a decrease in daily smoking habits." The best hope is the optimal outcome for the client, which would be cessation of smoking.

Alternative or complementary therapies

Alternative or complementary therapies are used to manage client care. These include relaxation, exercise, meditation with breathing techniques, music, imagery, or massage. These are often used by clients as an alternative pain management in lieu of pharmacological methods. They can also help to relax and calm clients who are anxious or distressed. Nurses can help to support clients when they choose to use these therapies to manage care. A nurse assists a client with guided imagery to help relieve pain. The client's report of pain decreases to 2 out of 10 on a 0-10 pain scale. Which is the best description for guided imagery? Focusing on a soothing multi-sensory image or feeling Guided imagery is a form of meditation that involves concentrating on an image or series of images to relax and calm the mind. NOT: Repeating a single word that has significance to the client This is a form of meditation used to calm the mind and focus. Closing of the eyes and focusing on patterned respirations This is a form of meditation that includes the use of breathing patterns to relax. Listening to soothing music with the eyes closed This is a form of meditation that includes music for distraction or emotional expression.

Bicycle safety

Bicycle injuries are a common cause of death in school-age children. Those at greatest risk are ages five to nine. Most are the result of a head injury. Using helmets reduces this risk. Parents and children need to be educated regarding hazards with taking risks or improper use of the bicycle while riding. Children should be taught to follow bicycle safety rules and be alert for cars when riding on sidewalks and roads. Children should avoid riding bikes during periods of low visibility, as it may be even more difficult to see them because they are often not at eye level of those driving nearby. Parents should monitor children while riding bikes and provide clear expectations when riding away from the parents' location. A parent brings an older school-age client to the clinic for a well child visit. The client is excited about learning to ride a bicycle. Which instructions does the nurse provide to the client and parent? Select All That Apply "Children should avoid riding a bicycle after dark." When visibility is compromised, it may be more difficult for children to be seen riding bikes. "Helmets are recommended and often required." Some states require the use of helmets for children of particular ages. Helmets reduce the risk of head injury with a bicycle-related accident. "Look around at your surroundings while riding." Children should be alert to their surroundings when riding bikes, look for moving vehicles, and move out of harm's way. NOT: "Parents should always be close by when riding." Parents do not need to be nearby but should provide children with clear expectations. "You should enroll in a bicycle safety course." A bicycle safety course is not necessary for riding a bicycle. This information can be provided by parents.

cardiopulmonary resuscitation (CPR)

Once a nurse has checked for responsiveness and a carotid pulse, if no carotid pulse can be felt, the nurse should start CPR with chest compressions. Once help arrives with an AED, the pads are placed in the appropriate position on the client's chest wall. The AED should be turned to the "ON" position, and the device will then begin analyzing the client's heart rhythm. After the heart rhythm has been analyzed, the AED will advise whether a shock should be delivered. If the AED advises that no shock should be delivered, the rhythm is not shockable. If no shock is advised, the nurse should resume CPR starting with chest compressions until a team arrives to initiate advanced cardiac life support (ACLS) protocols. The nurse on the medical-surgical floor discovers an unresponsive client. The nurse calls for help and then checks for a carotid pulse for ten seconds. When the nurse does not find a pulse, they begin cardiopulmonary resuscitation (CPR) with chest compressions. Another nurse arrives with an automated external defibrillator (AED), and the pads are placed on the client's chest. The AED is turned on and analyzes the heart rhythm. The device indicates "no shock advised." Which action does the nurse take next? Resume CPR with chest compressions. After the AED assesses the cardiac rhythm, if no shock is advised, the next step is to resume CPR starting with chest compressions without delay. This keeps the blood circulating and oxygen delivery minimally interrupted. NOT: Remove the AED pads, because no shock is needed. The AED pads should not be removed, as the rhythm may change to a shockable one when it is assessed next by the device. Check the client's vital signs and pulse. The pulse should be checked every two minutes. In order to improve outcomes, extra time should not be taken to assess the pulse. CPR should be immediately resumed after analyzing the cardiac rhythm. Give a set of two breaths before resuming chest compressions. Giving a set of two breaths before starting compressions is not correct. CPR should be resumed with chest compressions and then breaths in a cycle of 30 compressions to two breaths. New basic life support (BLS) guidelines emphasize C-A-B (compressions, airway, breathing). Early chest compressions provide perfusion to vital organs until defibrillation can be provided. If alone, and the nurse knows where an automated external defibrillator (AED) and can quickly obtain it, it is acceptable to do so. Otherwise, when alone, the nurse should call for help and an AED and begin chest compressions if unable to locate a pulse. When a client has an injury that may include spinal cord injury, the airway should not be opened by hyperextending the neck, but instead by use of the jaw thrust maneuver. The client should be immobilized in the position found until further medical help arrives. A 19-year-old suicidal client fell backward over a stair rail to the floor. The client is not breathing and does not have a pulse. After calling for assistance, which action does the nurse take? Begin chest compressions. Basic life support guidelines call for C-A-B (compressions, airway, breathing) priority, so chest compressions should be started first. NOT: Assess the client. The client should be immobilized until additional help arrives. Other assessment data is not obtained until there is help and resuscitation is underway. Begin rescue breathing. Chest compressions should be initiated first when no pulse is found after ten seconds. Open the client's airway. The client with a potential spinal cord injury should have the jaw thrust maneuver used, but opening the airway is not a priority over chest compressions. After witnessing the visitor become unresponsive, the next step is to activate the emergency response system or call for help. After calling for help, the nurse continues assessing pulse and breathing for no longer than 10 seconds. After 10 seconds, the nurse initiates CPR if the client is pulseless and apneic. The other team members can obtain the AED if needed. Once the AED is attached to the client, stop compressions to check for a shockable cardiac rhythm. Shock immediately if advised. • Calling for help activates the emergency response system. The other team members can obtain the AED if needed. • Checking a pulse is appropriate after activating the emergency response system. • Begin CPR after activating the emergency response system and after checking for the absence of pulse and breathing. • If no other team members are available, getting the AED would be appropriate. In an inpatient hospital setting, however, there would be help available to get the AED. When arriving on the scene, the second nurse should first get the automated external defibrillator device (AED) and apply the pads. The AED will check for a shockable rhythm, and then, after a shock is delivered (or if no shock is indicated), the second nurse should then relieve the first nurse to provide uninterrupted CPR by taking over compressions to allow the first nurse to rest. Thereafter, the two nurses should switch off providing compression after every five cycles (or every two minutes) to avoid fatigue. The 2010 AHA Guidelines for CPR changed the old basic life support (BLS) sequence from A-B-C (Airway, Breathing, Chest compressions) to C-A-B (Chest compressions, Airway, Breathing) for all ages except newborns. A nurse cares for a client who experiences cardiac arrest. The nurse initiates cardiopulmonary resuscitation (CPR). When a second nurse responds to the call for help, which action does this nurse take first upon arrival? Apply the automated external defibrillator pads to the client's chest. The first action is to place the automated external defibrillator pads to check for a shockable rhythm and to prepare for a shock if indicated. NOT: Provide artificial breaths with an oxygen source. The second nurse will switch with the first nurse and perform chest compressions after analysis, and shock if needed, by the automated external defibrillator. Call for additional help to administer medications. Quality compressions and airway management are the priority after the automated external defibrillator has been applied. Relieve the first nurse and continue compressions. After a shock has been delivered, if indicated, the second nurse will relieve the first nurse and then follow switching guidelines. The guidelines for cardiopulmonary resuscitation (CPR), basic life support (BLS), and advanced cardiac life support (ACLS) are continually updated by the American Heart Association. The nurse is responsible for staying competent and maintaining certification. Understanding the correct order of actions is the basis for executing successful crisis management. The nurse on the medical-surgical floor enters a client's room and finds the client unresponsive. Which priority action does the nurse take next? Call for assistance and an automated external defibrillator. According to the 2015 guidelines for basic life support, if a nurse finds an unresponsive client, the first action should be to activate the in-hospital emergency response system by calling for help. This gets the automated external defibrillator on the way to the client, should it be needed. NOT: Go retrieve an automated external defibrillator. The nurse should not leave the client to go retrieve an automated external defibrillator. Instead, the nurse calls for help and assesses breathing while checking for a pulse. The nurse should then start compressions if a pulse is absent or if no breathing or only gasping is present. Leaving the client without starting cardiopulmonary resuscitation would not be appropriate, as others can bring the automated external defibrillator and additional help. Begin high-quality cardiopulmonary resuscitation. Before starting cardiopulmonary resuscitation, the nurse should shout for help. Delaying help will delay when the automated external defibrillator arrives and potentially lead to a poor outcome. Furthermore, a team should be available to contribute to all other aspects of the crisis, such as medication administration and airway management. Assess for a carotid pulse while checking for breathing. Once help is summoned, the nurse should assess for breathing or gasping and check a pulse (at the same time). The pulse should be assessed for no more than ten seconds. If there is no breathing or only gasping, and if no pulse can be felt within ten seconds, the nurse should begin cardiopulmonary resuscitation immediately, starting with chest compressions. Once the AED arrives, it should be placed on the client as soon as possible. Compressions should continue while the AED is being placed and stopped only when the call for all to clear is made. Application of the AED should not be delayed as it may compromise client outcomes (2015, AHA). The nurse assists a client to the restroom when suddenly the client becomes limp and unresponsive. The nurse lowers the client to the floor and is unable to palpate a pulse. The nurse calls for help and begins chest compressions. Another nurse arrives with an automated external defibrillator (AED). Which action does the nurse take next? Apply the AED immediately and clear the client while the rhythm is analyzed. The AED should be applied as soon as possible to initiate defibrillation if needed. Compressions may be continued as the AED is being applied before the rhythm is analyzed. Then a shock is administered if indicated. NOT: Continue compressions until 100 have been completed. The nurse should begin compressions immediately but should not wait to complete 100 compressions before applying the AED and administering a shock. This may delay necessary defibrillation and compromise the client's outcome. Stop to reassess the client for the return of a pulse before applying the AED. Instead of interrupting compressions to check for a pulse and then applying the AED, the nurse should apply the AED as soon as possible. Time is valuable during a cardiac arrest, and stopping to check the pulse when it is not yet indicated may compromise the outcome of the arrest. The pulse should instead be checked at a set interval of every two minutes. Try to sternal rub the client to assess for the return of responsiveness. Time should not be taken to sternal rub the client between doing compressions and applying the AED. Once retrieved, the AED should be applied immediately to assess for a shockable rhythm.

discharge

The nurse should first evaluate clients who may be deemed stable and ready for discharge. The nurse should then complete a full assessment of each identified client to determine readiness for discharge. Once the nurse determines a list of clients appropriate for discharge, the health care providers should be contacted and provided all the information needed to provide a discharge order. Nurses may not initiate discharge on a client without an order. Each client who is a discharge candidate will need an assessment to determine actual discharge readiness prior to contacting the health care provider for an order. Each client deemed a discharge candidate requires a discharge order from a health care provider. The nurse will need to contact the provider in order to obtain an order. After completing the initial and final discharge readiness evaluation, the staff nurse would need to inform the charge nurse of the potential rooms which will be available for admissions. The nurse would not begin discharge preparations for clients until AFTER contacting the health care provider. As part of the discharge process and preparation, the clients will be prescribed any home med needs. This is done after clients are identified for discharge and the HCP agrees to discharge. Correct order: Perform an assessment on each client identified for potential discharge. Contact the health care providers with assessment data and request discharge orders. Inform the charge nurse of clients identified as ready for discharge. Begin discharge preparation for clients identified as stable and ready for discharge. Ensure all necessary prescriptions are available as needed by clients discharged home.

MyPlate

According to MyPlate, fruits and vegetables together should make up one-half of a person's meal, but there is no emphasis on a strict amount of either. The 2015-2020 update to the dietary recommendations uses MyPlate as a visual reminder to balance the diet, rather than suggesting a specific percentage or amount of intake recommended for each food group. Fruits and vegetables together should make up half the meal. This allows consumers to make decisions that suit them, such as having one cup of fruit with breakfast and one cup of vegetables with dinner, meeting the daily guidelines. According to the U.S. government's MyPlate, what portion of a person's meal should be made of fruits and vegetables? Fruits and vegetables together should make up half the meal. According to MyPlate, fruits and vegetables together should make up half the meal. NOT: Fruits and vegetables together should make up two-thirds of the meal. This is not consistent with the recommendations of MyPlate. If fruits and vegetables make up 67% of the meal, this is okay on occasion, but the client has to understand that foods from other food groups are essential to bone, muscle, and brain health. Fruits should make up one quarter and vegetables should make up half of the meal. Fruits and vegetables do not need to make up 75% of the meal. Depending on which foods are used, the client may be missing key nutrients, such as high quality protein. For a child, this may not offer enough fat to sustain adequate growth. Fruits and vegetables should in total make up one quarter of the meal. If fruits and vegetables comprise only 25% of the meal, the client may miss out on key nutrients largely found in them, such as water soluble vitamins that must be consumed daily. According to the USDA 2015-2020 update to the MyPlate dietary guidelines, eating "natural fats" like those in steak or eggs is not a recommendation. In fact, animal-based fats are saturated fats and are particularly high in cholesterol; eating more of these fats is not recommended. Instead, the USDA recommends using oils (e.g., olive or canola) but limiting the use of these to 3 tablespoons daily for adults. Additional dietary guidelines outlined by the USDA MyPlate campaign include consuming less than 10 percent of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids, and consuming less than 300 mg per day of dietary cholesterol. The nurse provides client teaching about the MyPlate guidelines for nutrition from the U.S. government. Which statement made by the client about dietary fats requires follow-up teaching? "I should eat natural fats like those in steak or eggs." The MyPlate guidelines stress the importance of decreasing animal fat consumption. This statement requires follow-up teaching. OK: "I should eat oils like canola oil instead of solids like butter." The MyPlate guidelines state that when oils and fats are used, oils should be used instead of solids, such as butter. This helps to prevent clogging of the cardiac arteries. "I should consume fewer than 300 mg per day of dietary cholesterol." The MyPlate guidelines state that no more than 300 mg of cholesterol should be consumed daily. This helps to prevent cardiovascular complications. "I should consume less than 10 percent of calories from saturated fatty acids." The MyPlate guidelines specify that saturated fatty acids should make up no more than 10 percent of daily calories in order to prevent cardiovascular complications related to fat consumption. According to the USDA 2015-2020 update to the MyPlate dietary guidelines, individuals should consume at least half of all grains as whole grains. Individuals should be told to increase whole-grain intake by replacing refined grains with whole grains. It is not recommended to replace all grains in the diet with whole grains because the guidelines are meant to be realistic. The American Academy of Pediatrics states that there is no evidence that waiting to introduce or limiting allergy-containing grains (such as wheat) beyond four to six months of age prevents food allergy or the onset of celiac disease. The current 2015-2020 update to the dietary recommendations suggests that too much of any food group is a bad thing. The guidelines emphasize adequate, healthy nutrition that is meant to be realistic and attainable for all Americans. According to the most recent U.S. government guidelines that accompany MyPlate as a nutrition guide, which guideline is recommended regarding the grain food group? At least half of all grains consumed should be whole grains. According to MyPlate, at least half of all grains consumed should be whole grains. NOT: Grains should be avoided until age 24 months. The MyPlate guidelines do not emphasize avoidance of any food group according to age. These guidelines are established by the American Academy of Pediatricians. Limit whole grains to avoid excessive weight gain. The MyPlate guidelines stress that whole grains should be consumed as part of the healthy diet in an effort to decrease the risk of excessive weight gain. All grains consumed should be whole grains. This is not consistent with the recommendations of MyPlate. The MyPlate guidelines stress the importance of reaching attainable dietary goals; requiring all grains to be whole grains is not attainable to the average individual.

Tracheostomy

Clients with tracheostomies are at increased risk for infection due to the potential accumulation of secretions in the tube and on the dressing surrounding the tube. Suctioning and care of the tracheostomy should occur routinely according to facility policy. Best practice is for the dressing to be changed daily or when the dressing is soiled. When securing ties, the nurse should be able to position one finger between the tie and the neck to maintain placement but prevent irritation. The suction catheter should be smaller than the lumen size of the tracheostomy tube and the suction catheter should be inserted to the base of the tube to ensure a fully patent airway. With suctioning, clients often become hypoxic. To help to prevent this, nurses should oxygenate clients prior to suctioning with a 100% oxygen delivery system. Clients with tracheostomy tubes often have difficulty with feeding due to the tube interfering with the larynx to move effectively. In addition, the inflated cuff will interfere with passage of food through the esophagus. Deflating the cuff partially or fully prior to meals will provide greater ease for feeding. A nurse cares for a young adult client who sustained a cervical spinal cord injury from a motorcycle accident. The client has a tracheostomy to facilitate long-term ventilation. Which actions by the nurse are correct regarding tracheostomy care? Select All That Apply Deflate the tracheostomy cuff prior to meals. Best practice is to deflate the cuff partially or fully for meals. Oxygenate the client prior to suctioning. To prevent hypoxia from a potential vagal response to suctioning, oxygenation should occur prior to suctioning. Change the tracheostomy dressing daily. Best practice is for the tracheostomy dressing to be changed daily to prevent infection. NOT: Secure the tracheostomy ties tightly. The ties should be secure, not tight, with the ability to place one finger between the tie tape and the neck. Suction only the top half of the tracheostomy tube. The entire length of the tracheostomy tube should be suctioned. Nurses should closely monitor clients with tracheostomies in order to clear secretions that may place them at risk for hypoxia. The nurse should frequently assess for secretions, noting color, consistency, and amount and provide suctioning if excessive or thick. Alert and oriented clients are generally able to note and clear secretions by covering the opening with a clean gauze and coughing. The nurse should note a change in alertness and assess for need to suction as indicated. Thick secretions can impair the client's ability to clear the airway, putting the client at risk for hypoxia. A nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a tracheostomy to relieve airway obstruction. Which assessment data requires the nurse to take additional actions? Select All That Apply The client has thick secretions. Thick secretions may be difficult for the client to clear and may require suctioning. The client has just received a dose of diazepam. Sedative drugs may decrease the client's alertness and ability to clear secretions. This will require a conversation with the healthcare provider (HCP) or increased monitoring for effectiveness and adverse events. NOT: The client covers the tracheostomy opening to cough. This is beneficial and appropriate and will help to clear the lungs of secretions as coughing without covering the tracheostomy will not allow for effective clearance. The client deep suctions the tracheostomy as needed. Deep suctioning will help to maintain patency of the tracheostomy. The client has bronchovesicular lung sounds. Bronchovesicular lung sounds are normal.

Organ donor

Compatible tissue and blood types are the most important factors when matching a donor to a recipient. A good match is one in which the blood types between the donor and recipient are compatible, the tissue typing is well-defined, and the crossmatch studies (looking for preformed antibodies) are negative. A nurse cares for an adult client who is on the organ transplant waiting list. Which factors are most important for selecting a donor-recipient match? Select All That Apply Tissue compatibility Tissue should be compatible and well defined. Blood type Blood type needs to be compatible. NOT: Gender Gender is not relevant. Age of client Age should be similar but does not need to be exact. Immediate need Need is not a determining factor for matching. Federal laws require that institutions have policies and procedures in place for clients who wish to be organ or tissue donors after death. Understanding the process is often difficult for the family. After a client is declared legally dead, life support continues in order to provide the vital organs with blood and oxygen prior to the transplant. Families often have many questions. Organ donation coordinators are experts related to knowledge of the process and time frame involved with organ donation and can be resources utilized for answering family questions. In some cases, the death is anticipated, and plans have been in process regarding the donation. When this is the case, the provider is usually informed and a part of the process. At other times, the death is unanticipated, and the provider has no knowledge of the client's wishes. The nurse may make initial contact with a donation organization without provider prescription to get the process in motion. The nurse should at all times, regardless of personal beliefs regarding organ donation, remain objective and support the family. A nurse cares for a client who has consented to organ donation. Which action by the nurse is correct? Notify the organ donation coordinator to set up a meeting with the family to answer questions. If the family has questions, they should have opportunity to speak with an organ donation coordinator in order to discuss the donation process. NOT: Contact the provider in order to obtain a prescription for contacting an organ donation organization. Provider support is desired, but a prescription by the provider is not required prior to the nurse making contact with the organization. Inform the family of the negative consequences of the organ donation process. The nurse can remain objective, provide information to the family, and remain supportive. Instruct the family of the need to say their goodbyes quickly so the organ donation team can begin the process. The family does not need to be rushed through the process of organ donation and needs to be provided with sufficient time to grieve. The transplant coordinator typically speaks with the family about the donor process and answers any questions they may have. This request should be passed on, and the transplant coordinator can facilitate this if they all agree. A nurse cares for a client who is an organ donor and who dies at the hospital. The client's family wishes to meet the organ recipient. Which response by the nurse is best? "I will reach out to the transplant coordinator so she can discuss this with you." The transplant coordinator is primarily responsible for coordination between the donor and recipient family and determines how and whether communication will take place between the two. NOT: "The recipient's family will be in contact after six months if the recipient does well." The recipient is not required or obligated to contact the donor family. "Legally, you will not be allowed to make contact with the recipient or family." Contact can be made if both parties are in agreement. "Both your family member's provider and the recipient's provider need to approve this." The providers have no role in decisions related to contact or communication between the donor and recipient families.

Diet

Older adults need to practice health promotion and illness prevention to maintain wellness. Common health issues faced by older adults involve poor nutrition and hydration. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A. Older adults need education about consuming a balanced diet and making healthy food choices.

Erik Erikson's stages of psychosocial development

The client who is adolescent experiences feelings of invulnerability, leading to increased risk of accidental injury. The nurse educates the client about injury prevention when possible. The nurse cares for an adolescent client with a broken foot from skiing. What developmental factor most contributes to the adolescent client sustaining this injury? Feelings of invulnerability leading to risk taking. According to Erikson, the client who is adolescent may experience feelings of invulnerability leading to increased risk taking. In other words, often adolescents do not think taking a risk will hurt them. NOT: Desire to explore new things and push limits. According to Erikson, a child between three to six years of age experiences initiative versus guilt. The child's desire to explore often conflicts with limits placed on behavior. Desire to imitate peers and be independent. According to Erikson, a child between one to three years of age experiences autonomy versus shame and doubt. Toddlers try to imitate others around them and may wish to accomplish tasks independently. Fear of rejection from other adolescent friends. According to Erikson, the client who is a young adult experiences intimacy versus isolation. This client may fear rejection. Although the client who is adolescent may also fear rejection, this is not the most likely cause of an injury to an adolescent. Erik Erikson believed that individuals at each stage of life must accomplish a task, framed with opposing conflicts, before moving on to the next stage of life. Clients who are middle age accomplish generativity by giving back to the next generation through parenting, teaching, mentoring, and working in the community. The other answers are examples of achieving developmental milestones in the Erikson model, but not for the client who is middle-aged. The nurse cares for a client who is middle-aged. What statement indicates that the client is achieving the middle age developmental milestone from Erickson? "I love coaching the seventh grade soccer team." The client in middle age experiences the stage of generativity versus self-absorption and stagnation. Volunteering is one way the client who is middle-aged may find fulfillment and achieve generativity. NOT: "I am finally figuring out who I am as a person." The client who is adolescent experiences the stage of identity versus role confusion according to Erikson. The adolescent must gain a sense of identity to progress with further decisions about careers or partners as an adult. "I feel satisfied with how my life is, even the mistakes." The client in old age experiences the stage of integrity versus despair according to Erikson. The client who reached integrity sees life as meaningful in spite of past mistakes and does not live with regret. "My significant other and family are so supportive of me." The client who is a young adult experiences the stage intimacy versus isolation according to Erikson. This client successfully achieves intimacy through meaningful relationships. Erik Erikson believed that individuals at each stage of life must accomplish a task, framed with opposing conflicts, before moving on to the next stage of life. Clients who are young adults accomplish intimacy by forming close relationships with family, friends and significant others. The other answers are examples of developmental needs in the Erikson model, but not the best choice for the client who is a young adult. The young adult client is postoperative from an emergency appendectomy. The nurse knows that which client question is an example of the client's developmental stage according to Erikson? "Can I see my significant other right away?" The client who is a young adult experiences the stage intimacy versus isolation according to Erikson. Having a significant other or family member present at a time of illness fills this client's need for intimacy. NOT: "I am lucky to make it through, right?" The client who is older experiences the stage of integrity versus despair according to Erikson. A client with integrity views life with a sense of satisfaction. "Can I help change my dressing?" The client who is school-age is eager to learn and apply what is learned. This stage is Industry versus Inferiority. "Will this leave a scar on my stomach?" The client who is an adolescent experiences identity versus role confusion according to Erikson. Clients at this age are preoccupied with body image and want to make decisions about their treatment plan.

Tuberculosis (TB)

The client with TB requires airborne precautions, which include using an N-95 mask or power air purifying respirator hood and placing the client in a negative pressure room. Strict adherence to these precautions helps prevent transmission of TB to other health care personnel or clients. The client with a positive tuberculin (TB) test requires airborne precautions. When completing an assessment, which personal protective equipment (PPE) does the nurse use? Select All That Apply N-95 mask An N-95 prevents transmission of TB from an infected client to hospital personnel. These masks are fit-tested to a person's head and jaw to prevent any gaps, maximizing protection from airborne contaminants like TB, measles, and varicella. Power air purifying respirator hood Certain personnel, especially those with beards, cannot safely use an N-95 mask, as the mask will not fit tightly enough to prevent contaminants from entering. These personnel use a specially designed power air purifying respirator hood, which contains a high efficiency particulate air filter and is more effective than an N-95 mask at filtering out contaminants. NOT: Gown A gown is not required for airborne precautions unless coming in contact with bodily fluids. Airborne precautions are standard precautions plus adding and N95 or respirator. Face shield A face shield is a component of droplet precautions, not airborne precautions. Surgical mask A surgical mask is appropriate for use with droplet precautions from conditions such as influenza, rubella, pertussis, and certain pneumonias. This mask does not protect from diseases spread by the airborne route. Patients with TB need to be in isolation using airborne precautions. Anyone entering the room needs to wear an N95 respirator at the minimum, but if there is a risk of any contact with sprayed respiratory fluids (including coughing), personal protective equipment (PPE) such as a gown, gloves, and eye protection should also be worn. The Centers for Disease Control (CDC) currently recommend the use of N95 or higher-level respirators for personnel exposed to patients with suspected or confirmed TB. Surgical masks do not provide sufficient protection and should not be confused with particulate respirators (including N95 masks) that are used to prevent inhalation of small particles transmitted by the airborne route. Removal of protective equipment, followed immediately by hand hygiene, should always be done before exiting the room. The removal of the N95 respirator should occur after removing other PPE after exiting the room and be followed immediately by hand hygiene. Dedicated equipment must be disposable or disinfected according to a respiratory protection program that meets Occupational Safety and Health Administration (OSHA) standards. An unlicensed assistive personnel (UAP) enters the room of a client with tuberculosis (TB) who is coughing up blood. Which action by the UAP requires additional education on airborne precautions? Select All That Apply After measuring blood pressure, the UAP removes the blood pressure cuff from the room. Equipment taken into a room stays in the room, providing dedicated equipment for this particular client. Before exiting the room, the UAP removes the N95 respirator before removing other personal protective equipment, followed by hand hygiene. The N95 respirator is removed last and after leaving the room for airborne precautions. Prior to entering the room, the UAP dons a surgical mask and gloves from the cart outside the room. A surgical mask does not provide the protection required with airborne precautions. OK: While providing care to the client, the UAP wears a gown, gloves, N95 respirator, and eye protection. The assistant should wear a gown, gloves, and an N95 respirator while in the room and providing care to the client. The only required PPE for airborne precautions is the N95 respirator or powered air-purifying respirator (PAPR). if there is a risk of any contact with sprayed respiratory fluids (including coughing), personal protective equipment (PPE) such as a gown, gloves, and eye protection should also be worn. The UAP removes most protective equipment in the room and removes the N95 respirator outside, followed by hand hygiene. The mask is removed after leaving the room when a client is on airborne precautions.

Non-profit organization

The difference between for-profit and nonprofit organizations is not in how revenue is generated but in how the revenue is distributed when the income exceeds the expense. In for-profit organizations, excess revenue is distributed among shareholders and providing services. In nonprofit organizations, excess revenue is used for organizational purposes, such as facility improvement, improved services, or better equipment. A nurse works for an insurance company as a reviewer for client claims. The nurse notes the nonprofit healthcare organization has had a large increase in revenue over the past year without a significant increase in expenses. Which action does the nurse anticipate? The revenue is distributed across departments for client service improvement. Revenue earned in a not-for-profit organization is used to continue to develop the organization NOT: The profit is used to pay bonuses to the organization's top performers. A not-for-profit organization does not function to gain revenue and increase pay within the organization.. The profit is used to pay annual taxes which the organization has accrued. Not-for-profit organizations are tax-exempt. All increased profits are distributed to stockholders of the organization. Not-for-profit organizations do not have stockholders.

Pressure injury

A pressure injury is localized damage to the skin or underlying soft tissue. Injuries usually occur over a bony prominence. The injury occurs as a result of intense or prolonged pressure or shear. Prolonged pressure reduces perfusion to the tissue and results in ischemia. Skin is more susceptible to injury when moisture, nutrition, and perfusion are compromised. Pressure injuries can pose serious risks to the client's health, because skin breakdown eliminates the body's first line of defense against infection. The nurse performs a skin assessment on a client. The nurse notes a stage 2 pressure injury on the client's sacrum. Which does the nurse document as characteristic of a stage 2 pressure injury? "The client's sacrum has partial-thickness skin loss with exposed dermis. The wound bed is pink and moist. Adipose tissue is not visible." An area of partial-thickness skin loss without visible adipose tissue is a stage 2 pressure injury. NOT: "The skin covering the client's sacrum is intact. The client reports decreased sensation in the area. The area displays nonblanchable erythema." An area of redness with sensation changes and nonblanchable erythema is considered a stage 1 pressure injury. "The area covering the sacrum is open. Adipose tissue is visible in the wound. There is no evidence of muscle or bone." An area of full-thickness skin loss with adipose tissue without deeper body structures visible is a stage 3 pressure injury. "The skin covering the client's sacrum is intact. The area is slightly warm to the touch and appears reddened. The redness blanches when palpated." An area of redness that blanches on palpation is not at risk for skin breakdown. Blanching indicates normal reactive hyperemia. Tissue that does not blanch with palpation indicates possible ischemic injury.

Roux-en-Y gastric bypass

Bariatric surgeries are procedures that help clients to manage obesity. Several types of surgeries are available. Roux-en-Y gastric bypass surgery is the most common malabsorption surgery in the United States. A malabsorption surgery interferes with the absorption of food and nutrients from the digestive tract. In Roux-en-Y gastric bypass surgery, the client's stomach, duodenum, and part of the jejunum are bypassed so fewer calories can be absorbed. Clients feel full faster due to the decreased stomach size. The malabsorption of food means clients typically need vitamin supplements. The nurse provides preoperative teaching to a client undergoing Roux-en-Y gastric bypass surgery. The nurse recognizes further education is needed after which client statement? "I will be on bed rest for the first 24 hours following my surgery." Clients are encouraged to get out of bed on the first day of surgery to prevent postoperative complications such as deep vein thrombosis and pulmonary embolism. NOT: "I will sleep with the head of the bed elevated following surgery." Clients are encouraged to sleep in the semi-Fowler position to improve breathing and decrease risk for sleep apnea, pneumonia, and atelectasis. "I will have sequential compression stockings on my legs." Sequential compression stockings are used along with a prophylactic anticoagulant to prevent thromboembolic complications. "I will be limited to one-ounce servings of clear liquids after surgery." Clear liquids are introduced slowly after surgery. One-ounce cups are used to offer clear liquids. Pureed foods, juice, thinned soups, and milk are added after 24-48 hours. The client can typically increase their intake to one ounce every five minutes until satisfied. Liquids and pureed foods are continued for six weeks following surgery.

Death and Dying

Beliefs regarding death and dying vary between different individuals and cultures. Clients who are older commonly fear burdening their family, suffering, being alone, and use of life-prolonging measures. Typically, clients who are older do not fear death itself, expressing peace with their life's difficulties and triumphs. The nurse cares for a client who is 85 years old talking about dying. Although beliefs surrounding death are different for each individual, the nurse knows what statement regarding dying is most common from the client who is 85 years old? "I do not want to be a burden to my family." Clients who are older are concerned with being a burden to their family. NOT: "I am afraid I will not wake up one morning." The latest evidence shows that clients who are older are not typically afraid of their own death. Rather fears surrounding death typically stem from suffering or being a burden to family. "I am strong and unafraid of suffering or pain." Clients who are older typically fear extended suffering and pain which surrounds the dying process, but not death itself. "I want everything done to prolong my life." Clients who are older may fear life prolonging measures and the suffering and pain associated with prolonging the dying process. It is typical that the client does not fear death, but simply does not want to prolong life.

Budget

Budget evaluations occur annually for facilities. Nursing managers are responsible for providing input and making budget requests for the overall financial budget for a facility. The overall budget has varying smaller budgets for different areas of management and concern within the facility. The overarching goal is to maintain a healthy budget for the entire organization. The nurse manager is responsible for evaluating unit needs and submitting requests based on need from capital budget, personnel budget, and general operating budget. The capital budget deals with purchases of large expense items and maintained assets. The personnel budget deals with the personnel necessary for care delivery, including salary and benefits. The operating expense budget includes needed items for day-to-day activities on the unit, including office supplies. The nurse manager of a busy medical-surgical unit prepares an annual budget to ensure quality client care. Which items are included as part of the operating budget? Pens and markers Pens and markers are included in the operating budget. NOT: Computers Computers and large purchase items are included in the capital budget. Ultrasound machine An ultrasound machine is a large purchase item and would be included in the capital budget. Overtime for nursing staff Overtime, salaries, and benefits are included in the personnel budget. Budget evaluations occur annually for facilities. Nursing managers are responsible for providing input and making budget requests for the overall financial budget for a facility. The overall budget has varying smaller budgets for different areas of management and concern within the facility. The overarching goal is to maintain a healthy budget for the entire organization. The nurse manager is responsible for evaluating unit needs and submitting requests based on need from capital budget, personnel budget, and general operating budget. The capital budget deals with purchases of large expense items and maintained assets. The personnel budget deals with the personnel necessary for care delivery, including salary and benefits. The operating expense budget includes needed items for day-to-day activities on the unit, including office supplies. A newly hired manager for a long-term care unit reviews the budget prior to the first financial planning meeting. Which items does the nurse include in the personnel budget requests? Select All That Apply Compensation for overtime The personnel budget includes salary to be paid for regular and overtime work. Staff salary and benefits The personnel budget includes salary to be paid for regular and overtime work. NOT: New computer monitors A new computer is a large expense item and an asset and is included in the capital budget. Pens and markers Pens and markers are a part of items needed for day-to-day activities and are a part of the operating expense budget. Ultrasound machine An ultrasound is a large expense item and an asset and is included in the capital budget. Budget evaluations occur annually for facilities. Nursing managers are responsible for providing input and making budget requests for the overall financial budget for a facility. The overall budget has varying smaller budgets for different areas of management and concern within the facility. The overarching goal is to maintain a healthy budget for the entire organization. The nurse manager is responsible for evaluating unit needs and submitting requests based on need from capital budget, personnel budget, and general operating budget. The capital budget deals with purchases of large expense items and maintained assets. The personnel budget deals with the personnel necessary for care delivery, including salary and benefits. The operating expense budget includes needed items for day-to-day activities on the unit, including office supplies. A nurse manager prepares a budget request for the upcoming fiscal year. Which items needed for quality client care does the nurse manager include in capital budget requests? Select All That Apply Handheld ultrasound bladder scanner A handheld ultrasound bladder scanner is a large expense item and an asset and is included in the capital budget. Wall-mounted computer monitors Computer monitors are large expense items and assets and are included in the capital budget. New portable telemetry monitors New portable heart monitors are large expense items and assets and are included in the capital budget. NOT: Copy paper and printer ink cartridges Copy paper and printer ink cartridges are items needed for day-to-day activities and are included in the operating expense budget. Cost-of-living employee salary adjustments Overtime, salaries, and benefits are included in the personnel budget.

sexually transmitted infections (STIs)

By the time individuals graduate high school, more than two-thirds have had sex. The school environment is a key setting in which student's behaviors and ideas are shaped. Teaching on STIs in high school is very important to prevent the spread of STIs. The presence of co-existing infection, disease transmission, and discussion on privacy rights are important topics to discuss with this population. A nurse teaches a group of high school students about sexually transmitted infections (STIs). Which student statement indicates that the teaching is effective? Select All That Apply "My parents may find out about my STI if it is a reportable condition." Reportable STIs must be disclosed to the state board of health, including the individual's name and date of birth. This information may end up being accessed by the individual's parent. "Every state in the U.S. allows a minor to consent to treatment of an STI." Every state in the U.S., including the District of Columbia, allows a minor to consent to the treatment of an STI. "It is likely that if I have one STI, I may also have another STI." Co-existing sexually transmitted infections are likely. This is due to the fact that these individuals often engage in risky lifestyle choices such as unprotected sex or sex with multiple partners. NOT: "My parent's insurance company cannot reveal my STI treatment to my parents." Despite HIPAA laws used to protect the privacy of an individual's protected health information, adolescents and teenagers who are covered under their parent's private health insurance may find that the insurance company does not keep all information secure, particularly regarding exposure to a reportable STI. A minor is covered under the protective rights outlined in HIPAA; however, some records related to the individual's care may reveal this information. "Transmission of genital warts is unlikely if my partner doesn't have symptoms." Transmission of genital warts caused by HPV may occur despite the fact that an individual may be asymptomatic.

Enteral feeding

Enteral nutrition is available to clients who cannot meet nutritional demands through oral intake. Enteral nutrition is provided through nasoenteric or enterostomal tubes. A nasoenteric tube is inserted nasally and advanced to the GI tract. These are used for delivering short-term enteral feedings. Enterostomal tubes are inserted through the abdomen directly into the GI tract. These are used for long-term enteral feedings. Tube feedings can be given as boluses or as continuous or cyclic feedings. Infusion rates and type of feeding are determined by the health care provider and dietitian. Feeding tubes can be used in both the health care and home settings with proper education. The nurse educates a student on the care of a client with a feeding tube. The nurse recognizes further education is needed after which student statement? "I will keep the head of the bed elevated to 90 degrees during feedings." Keeping the head of the bed elevated to at least 30° during and one hour after a feeding is adequate to prevent aspiration. A client does not need to be sitting at a 90° angle for feedings. OK: "I will wait for confirmation of tube placement before starting feedings." A feeding tube should not be used until x-ray confirmation of placement is made following initial placement of the tube. "I will fill the feeding bag with only four hours of formula at a time." Filling the feeding bag with more than four hours' worth of formula encourages bacterial growth. If a closed feeding system is used, the system should be changed every 24 hours. "I will flush the tube with 20-30 mL of water after each bolus feeding." Flushing the tube with 20-30 mL of water after each feeding will help to maintain tube patency. Feeding tubes are used for clients who are in need of long-term enteral feedings. Clients may be prescribed continuous feedings by way of a pump or intermittent bolus feedings, typically every 4 hours. A bolus feeding can be done manually or by use of a pump. The nurse is responsible for care of the tube and for management of feedings. After initial placement, correct placement should be verified by x-ray prior to use. Residual volume should be checked every four to six hours and prior to each bolus feeding, with reporting per facility protocol or provider prescriptions. When following bolus feeding orders, the feeding tube should be flushed with 20 to 30 mL of water prior to and after feeding to ensure patency. Warm water should be used. To prevent aspiration with feeding, the client should be positioned with the head of the bed elevated at least 30 degrees during feeding and for at least one hour after a bolus feeding. Checking for borborygmi sounds (rumbling and gurgling) helps the nurse assess for gastrointestinal (GI) function and movement. A nurse administers an enteral feeding for a client with pancreatitis. Which action does the nurse take before administration of the feeding solution? Measure residual volume of the previous feeding. Residual volume should be checked prior to each feeding and reported according to facility protocol or provider prescriptions. NOT: Flush the tube with 50 mL of water. The tube should be flushed with 20-30 mL of water prior to and after intermittent feeding. Ask the family regarding the volume of the last feeding. The nurse should refer to previous documentation for the amount of the last feeding and not rely on information provided by the family. Assist the client to a right-side lying position. The head of the bed should be elevated at least 30 degrees during feeding.

Cranial Nerves

Extraocular movements are guided by six small muscles of each eye. Assessing the six directions of gaze evaluates both the client's eye muscles and the cranial nerves associated with each movement. Lateral movements involve CN VI, upper eye movements, downward-outward diagonal movements, and lateral inward movements involve CN III, and downward-inward diagonal movements involve CN IV. The nurse assesses a client's six directions of gaze. The nurse identifies cranial nerve (CN) VI is intact by which extraocular movement? The client moves the eyes laterally to the right and left. A right and left outward lateral movement is controlled by the lateral rectus muscle and CN VI. NOT: The client moves the eyes diagonally downward and outward. A diagonal downward and outward movement is controlled by the inferior rectus muscle and CN III. The client moves the eyes diagonally upward and outward. A diagonal up and out movement is controlled by the superior rectus muscle and CN III. The client moves the eyes diagonally downward and inward. A diagonal inward and downward movement is controlled by the superior oblique muscle and CN IV.

Elective surgery

For elective surgeries the benefits should be weighed against the risks when deciding if a client is a good candidate. Certain factors, such as malignant hypertension, place the client at great risk for surgery. Because this surgery is not emergent, the client should be treated and have controlled blood pressure before having this procedure. The nurse performs a day-of-surgery preoperative assessment on a client with diabetes who is scheduled for an elective knee replacement. Which assessment finding is a contraindication for this surgery? Blood pressure reading of 204/99 mmHg A systolic blood pressure reading greater than 200 mm Hg is considered malignant hypertension, a severe type of high blood pressure. Without prompt intervention, the client may experience left ventricular heart failure, kidney failure, or stroke. This factor makes the client too unstable to undergo an elective procedure. NOT: Glycosylated hemoglobin (A1C) level of 6.1% A glycosylated hemoglobin (A1C) of greater than 8% indicates poor diabetic control. An A1C of 6.1% suggests that the client is a well-controlled diabetic. Report of a myocardial infarction (MI) seven months ago Clients with a history of a myocardial infarction (MI) within the past six months are not good candidates for an elective procedure. After having an MI there is a decreased ability of the body to tolerate the hemodynamic changes associated with surgery. Furthermore, the response to anesthesia is negatively affected. Because this client had an MI more than six months ago, this would not be an inhibitory factor for surgery. Personal history of malignant hyperthermia Malignant hyperthermia (MH) is an inherited muscle disorder that causes a life-threatening reaction to certain general anesthetic agents including halothane, enflurane, isoflurane, desflurane, sevoflurane, and succinylcholine. A client with a known history of MH can have precautions taken to prevent it from occurring, and it is not a contraindication for surgery.

Healthy People 2020

Healthy People 2020 provides guidelines for people to live a healthier lifestyle through better choices in physical activity, calorie intake, and types of calories consumed. Though the guidelines recommend certain amounts of physical activity, they also state that some activity is better than none at all. Individuals should tailor the recommendations to suit the needs of their age or condition of health. A nurse in a wellness clinic prepares physical activity educational materials for a group of clients. According to Healthy People 2020, the nurse includes which guideline? Small amounts of activity have worthwhile benefits. Even small amounts of physical activity can produce some health benefits and is worthwhile. NOT: Adults should include muscle training in their physical activity routine no more than two days a week. Adults should include muscle training in their physical activity routine two or more days a week, not two days or less. Older adults at risk for falling should not exercise. Older adults at risk of falling should exercise to maintain or improve balance issues. Older adults should be as physically active as their condition allows. Substantial benefit is gained from adults doing moderate-intensity activity of five hours a week. Substantial benefit can be gained from adults doing moderate-intensity activity of at least 2 hours and 30 minutes a week. Even more benefit is gained from vigorous-intensity aerobic activity of at least one hour and 15 minutes a week. Aerobic activity should be done in at least ten-minute increments.

functional nursing model

Historically, there have been four nursing care models which have been utilized for implementation of inpatient nursing care. Functional and team nursing both involve the use of a mix of nursing personnel, with functional nursing primarily focusing on tasks to be completed. Team nursing often involves bringing additional members of the health care team to ensure the needs of the client are met. Primary nursing and case management both rely heavily on registered nurses (RNs) to deliver focused client care. A nurse works in a hospital where a severe flood has reduced road access, creating a staff shortage. The staff are informed they will be utilizing the functional nursing model. Which explanation best represents this nursing delivery system? A registered nurse, a practical nurse, and unlicensed assistive personnel work together to complete tasks for client care. Functional nursing is task-oriented. NOT: A group of health care providers work together in planning and coordinating the care received by clients. This is an example of team nursing, which may include the functional nursing model. A primary nurse works together with members of the health care team to manage care of a client during a hospital stay. This is an example of primary care nursing. A registered nurse manages the care of a client coordinating needs, identifying resources, and establishing referrals for services needed. This is an example of case management.

Clostridium difficile (C. diff)

Hospitalized clients may require multiple types of infection control precautions. Clostridium difficile, a highly infectious, potentially hospital-acquired infection, requires strict contact precautions (e.g., gloves and gown) to prevent spread to other clients or health care workers. A client hospitalized for influenza B tests positive for a Clostridium difficile infection after having multiple loose, foul-smelling bowel movements each shift. The nurse uses which equipment while caring for this client? Select All That Apply Gloves The client with a Clostridium difficile infection requires contact precautions, which include gloves and gown. Gown The client with a Clostridium difficile infection requires contact precautions, which include gloves and gown. Mask The client with influenza requires droplet precautions, which include wearing a surgical mask when within three feet of the client. NOT: Face shield A face shield is not an official component of contact, airborne, or droplet precautions. Rather, the nurse uses a face shield if there is risk of body fluid coming into contact with the area around the eye. Shoe covers Shoe covers are not an official component of contact, airborne, or droplet precautions. However, the nurse may apply shoes covers if anticipating that shoe may come into contact with blood or body fluids. Clostridium difficile (C. diff) is a bacteria that infects the colon. It is a common health-care-associated estimated to have caused almost 500,000 infections in the United States in 2011. Of those infected, 29,000 died within 30 days of the diagnosis. Older adults and those taking antibiotics are most at risk. Infection control techniques help to prevent the spread of infection. Clients with C. diff are placed on contact precautions. Signs and symptoms of C. diff include watery diarrhea, fever, nausea, and abdominal pain. Treatment is done with antibiotics. The nurse cares for a client with a Clostridium difficile (C. diff) infection. Which action does the nurse take when leaving the room? Inside the room, remove the gloves first and the gown second. Wash the hands thoroughly with warm water and antibacterial soap. All personal protective equipment should be removed before leaving the client room. Isolation gowns are the first piece of personal protective equipment to be donned and the last to be doffed. Gloves are donned last and doffed first. Hands should be washed with warm water and antibacterial soap. Hand sanitizer is not sufficient when caring for a client with C. diff. NOT: Outside the room, remove the gloves first and the gown second. Wash the hands thoroughly with warm water and antibacterial soap. All personal protective equipment should be removed before leaving the client room. Isolation gowns are the first piece of personal protective equipment to be donned and the last to be doffed. Gloves are donned last and doffed first. Hands should be washed with warm water and antibacterial soap. Hand sanitizer is not sufficient when caring for a client with C. diff. Inside the room, remove the gown first and the gloves second. Wash the hands thoroughly with alcohol-based foam hand cleanser. All personal protective equipment should be removed before leaving the client room. Isolation gowns are the first piece of personal protective equipment to be donned and the last to be doffed. Gloves are donned last and doffed first. Hands should be washed with warm water and antibacterial soap. Hand sanitizer is not sufficient when caring for a client with C. diff. Outside the room, remove the gown first and the gloves second. Wash the hands thoroughly with alcohol-based foam hand cleanser. All personal protective equipment should be removed before leaving the client room. Isolation gowns are the first piece of personal protective equipment to be donned and the last to be doffed. Gloves are donned last and doffed first. Hands should be washed with warm water and antibacterial soap. Hand sanitizer is not sufficient when caring for a client with C. diff. Gown and gloves should be worn when caring for clients with Clostridium difficile at all times. A supply should be kept outside the patient's room with a sign posted outside the patient's room to remind staff and visitors of the precautions. Hand sanitizer is not sufficient for prevention of the spread of clostridium difficile and after contact, health care providers should perform hand hygiene with soap and water.Correct order rationale:The nurse should first place a sign on the door identifying the need for contact precautions for any entering the room.The nurse should next gather supplies or obtain a designated cart with supplies needed and place outside of client's room.The nurse should wash hands with soap and water or hand sanitizer prior to donning apparel but should use soap and water after removing protective apparel for clients with clostridium difficile.The nurse should don gown and gloves when caring for clients with Clostridium difficile to prevent contamination.

intake and output (I&O)

Intake and output is the monitoring of fluid that a client takes in and puts out. Oral intake includes the measurement of fluids and solids that become liquid at room and body temperature. It does not include solid food. Output refers to loss of fluid from the body. Sensible fluid loss can be accounted for and measured, such as diarrhea, emesis, blood, or urine. Wound drainage in devices can be measured but only approximated on dressings. Clients also experience insensible fluid loss, which can only be approximated. This includes fluid loss through the skin and lungs. Insensible loss may increase if a client is hyperthermic or tachypneic. A nurse cares for a client with a prescription for recording strict intake and output for the purpose of volume replacement. Which information does the nurse include in the documentation? Select All That Apply Urinary output Urinary output is sensible fluid loss and must be measured and recorded. Emesis Emesis is sensible fluid loss and must be measured and recorded. NOT: Diaphoresis Diaphoresis is insensible fluid loss. This can be noted in the progress notes, but cannot be counted for intake and output. Stool count Numbers of stools are not counted as a measurement of volume output. If the client is having diarrhea stools, the actual fluid volume is measured and recorded in mililiters. Dressing drainage Drainage on a dressing can be approximated but not accurately measured. It is documented on a narrative note. Drainage into a post-surgical collection drain, like a Jackson-Pratt bulb, is measured and recorded in intake and output.

Health disparities

Nurse advocates work to change unfair laws, policies, and practices. In order to review current health disparities, the nurse advocate will study eras prior to the Civil Rights Movement, which provided greater equality for those of various ethnicities and cultures. The nurse advocate may challenge state or federal laws; however, this occurs when the nurse is trying to change unfair laws. A public health nurse is inspired to work as an advocate, helping to eliminate health disparities within the community. What action does the nurse take to best support eliminating health disparities? Studying pre-Civil Rights Movement health care issues. Studying the eras prior to the Civil Rights Movement, during which time discrimination based on race, gender, and other factors was both legal and accepted as the cultural norm, can inform current efforts to eliminate health disparities. NOT: Working to change state health care law. The nurse acting as advocate works to change unfair laws, policies, and practices. As advocate, the nurse may challenge unfair state laws; however, this is not the best answer choice because the question does not indicate that there is an unfair state law in need of changing. Working to change federal health care law. The nurse acting as advocate works to change unfair laws, policies, and practices. As advocate, the nurse may challenge unfair federal laws; however, this is not the best answer choice because the question does not indicate that there is an unfair federal law based on nursing ethics. Studying post-Civil Rights Movement health care issues. While it is not uncommon for the nurse advocate to study eras which have occurred after the Civil Rights Movement, this action would not be best for informing current efforts to eliminate health disparities because significant health disparities occurred prior to the Civil Rights Movement.

Sterile field

Nurses should take care to perform procedures that require sterile asepsis in order to avoid risk of contamination. A sterile field should have a sterile surface which may be a work area draped with a sterile towel or wrapper. Nurses need to follow principles of asepsis in order to keep the client free from risk of infection. A nurse prepares for a sterile dressing change for a client. Which are necessary components of maintaining sterility during a procedure? Select All That Apply Keeping the sterile paper sheet free from moisture Moisture allows microorganisms to move across a cloth or paper barrier. Avoiding coughing or talking during the procedure Coughing or talking may transmit microorganisms from saliva. Maintaining a position that faces the sterile field Those using the field should be face to face and should not turn the back to the sterile field. NOT: Reaching across the created field for needed supplies Reaching over a sterile field during a procedure could result in contamination. Keeping arms below waist level during the procedure Arms should be above the level of the waist to prevent contamination. A sterile field is an area free of microorganisms that is used as a work area during a surgical procedure. Always be aware that the sterile field is understood to be contaminated and must be redone if an unsterile item touches the field, someone reaches across the field, the field becomes wet, the field is left unattended and uncovered, or the nurse's back is turned away from the field. The nurse uses which technique for preparing a sterile field when assisting in surgery on a client? Drop packaged sterile items into the field with the opening facing down. When adding a sterile packaged item, grasp the package flaps and pull apart half way, bringing the corners of the wrapping beneath the package. Hold the package over the field with the opening facing down, pull the flap completely open, and snap the sterile item onto the field. NOT: Open the outermost fold of the sterile pack toward the body. When opening a sterile pack, unfold the outermost fold away from the body. Unfold the sides of the pack outwards, and open the final flap toward the body, stepping back and away from the sterile field. Place basins toward the middle of the sterile field. Place basins and bowls near the edge of the sterile field so that liquids can be poured without reaching over the field, potentially dropping contaminants into the field. Use any available forceps to add additional items to the field. Use only sterile forceps if necessary to add additional items to the sterile field. A sterile field is an area free of microorganisms that is used as a work area during a surgical procedure. Always be aware that the sterile field is understood to be contaminated and must be redone if an unsterile item touches the field, someone reaches across the field, the field becomes wet, the field is left unattended and uncovered, or the nurse's back is turned away from the field. The nurse prepares a sterile field for a procedure. The nurse performs the steps in what order? (Place each option in order, from first action to last.) Inform client of procedure and how to avoid contaminating the field. Inspect the sterile packages for tears, wetness, and expiry dates. Open packages and pop onto sterile field without touching field. Don sterile gloves being careful to keep hands above waist level. Arrange equipment on the sterile field avoiding the one-inch outer border.

Diet

Older adults need to practice health promotion and illness prevention to maintain wellness. Common health issues faced by older adults involve poor nutrition and hydration. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A. Older adults need education about consuming a balanced diet and making healthy food choices. The nurse discusses healthy behaviors with an older adult client. Which health-promoting behaviors does the nurse recommend for the client? Select All That Apply Increase calcium intake to at least 1,000 mg daily. Calcium intake should be between 1,000-1,500 mg daily. Older adults should also discuss taking a vitamin D supplement with their health care provider. Consume five or more servings of vegetables per day. The recommended consumption of vegetables for older adults is at least five servings per day. Vegetables can be fresh, frozen, canned, or dried. NOT: Consume three or more servings of grain products per day. The recommended consumption of grains for older adults is at least six servings per day. At least half of grain servings should be whole gain and high in dietary fiber. Consume 60-75 grams of fiber per day. Older adults should increase fiber intake to 35-50 g per day to prevent constipation. Reduce saturated fat intake to less than 30% of calories. Total fat intake should be less than 30% of total calories. Saturated fats should be less than 10% of total calories.

Older adult

Older clients must adjust to many developmental changes associated with aging, such as retirement, fixed income, decreasing health, redefining relationships, and death of loved ones to maintain a high quality of life. The nurse listens carefully to the client's statements to determine risk of negative coping mechanisms. The nurse cares for an older adult client who retired after 30 years at the same job. Which of the client's statements concern the nurse that the client may not be coping well with the transition? Select All That Apply "I just take it easy most days since my knee hurts." A developmental task of the client who is older is adjusting to a decrease in health and physical strength. The client who is coping with this might find an alternative way to exercise in spite of knee pain. "I like to stay home because I am on a tight budget." Adjusting to a fixed income is a challenging task for many clients who are retiring. However, there are volunteer and community activities that require little or no money. "I sleep a lot because no one needs me anymore." Retirement means not seeing work friends and colleagues on a daily basis. Adjusting to this is a developmental task for the client who is older. NOT: "I just joined a gardening club in my neighborhood." Volunteering in the community is a positive way to cope with retirement. "I watch my granddaughter every afternoon now." Watching grandchildren is a way older clients can redefine relationships and provide a sense of purpose to life in retirement. In older adults, decline in mobility and increased fall risk is often a result of fear of falls and client's avoidance of activities. The nurse asks the client about what is happening from their perspective before continuing the assessment based on assumptions. The nurse performs an admission assessment for an older adult client with a sacral ulcer, balance problems, and depression. The client states, "I don't take walks as much as I used to." What is the best response by the nurse? Ask the client to talk more about the decrease in walking. The first thing the nurse needs to do is gather additional information about the client's reported decrease in movement. Through discussion, the nurse determines if the problem is related to depression, dizziness, decreased strength, fear of falling, or other reasons. NOT: Observe the client ambulating in the room and hallway. The nurse does need to assess the client's gait, but first needs to determine what the client sees as the issue. This helps the nurse perform focused assessment and interview. Assess the client's wound pain using an intensity scale. The nurse does assess the client's pain, but it is more important to get to the root of the problem. Why did the client get an ulcer? Is it related to the decreased ambulation? Screen for depression using a standard tool. The client is known to experience depression. Screening again may offer additional insight, but is not the most useful nursing action.

Pain Origin

Pain of a peritoneal origin can result from a variety of client problems. It is important to locate the origin of pain to help determine the cause of the pain. Pain can be localized, projected, referred, or radiating. Communicating assessment findings to the provider requires a thorough assessment and determination of a suspected location of origin. Peritoneal pain is localized to the abdominal muscles, which are usually rigid, with no radiation to other areas. Renal pain is primarily in the flank area but radiates to the abdomen, back, and groin region. Biliary pain is generally reported only in the right upper quadrant but often radiates to the right shoulder. Meningeal pain is associated with the head and neck region. A nurse completes an assessment on an assigned client. The client is lying still and reports abdominal pain. The nurse palpates a rigid abdomen and the client reports increased pain with any movement. How does the nurse document the origin of the client's pain? Peritoneal Peritoneal pain results in a rigidity of the abdominal muscles and is increased with movement. NOT: Meningeal Pain of meningeal origin is associated with a headache, nuchal rigidity, and photophobia. Biliary Pain of biliary origin would be indicated in the right upper quadrant and likely radiate to the right shoulder. Renal Pain of renal origin would begin in the flank area and radiate to the lower abdomen, back, and groin regions.

Float nurse

Pediatrics is a very different specialty, and nurses should not jeopardize their RN license by taking on an assignment without proper training. The charge nurse for this temporary assignment will usually be aware of the nurse's restricted knowledge and adjust the assignment accordingly. The nurse should ask the supervisor for advice about which tasks the nurse is qualified for. A nurse who works in adult medical-surgical care floats to a pediatric intensive care unit (PICU). The nurse has no pediatric experience. Which action does the nurse take? Contact the nursing supervisor to determine tasks the nurse is qualified to perform while working in the PICU. The nurse should contact the supervisor to identify tasks the nurse is qualified to perform and ones the nurse should not take on as an assignment without appropriate training. NOT: Ask the charge nurse on the pediatric unit to explain differences in the care of pediatric clients. Asking the charge nurse to explain the differences in care does not ensure the nurse is qualified to provide needed care. Ask the charge nurse for a reduced assignment load because the nurse is unfamiliar with the care provided. Asking the charge nurse for a reduced assignment may be appropriate after identification of tasks the nurse is qualified to perform. Inform the charge nurse on the home unit of a refusal to float due to inexperience with pediatric clients. The nurse should not refuse to float to another unit but should work to determine appropriate tasks that can be performed.

proper documentation

Proper documentation criteria includes descriptions, such as objective findings that are smelled, seen, felt, or heard. Subjective information including symptoms and response to therapies may include statements made by the client which should be recorded using exact words with the use of quotations when appropriate. Changes should be noted and documentation should be sequential and organized. Documentation should relate to the care of the client, be factual and specific, and avoid judgements and interpretations. Drawing conclusions about a client's feelings or thoughts is not appropriate documentation. The nurse makes a client care note. Which note demonstrates appropriate nursing documentation by the nurse? Select All That Apply Stage II pressure ulcer on sacrum, measures 4 cm by 2 cm; wound border pink; absorbent dressing intact, no drainage. This provides objective, factual data related to assessment findings and is correctly documented. Left lower lobe lung with coarse crackles, right lobe clear to auscultation, client reports cough is improved. This provides objective, factual data related to assessment findings and is correctly documented. NOT: Client makes reports regarding previous shift nurse and requests discharge home due to poor care received. This is information about client feelings and is not objective documentation. If this note used quotation marks to demonstrate it was a direct client communication, it could be considered correct documentation. Client didn't sleep at all during night, feels worse today, and demands intravenous line be removed. This does not provide information regarding specifics of what the client feels and should be in quotation marks if stated by client. Abdomen hurts when touched; bowel sounds can't be heard; client hasn't passed gas all day. Documentation should include professional and clear terminology.

Post-op hypothermia

Surgical suites are kept at cooler temperatures for safety precautions during procedures. Due to this and blood loss during the procedure, heat loss commonly occurs during surgery, and clients are admitted to the post-anesthesia recovery unit (PACU) with lower-than-normal body temperature readings. The use of forced air warming units in the PACU not only helps to begin to stabilize the client's temperature back to normal levels but also provides comfort for the client. Assessment data including level of consciousness, temperature, pulse, respirations, oxygen saturation and blood pressure are documented frequently. Clients must reach discharge criteria before moving to a regular care unit. Criteria for discharge may include stable vital signs, normal body temperature, return of reflexes (if general anesthesia), ability to tolerate fluids, and adequate urine output. A nurse cares for a postoperative client who is in the post-anesthesia care unit (PACU) after an appendectomy. On admission to the PACU, the nurse assesses the client's vital signs and documents a temperature of 94.5 ℉ (34.7 ℃). What does the nurse do next? Select All That Apply Apply a forced warm air blanket. Forced warm air blankets can be utilized to re-warm a client who is cold after surgery. Continue to monitor vital signs. The client's vital signs should continue to be monitored until the client meets discharge criteria. NOT: Contact the primary provider. The primary care provider should be notified if the client's temperature does not begin to stabilize after being in the PACU for one to two hours. Turn up the room's thermostat. Adjusting the thermostat in the PACU will not help to improve a client's core temperature. Wait for the temperature to rise naturally. Because heat loss is common and surgical suites are kept at cooler temperatures, clients often need some assistance with returning to a normal body temperature.

Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA privacy rule establishes guidelines for the protection of protected health information. Covered entities may provide medical records to receiving facilities without the authorization of the client; however, the sending facility should use judgment to send only pertinent medical records necessary for the referral. A nurse cares for a client who requires a referral to a wound care center for a non-healing ulcer. What is the nurse's understanding of the referral process as it relates to the HIPAA privacy policy? The health care provider may provide pertinent medical records to the receiving facility without the client's authorization. The HIPAA privacy rule establishes protection for personal health information. However, covered entities may provide the client's medical records to a receiving facility without the client's authorization, in order to ensure the continuity of care for the client. NOT: The health care provider cannot provide the client's medical records to the receiving facility without the client's authorization. It is not a violation of the HIPAA privacy rule to provide the client's medical records to the receiving facility without the client's authorization, as long as the disclosure is for the continuity of care. The health care provider may only provide demographic medical records to the receiving facility without the client's authorization. The receiving facility requires more than just demographic information in order to procede with a referral. The health care provider may send the entire client medial record to the receiving facility without the client's authorization. While covered entities may send medical records to receiving facilities without the client's authorization, the sending facility should use good judgment and due diligence in providing only pertinent information for the referral.

Maslow Hierarchy of Needs Theory

The Maslow hierarchy of needs is used by nurses to understand how different human needs are related to one another. According to the model, certain needs are more basic than others. The model is in pyramid form: physiological needs form the base, followed by safety and security, love and belonging, self-esteem, and self-actualization. Self-actualization tops the model because it is the highest expression of an individual's potential. A client experiences an acute myocardial infarction (MI). The nurse plans care for the client and knows which nursing diagnosis is the most important? Risk for self-care deficit related to physical illness Risk for self-care deficit related to physical illness is the priority nursing diagnosis. According to the Maslow hierarchy of needs, physiological needs are to be met before others can be. NOT: Risk for ineffective coping related to current medical condition Risk for ineffective coping related to current medical condition is not the priority nursing diagnosis. Physiological needs should be met before all other needs can be met appropriately. Risk for situational low self-esteem related to crisis of MI According to the Maslow hierarchy of needs, self-esteem needs cannot properly be met before the physiological, safety and security, and love and belonging needs. Risk for spiritual distress related to physical illness Risk for spiritual distress would not be the priority nursing diagnosis. According to Maslow's hierarchy of needs, other needs should be met before spiritual ones.

Adolescent client

The adolescent client is transitioning between childhood and adulthood. The nurse promotes a therapeutic relationship with this client by promoting independence with health interviews, empowering the client to ask questions, and remaining objective. A nurse cares for an adolescent client. What statement from the nurse promotes therapeutic communication? "What concerns do you have at the moment?" The nurse communicates with open-ended questions, allowing the adolescent client the opportunity to discuss concerns before asking additional questions. Then, the nurse might explain that it is necessary to ask additional questions to better understand the client's health. NOT: "Are you feeling more depressed today?" The nurse avoids closed questioning and leading questions. Only use directed questions if necessary, after asking open-ended questions. "Let's include your parents in this checkup." The nurse ensures confidentiality and privacy of the adolescent client. It is best to interview the client without parents, if possible. "Everything that you tell me is confidential." The nurse legally must report physical abuse, sexual abuse, or if the client is suicidal. Promoting a therapeutic relationship involves being truthful with the client.

Fever interventions

The average temperature range for an adult client is 96.8 °F (36 °C) to 100.4 °F (38 °C). When the body temperature elevates, interventions can be applied to increase heat loss, reduce heat production, and prevent complications.The health care provider may request culture specimens for analysis, such as urine, blood, sputum, and wound drainage. The nurse cares for a client with the following vital signs: temperature 102.2 °F (39 °C), pulse 95 beats/min., respirations 18 breaths/min., and blood pressure 118/79 mmHg. Which nursing intervention does the nurse implement? Encourage the client to perform oral hygiene. When clients have a fever, the mucous membranes dry easily from dehydration. Clients should be encouraged to perform oral hygiene such as mouth rinses to promote comfort. NOT: Limit the client's fluid intake. Fevers cause an increased metabolic rate and insensible water loss. Clients should be encouraged to drink eight to ten eight-ounce glasses of fluid per day if cardiac and renal function are intact. Encourage the client to ambulate frequently. The nurse should attempt to minimize heat production by limiting physical activity and reducing activities that increase oxygen demand such as excessive turning and ambulation. Rest periods should be encouraged. Cover the client with additional blankets. The nurse should attempt to maximize heat loss by reducing external coverings such as additional blankets and heavy clothing as tolerated by the client (without causing shivering).

Circulating Nurse

The circulating nurse is responsible for positioning the client and supplying the appropriate equipment and sterile supplies preoperatively. The circulator also helps ties the surgeon's and scrub nurse or scrub technician's gowns. Intraoperatively, the circulating nurse is responsible for monitoring the sterile field for any contamination during the procedure but is not "scrubbed in," or sterile, and is instead available to provide any additional supplies needed (or to replace any contaminated supplies) and to document the procedure. The circulator must also account for all gauze, needles, and equipment used intraoperatively before the incision is closed. A nurse completes an orientation program to be a circulating nurse in the operating room. As a circulator, for which tasks will the nurse be responsible? Select All That Apply Tying the surgeon's and scrub nurse's gowns The circulating RN assists both the provider and scrub nurse with gowning and maintaining sterility by tying the gowns in the back. Positioning the client according to procedure The circulating RN is responsible for positioning the client on the operating room table. Providing the scrub nurse with supplies The circulating RN is responsible for providing additional supplies as needed during the surgical procedure utilizing surgical asepsis. NOT: Maintaining strict asepsis inside the sterile field The circulating RN is responsible for monitoring for a break in asepsis, but the scrub nurse is responsible for maintaining surgical asepsis within the field. Handing instruments to the surgeon intraoperatively The scrub nurse is responsible for handing instruments to the surgeon during the procedure.

Falls

The most common accident among older adults in a hospital or nursing home setting is falling. All inpatient health care settings are required to perform a fall assessment on admission and daily. Common risk factors associated with falls include multiple illnesses, weakness, confusion, sensory impairment, and substance abuse. Evidence-based interventions to prevent falls are in place for all clients. These include monitoring activities, reminding clients to call for help before getting out of bed, encouraging clients to use grab bars, assisting clients to the toilet regularly, providing adequate lighting, and keeping clients' belongings within reach. Additional interventions should be applied for clients at high risk for falls, including moving clients near the nurse's desk, encouraging family to stay with the client, using alarms for the bed and chairs, and using low beds. Place call light and frequently needed objects within reach of patient. • Encourage patient / families to call for assistance. • Keep eyeglasses regularly cleaned and accessible. • Use properly fitting, nonskid footwear or socks. • Keep floors clutter / obstacle free (with attention to path between bed. The nurse cares for a client at high risk for falls. Standard fall precautions are already in place. Which additional intervention does the nurse implement for the client? Select All That Apply Provide the client with a low bed. Use of a low bed is an intervention used specifically for clients at high risk of falls. It is implemented in addition to standard fall prevention interventions. Use a bed and chair alarm. Use of a bed or chair alarm is an intervention used specifically for clients at high risk of falls. It is implemented in addition to standard fall prevention interventions. NOT: Remind the client to use eyeglasses. Reminding the client to use eyeglasses or hearing aids is a Standard fall reduction intervention that should be in place for all clients in a health care setting. Keep the call light within reach. Keeping the call light within reach is a Standard fall reduction intervention that should be in place for all clients in a health care setting. Orient the client to the environment. Orienting the client to the environment is a Standard fall reduction intervention that should be in place for all clients in a health care setting. The most common accident among older adults in a hospital or nursing home setting is falling. All inpatient health care settings are required to perform a fall assessment on admission and then daily. Common risk factors associated with falls include multiple illnesses, weakness, confusion, sensory impairment, and substance abuse. Evidence-based interventions to prevent falls are in place for all clients. Additional interventions should be applied for clients at high risk for falls. The nurse performs a fall assessment on a client. The nurse identifies which as the most important predictor for a fall? The client reports falling last week. A recent history of falling is considered the single most important predictor for falls. NOT: The client reports urinary urgency. Urinary urgency and incontinence are considered risk factors for falls. The client uses a walker to ambulate. Gait instability is considered a risk factor for falls. The client is 85 years old. Advanced age (greater than 80 years old) is considered a risk factor for falls.

nursing diagnosis

The most important nursing diagnosis is one that presents an active threat to the client's physiological status. Current nausea and the associated immediate risks take priority over impaired transfer ability, risk of infection, and mild acute pain. When treating multiple problems, the nurse should prioritize and address the most urgent and active problems before addressing other issues as a means of promoting safety and physiological integrity. The nurse cares for a client in the postanesthesia care unit (PACU) after general anesthesia was given for an open small-bowel surgery. The nurse determines which nursing diagnosis is the most important when caring for the client? Nausea related to manipulation of intestines as evidenced by client report Nausea can occur when the intestines are manipulated. Nausea and vomiting may be further increased as a result of general anesthetics received during surgery. Postoperative nausea and vomiting can stress the abdominal incisions and place the client at risk for aspiration. NOT: Acute pain related to surgery as evidenced by pain score of 4 out of 10 Pain of 4 out of 10 is considered mild. Although it should be addressed, it is not the most important nursing diagnosis as it does not pose an immediate physiological threat. Risk for infection related to recent open abdominal surgery Risk for infection is significant after surgery, but it is not the priority, because an active problem (e.g., nausea) takes precedence. Impaired transfer ability related to sedation as evidenced by drowsiness Inability to transfer related to drowsiness is not a priority because transferring does not have to occur in the immediate postoperative phase, such as in the PACU.

Ambulation

The nurse offers ambulatory clients opportunities to ambulate. When these are refused, the nurse helps the client in any way that is needed and documents care refused and teaching performed. When the nurse offers bathroom assistance for a client with chronic nocturia, the client refuses, stating, "I only use my bedside commode at home." What is the best response by the nurse? Agree to the client's wishes and explain the benefits of ambulation. The nurse assists the client and meets the request. The nurse also teaches the importance of increased activity for respiratory, circulatory, and musculoskeletal status. NOT: Tell the client they are required to ambulate to prevent blood clots. The nurse cannot force the client to ambulate. Ambulation does reduce blood clot occurrence, but a trip to the bathroom is not enough activity to definitely produce this benefit. Ask the client to talk more about why they desire the bedside commode. The client does not owe the nurse an explanation for wanting to use a bedside commode. Tell the client that using the bedside commode reduces the risk of falls. A bedside commode can reduce falls if the client is unstead and does not have assistance available. While under the nurse's care this may not be an issue. There are many causes for a client to lose the ability to support themselves while ambulating. Syncope (loss of consciousness due to poor cerebral perfusion), muscle weakness, or neurological causes are a few. The nurse's priority is to minimize the risk for injury to both the client and the nurse. Prevention is preferred and for clients with risk factors the nurse assesses lying and standing blood pressure, assesses the client as positions are gradually changed, and advocates for the use of assistive devices. The nurse assists a client with ambulation when the client no longer can support themselves. What actions does the nurse take? Select All That Apply Reassure the client and guide them through the actions. The client will be frightened and the nurse offers reassurance while telling the client the nurse will be lowering them to the floor. Extend one leg and let client slide against it to the floor. Taking a wide stance and extending a leg help ease the client down while distributing the client's body weight more evenly, protecting the nurse from back injury and the client from abruptly falling to the floor. Bend knees to lower the nurse's body and ease client to the floor. Once leaning on the nurse's extended leg, the nurse bends the knees to reduce the distance the client needs to be lowered to the floor. NOT: Embrace the client from behind under the arms for support. The nurse should not hold the client under the arms as this may cause injury. When ambulating a weak or unsteady client, the nurse should have a transfer belt on the client. The nurse should use this to support the client on the way to the floor. NOT: Call loudly for help in assisting the client back to bed. Before calling out, the nurse secures the client and eases them to the floor. Shouting for help may panic the client and increase the risk for injury. The nurse will call for assistance once the client is safely supported on the floor.

older adult health promotion

The nurse promotes the health of this client by teaching the client to exercise regularly, maintain appropriate weight, use alcohol in moderation, quit smoking, socialize, wash hands, get immunizations, and participate in regular health checkups. These measures improve the quality of life for the client who is older and prevent health complications. The nurse cares for a client who is 69 years of age at an outpatient checkup. Which client statements demonstrate to the nurse that the client understands health promotion teaching? Select All That Apply "I will see my dentist at least twice a year." Regular dental checkups are part of health promotion for the client who is older. "I will try to eat leaner meats from now on." A low-fat diet is recommended for the client who is older to reduce vascular disease risk. NOT: "I will avoid exercising when I feel tired." Regular exercise is recommended for the client who is older. Encourage the client to find an alternate exercise routine if feeling fatigued. "I will avoid people during the cold season." Socialization is recommended for clients who are older. Promote good hand washing for the client who is older during cold season. "I will quit drinking any wine, beer, or liquor." Moderate alcohol use is acceptable for the client who is older.

Diabetes Diet

The nurse's role is to help the client make informed choices by ensuring the client is aware of the consequences of those choices. This is in keeping with principles of autonomy and respect for the client as an individual. Once the client is aware of the risks, the choices made have to be accepted as the client's right. Within the parameters of what the client is able to adhere to, the nurse then works with the health care provider to individualize the care to ensure the plan works for this client. A client continues to eat foods outside the prescribed diabetic diet despite repeated education about the risks. What is the best response by the nurse? Assist in revising the plan of care to accommodate the client's preferred diet. The nurse and health care provider work with the client to devise a treatment plan the client can adhere to in an effort to optimize blood glucose levels. NOT: Ask the dietician to limit meals to fewer carbohydrates to compensate for the client's snacks. Without the client's knowledge and participation, this would breach ethical practice, which respects the client as an individual with the right to self-determination. Restrict the client's access to foods and beverages outside the prescribed diet. The client has the right to self-determination. If the client understands the risks associated with the choice, the nurse cannot restrict the client's right to make this choice. Once discharged, the client will make choices freely, and the nurse posing external controls while in the hospital will create a false impression of the client's treatment needs. Tell the client treatment can be refused if noncompliance continues. This is not a grounds for treatment refusal; the plan of care can be altered to meet the client's needs and abilities.

Home care nurse

The role of the home care nurse is to monitor the client's health and safety in their home. If a client is not compliant with their care the nurse must first assess their current health status to ensure they do not require immediate medical interventions. The nurse will re educate and reinforce health education and goals with the client to ensure they fully understand the need for oxygen and how it impact their overall health. A client with chronic obstructive pulmonary disease is not wearing their oxygen when the home care nurse arrives. How does the nurse respond? Select All That Apply Assess the client's movement around the home. Assessing a client's ability to navigate safely in their home is important. Assessing their oxygen levels and breathing would take priority. Obtain a reading with the pulse oximeter. It is important for the nurse to assess the client's oxygen levels. Orders are created to keep a client's oxygen at a certain level. A low oxygen level could be an emergent situation. Listen to the client's lungs. Assessing lung capacity is an important part of the assessment process. The nurse must know how much air is getting into the client's lungs and if there are any wheezes or diminished areas. Check skin integrity and placement of the nasal cannula. The nasal cannula may have a poor fit and be causing skin breakdown. This would be a reason that the client is not wearing their oxygen if it is causing pain and discomfort. NOT: Call the health care provider to request a prescription change. It might be appropriate to review the order with the HCP but noncompliance with O2 use would not warrant changing the prescription. The client needs to be reeducated on the importance of using oxygen.

suicidal attempts

The safety of the nurse and client is the first priority. The client cannot be safely assessed in this situation. Remaining calm, the nurse should call for help and then request that the client leave the area to move to a treatment room to be assessed. If the client does not agree, another staff person can provide assistance by removing the broken glass, but only after the first nurse confirms that the client is not a threat to the staff. A nurse makes rounds on assigned clients. In one of the rooms, the nurse finds a client in the bathroom with lacerations to the wrists. The client is surrounded by broken glass and blood and appears calm. Which action by the nurse is the priority? Immediately call for help from another staff member. The safety of the nurse and client requires that the nurse first call for help. NOT: Move the glass away from the patient to provide for safety. Moving the glass may be necessary, but the nurse should first call for help. Kneel on the floor beside the client and assess injuries. The nurse will need to assess the extent of injury but should first call for help. Assist the client to an area for treatment of injuries. The client may need to be moved to an area for treatment, but the nurse should first call for help.

Toddler Safety

The toddler stage is a period where there is much exploration of the environment in which the client lives. Toddlers are at risk for sustaining injuries due to increased activity. Safety and prevention information needs to be communicated to parents by healthcare providers regarding motor vehicle accidents, falls, drownings, burns, and accidental ingestion of poisonous substances, including medications. A nurse provides education to a parent regarding safety measures when caring for a toddler-age client. Which statement by the parent indicates that the teaching provided by the nurse regarding safety has been effective? "All medications should be kept in a locked cabinet." Toddlers are curious, and medications and other poisonous substances should be kept away from reach and in a locked cabinet. NOT: "I should give ipecac syrup if a poisonous substance is ingested." Ipecac syrup is not recommended for routine poison treatment in the home. The poison control center should be contacted to determine whether vomiting is appropriate. "I should keep my child within my sight at all times." Parents should monitor toddlers closely, but keeping them within eyesight at all times is an unrealistic expectation. "Feeding my child cooked food can cause burns." Food should not be too hot, but it is reasonable for it to be cooked.

preventative care

There are six levels of health care services: primary, preventive, secondary, tertiary, restorative, and continuing care. -Primary care involves health promotional activities such as yoga classes, prenatal care, family planning, and nutritional counseling. -Health promotion lowers the cost of health care by reducing the occurrence of disease and minimizing complications. -Preventative care is disease-oriented and reduces and controls risk factors for disease like immunizations and occupational health programs. -Secondary care is for emergent needs, and tertiary care involves intensive and subacute care. -Restorative care includes activities such as rehabilitation programs and home care. -Continuing care includes care in assisted-living facilities and psychiatric and older adult day care. The nurse teaches a class about health care services for disease prevention. Which information does the nurse include related to preventative care? Select All That Apply Immunization Preventative care, such as immunizations, focuses on risk factors for diseases and activities that lower and control risk factors. Wearing a bicycle helmet Wearing a bicycle helmet is considered preventative care as it is an activity that targets risk factors for a particular problem. Blood pressure assessment Blood pressure monitoring is preventative care because it is designed to assess for risk factors for disease (e.g., heart attack risk, renal failure risk) and serves to lower the disease incidence. NOT: Exercise classes Taking exercise classes is part of primary care because it lowers the incidence of disease and reduces complications. Nutrition counseling Nutrition counseling is considered primary care because it reduces the incidence of disease and helps lessen complications.

transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) is a form of neuromodulation analgesia that safely administers low-voltage electrical current to both deep and superficial nerves. It is used for chronic pain. The electrodes should be placed over or near the site of the pain. Hair or other skin preparations should be removed prior to application of the electrodes. The client maintains control of the unit and turns the transmitter on when experiencing pain. Intensity of stimulation is adjusted until the client experiences relief of pain. A nurse provides discharge instructions to a client who is receiving transcutaneous electrical nerve stimulation (TENS). Which information does the nurse include? Select All That Apply "Electrodes are placed over the painful site." Electrodes should be placed over or near the site of pain. "You can adjust the voltage yourself." The client controls the voltage settings. "You can adjust the pulsation yourself." The client controls the pulsation settings. "TENS is a form of neuromodulation analgesia." TENS is a form of neuromodulation therapy. NOT: "This therapy is often not very effective." Effectiveness varies but is known to be quite effective for most clients.

Reporting injuries

Work-related injuries or illnesses other than minor ones must be reported to OSHA. OSHA determines that minor refers to injuries or illnesses that require first aid only, such as bandages, irrigation, or rest. Minor injuries or illnesses can be recorded internally but do not need to be reported to OSHA. An occupational health nurse performs irrigation and places an eye patch for a client with a foreign body in the eye. How does the nurse record this interaction? Record first aid measures in the internal medical record. The Occupational Health and Safety Health Administration (OSHA) states that minor injuries that require first aid measures only do not need to be reported to OSHA as occupational injuries. Irrigation and the placement of an eye patch is considered first aid and would not need to be reported to OSHA. NOT: Record as an accidental injury in the reportable injury record. The client's injury is likely accidental; however, this injury is considered minor and would not be a reportable injury. Record as a minor injury and document in reportable injury records. Eye irrigation and the placement of an eye patch is considered a minor injury; however, this does not need to be documented as a reportable injury. Document as a secondary injury in internal records. There is not enough information in the question to determine that the client's injury is a secondary injury. Additionally, the injury is considered minor and would be documented in the internal record only.

Wound assessment

Part of comprehensive wound assessment includes identifying the amount and type of wound drainage. Nurses should be aware of the cause of the wound and the amount and type of drainage expected. The health care provider should be alerted if drainage is outside expected findings. The nurses cares for a client with a leg wound. When performing a dressing change, the nurse notes a clear, watery drainage on the soiled dressing. The nurse uses which statement to describe the drainage when charting? "The wound drainage is serous." Serous drainage is a clear, watery plasma. This is the correct terminology for this client's drainage. NOT: "The wound drainage is purulent." Purulent drainage is thick, yellow, green, tan, or brown drainage. Purulent drainage may indicate infection. This is not the correct terminology for this client's drainage. "The wound drainage is serosanguineous." Serosanguineous drainage is light red and more watery than sanguineous drainage. "The wound drainage is sanguineous." Sanguineous drainage indicates fresh bleeding and appears bright red. This is not the correct terminology for this client's drainage.

Adolescent injury prevention

Injury prevention is an important component of education for the adolescent. During this period of time, these individuals seek independence and freedom from adult control. They begin to test the boundaries of independence and have a tendency to take risks. They often think illogically and lack self-control. They desire peer approval. For these reasons, they need education related to the prevention of sexually transmitted diseases when sexually active, basic safety precautions, instructions in skills required for handling motor vehicles, and safety instructions when participating in sports activities. This information is much more effective when the adolescent is involved directly. Birth control pills do not protect against sexually transmitted infections. All sexually active adolescents should be encouraged to use condoms, even if they are using another form of birth control.

Surgical Incision cleaning

The surgical incision should be cleansed in a way that is from the cleaner area to the less clean areas to avoid dragging bacteria into the granulating, healing tissue. Top to bottom is from cleaner to less clean. In to out is also from cleaner to less clean. A nurse performs wound care on a three-day postoperative client who has undergone exploratory laparotomy with vertical abdominal incision. Which describes the correct way for the nurse to cleanse the operative site? From top to bottom and then laterally from the center out In a vertical incision, top to bottom is considered cleaner to less clean. NOT: From the outer portion of the incision to the inward portion From outer to inner will bring contaminants into the area of incision. From the center of the incision and then side to side Side-to-side does not address whether the area is being cleansed from top (cleaner) to bottom (less clean). From the center of the incision and in a circular motion Horizontal incision sites are cleansed from the center outward.

Escherichia coli (E. coli)

Most E. coli are harmless and are actually an important part of a healthy human intestinal tract. However, some E. coli can cause diarrhea, urinary tract infections, respiratory illness, bloodstream infections, and other illnesses. The types of E. coli that can cause illness can be transmitted through contaminated water or food, or through contact with animals or people. It can then grow in meat that is half-cooked. It may be found in standing water, particularly in areas where animals may void or defecate. There is a community outbreak of Escherichia coli. A public health nurse instructs parents regarding measures to prevent additional infections. Which measures does the nurse include in the instructions? Select All That Apply Cook all meat thoroughly. E. coli proliferates in undercooked meat. Drink only purified water. Because E. coli can be transmitted through the intestinal tract of animals, drinking purified water helps decrease the risk of transmission. Avoid swimming in standing water. Swimming in non-treated water increases the risk of transmission and should be avoided. NOT: Sanitize kitchen surfaces twice a day. Surfaces contaminated with raw meat should be sanitized whenever indicated, not on a schedule. Wash hands with hand sanitizer after preparing food. Hands should be washed with soap and water before and after food preparation.

Teenage Health Promotion

75% of deaths for clients who are teenagers stem from suicide, homicide, motor vehicle accidents, or other accidental injuries. Cyberbullying and drug use may increase the risk of suicide or homicide for the client who is a teenager, so the nurse makes sure to address these matters. The nurse prepares a health promotion presentation for clients who are teenagers. The nurse includes which instructional material in the presentation for the clients? Select All That Apply Texting while driving Texting while driving has been shown to cause motor vehicle accidents at the same rate as driving under the influence of alcohol or drugs. Teens should be educated on these facts to prevent dangerous behaviors. Cyberbullying prevention Teenagers are at increased risk of being a victim of cyberbullying online or through texting. Educating teens about the negative effects of cyberbullying for the victim may help decrease the incidence of cyberbullying. Effects of drug use Use of street drugs and prescription drugs may have long-term negative consequences for the client who is adolescent. Educating teens and their parents about drug use may help to decrease the risk of drug usage in the teenage years. Suicide prevention Suicide risk increases into late adolescence for many groups of teenagers. Educating teens on the risks of suicide and resources available throughout the teenage years may help prevent a suicide later on. NOT: Cardiovascular disease While cardiovascular disease may occur in teenage years, it is less likely to occur than suicide, homicide, drug use, and cyberbullying. Acording to the CDC's leading causes of death by age in 2016, mortality from heart disease increases around age 35, becoming the leading cause of death around age 65.

Influenza Pandemic

Influenza pandemic is more severe than seasonal influenza in that a pandemic typically infects a greater number of individuals, has a faster rate of spread, and has a greater impact on society. Once a potential pandemic is identified, it is important to quickly notify both local and state public health departments, determine the need for isolation and quarantine, and determine the need for the entire closure of the campus in order to stop the spread of illness. A student health services nurse receives over 100 reports of university students with severe flu-like symptoms, all of whom live in the same housing unit on campus. Which actions does the nurse take in response to these reports? Select All That Apply Report the findings to both the state and local health departments. An outbreak of the influenza virus may become a pandemic and reports of these incidences are vital in making sure the spread of illness is slowed or stopped. Determine the need for isolation or quarantine measures. According to the CDC, isolation separates sick individuals with a contagious disease from individuals who are not sick. Quarantine separates and restricts the movement of individuals who were exposed to a contagious disease to see if they become sick. In a potential pandemic, isolation and quarantine may be essential to ensure that illness does not continue to spread. Determine the need for immediate closure of the entire campus. All college campuses should have an emergency response plan that includes actions to decrease the spread of communicable diseases. Determining the need for immediate closure of the entire campus is an aspect of the emergency response plan. The CDC identifies school closure as an effective means of reducing overall illness rates within communities and suggest that the value of this intervention is greatest if school closure occurs early in the course of a community outbreak. NOT: Follow campus pandemic protocols regardless of campus emergency response protocols. It is essential to follow both the campus pandemic protocols as well as campus emergency response protocols in situations involving a potential outbreak of disease or illness. Report the findings to the Centers for Disease Control and Prevention (CDC). The CDC will likely be informed of this outbreak; however, the campus first reports to public health officials prior to reporting to the CDC. This chain of command allows local government to assess various situations prior to reporting to the CDC.

demographic factors

Some of the demographic factors that are important in setting priorities for planning mental health services include poverty status, family organization, population mobility, and population heterogeneity. Demographic data of the individuals in a population may also include age, sex, education levels, incomes, marital status, occupations, religion, birth and death rates, and statistics measuring the average age at marriage or age at death.If a population has many younger people in an area with high mortality from drug-related deaths, this demographic data can be used to plan services for drug-prevention education, behavioral disorder treatment, and drug treatment. If the population is largely older, the community might instead plan for more services for those with cognitive disorders and depression. Historically, the need for mental health services in a community was based on utilization of services, but that approach was circular in that it did not plan well for unmet needs. The community health nurse evaluates the types of mental health treatment available to clients in the community. Which factor does the nurse consider as directly impacting the care needed? Community demographics Studying the demographics of a community is the most direct assessment data. NOT: Opinions of the residents Community demographics are a more reliable and direct method of assessing needs than are the opinions of the residents. Recreational facilities The number of recreational facilities may have an indirect impact on the mental health needs of the community. Religious affiliations The effect of religious affiliations on community mental health needs is indirect, not direct.

preventing food borne illness

When educating clients regarding basic techniques for food handling, storage, and preparation, information should be included regarding proper refrigeration temperatures in order to prevent the risk of foodborne illnesses. Instructions should be provided regarding storing perishable items in the refrigerator. Washing hands and rinsing fruits and vegetables should be emphasized as well. Clients should be instructed that bacteria can grow at room temperature, spoiling foods and creating risks for illness quickly. Unpasteurized milk can carry harmful microorganisms that could cause food poisoning. A community health nurse conducts health teaching on preventing food-borne illnesses among high-risk individuals. The nurse emphasizes the importance of proper food handling, food buying, and eating. Which information does the nurse include? Select All That Apply Only buy milk that has been pasteurized. Unpasteurized milk can carry harmful microorganisms that could cause food poisoning. Clean the wheel of the can opener after every use. This removes the potential for growth of microorganisms and transfer to future foods that are opened. NOT: Store-bought eggs can be stored on the counter. Store-bought eggs should be stored in the refrigerator between 34° and 40° F (1.1° and 4.4° C). Set the freezer temperature to 20° F (−6.7° C) or colder. Freezer settings should be at 0° F (−17.8° C) to prevent food from spoiling. Set the refrigerator temperature to 44° F (6.7° C) or colder. Refrigerators should be set between 34° and 40° F (1.1° to 4.4° C), with the ideal setting being 37° F (2.8° C).

Health Maintenance Organization (HMO)

A health maintenance organization (HMO) is a group of healthcare providers that have contracted with an insurance company to offer their services at a fixed price. Because of this, patients are required to select a primary care provider who is a member of the HMO to manage all aspects of their care. Rates are negotiated at a rate per member per month for each client regardless of how often services are used. It is an independent prepayment plan. A client reviews health insurance plans and discusses them with a nurse. Which option is best suited if the client wishes to have fixed payment rates? Health maintenance organization Health maintenance organizations contract with insurance companies to provide a fixed price. NOT: Private health insurance Private insurers do not offer services for a fixed price, which can lead to an unpredictable and higher cost of care. Preferred provider organization Preferred provider organizations provide healthcare services under contact with the organization but not at a fixed rate. Catastrophic health insurance Catastrophic insurance is a high-deductible, low-premium plan intended to be used in the event of a catastrophic event or illness.

needlestick injury

Avoiding needlestick injuries includes using needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices. If the nurse must use a standard syringe and needle, the nurse does not recap any needle and disposes of the sharp immediately ensuring sharps containers are not filled more than two-thirds full. The nurse administers a subcutaneous injection. What actions does the nurse take immediately after performing the procedure? Discard syringe in sharps container in client's room and put cap in a garbage can. The nurse disposes of the used syringe immediately after administration, in the client's room, and without recapping. The cap does not need to be in a sharps container so may be disposed of in a regular garbage. NOT: Recap using a scooping method, ensuring not to touch the cap until needle covered. The nurse does not recap a used needle, regardless of method used. Discard syringe without recapping in sharps container in medication room. The nurse does not transport an exposed needle from the client's room to the medication room. Place syringe with needle down into medication cup until it can be safely discarded. The nurse does not transport an exposed needle from the client's room to the medication room.

Restraints

Restraint devices should be used only when necessary and after all other considerations are exhausted. When instituted, the least restrictive device needed for the indication should be chosen. A pediatric client receives scalp vein infusion and the nurse determines restraint is needed. The nurse uses what form of restraint? Elbow device An elbow device fits around the arm at the elbow bend, is secured with a strap, and prevents flexion of the elbow. This restraint is especially useful following procedures where touching the upper extremities, head, or neck should be prevented. NOT: Belt device A belt device fits a child like a wide belt with a buckle in the back and attaches like the jacket device and would not prevent access to the scalp intravenous site. Jacket device A jacket device fits a child like a jacket or halter with long tapes attached to the side. This restraint is used to keep a child in a wheelchair, high chair, or crib. This does not prevent the child from removing a scalp intravenous. Mummy device The mummy device is a short-term restraint used on infants or small children that involves securing a sheet or blanket around the child's body so that the arms are held to the sides and leg movements are restricted. This would be excessive restraint for the indication in the question.

Discharge teaching

Discharge planning and education are aimed at teaching self-care in preparation for the client's transition from the hospital setting to home or a long-term care facility. This is beneficial because it reduces the likelihood of readmission. The client needs primary care to reduce hospitalization and medical costs. Discharge planning and client teaching should help the client become less dependent on the hospital. Increasing hospital stays will increase costs and may negatively affect client outcomes. A nurse prepares discharge planning for a client. Which best describes the goal of discharge planning and education? Educates the client on how to provide self-care while at home The goal of discharge education is to provide the client with needed information. NOT: Ensures the client will have long-term dependence on the hospital The goal is for the client to become independent with best possible outcomes. Increases the duration of the client's hospital stay to improve client outcomes The goal of client care is to decrease and minimize hospital stays with optimal client outcomes. Prevents the client's need for hospital stays in the future There is no guarantee of the prevention of hospital stays, regardless of the education provided.

Secondary Prevention

Primary health promotion promotes the health of the client. Secondary health promotion includes disease prevention and screens for testicular or breast cancer, hypertension, high cholesterol, cervical cancer, and skin cancer. Finally, tertiary health promotion begins after a client has an illness, and its goal is to return client maximum functioning. • The American College of Gynecologists (ACOG) recommends women ages 45 and older get a yearly mammogram. Women 40 to 44 years of age should have a discussion with their provider and choose whether to have a mammogram screening annually. • ACOG now recommends that women ages 21-29 receive a pap smear every 3 years, and women ages 30-65 receive either a pap smear and HPV test every 5 years or a pap smear with cytology every 3 years. The old recommendation was for yearly pap smears. • ACOG recommends a yearly clinical breast exam for female clients ages 19 and older. Encourage all female clients to have breast self-awareness, which may detect palpable breast cancer. • Teach the client to watch for the ABCDE's of melanoma, asymmetry, border irregularity, color, diameter or evolving (changing appearance). Moles with ABCDE characteristics should be checked by the dermatologist. The client who is a 46 year old female presents to a routine office visit. What teaching from the nurse promotes secondary prevention? Get a mammogram once every year. According to the American Cancer Society, women 40 to 44 years of age should choose whether to have a mammogram screening annually. Women 45 years of age and older should have an annual mammogram to screen for breast cancer malignancies. NOT: Get a pap smear once every 6 months. The client without history of cervical disease would get a pap smear every 1 to 3 years, based on factors assessed by the health care provider. Have a clinical breast exam every 2 years. When used, the clinical breast exam should be performed annually for the best chance of detecting growths and changes. Have all moles checked by dermatologist. Moles do not have to be checked by a dermatologist unless the client has suspicion of a cancer due to changes in the moles size, shape, color, or other characteristics. An annual self-skin exam is recommended.

Sleep

The nurse can institute many nonpharmacological interventions to facilitate rest and sleep. These should be based on a client assessment to develop individualized sleep hygiene interventions. However, some universal interventions include clustering of nursing activities, providing staff with noise-reduction strategies, incorporating a quiet time into the day, and reducing lighting and noise during the night. A nurse cares for a client in the acute care setting who reports lack of sleep. The nurse takes what actions? Select All That Apply Instruct staff to reduce nighttime noise. Being in an environment with nighttime activity is a primary reason the hospitalized client experiences sleep disruption or difficulty falling asleep. All staff should make an effort to be as quiet as possible to facilitate clients' rest and sleep. Cluster client care activities whenever possible. The nurse plays an important role in organizing the care of clients to reduce interruption of sleep. Not being time bound and thinking critically about what is time-sensitive versus interventions that can be delayed is part of planning care. Designate a quiet time during the day. Having a period where visitors and interventions are restricted provides the client with time to rest and is recommended but difficult to achieve in some settings. NOT: Administer sedatives 30 minutes before bed. Sedatives should be reserved for clients for whom nonpharmacological methods fail to help with sleep problems. Many sedatives carry serious risks that should be avoided, especially in the elderly. Restrict oral intake within three hours of bedtime. Some clients benefit from a bedtime snack to facilitate sleep. This can be very individual, and nurses should not restrict all intake for three hours prior to bed; caffeine should be limited and other interventions tailored to the individual experiencing difficulty sleeping.

Nursing process

The nursing process consists of assessment, nursing diagnosis, planning, implementation, and evaluation. These components are performed in consecutive order to achieve appropriate and optimal client outcomes. Understanding each component and applying it properly helps ensure the best plan of care is given to the client. The nurse cares for a client hospitalized due to postoperative complications. The nurse determines the client's care plan needs revision. The nurse demonstrates which part of the nursing process? Evaluation During the evaluation process, the nurse revises and updates the client's plan of care according to the client's status and any changes that occur. NOT: Assessment During the assessment phase of the nursing process, the nurse collects client data. Diagnosis In the diagnosis phase, the nurse determines potential or actual health problems for the client. Planning In the planning phase, the nurse determines a strategy to resolve the client's problems.

post tonsillectomy

A post-tonsillectomy client should follow the normal progression of diet after surgery, with a special consideration of preventing irritation to the throat area where the surgery took place. The client will provide the best indication of when the diet can be advanced. This may occur over just a few hours or over a day's time. A nurse receives a client from the post anesthesia care unit (PACU) after a tonsillectomy. The health care provider's prescription is to advance diet as tolerated. In which order will the nurse advance the client's diet? (Place each option in order, from first priority to last.) Correct Answer NPO Clear liquids Full liquids Soft diet Regular diet

lung sounds

Auscultation of the lungs assesses the movement of air through the tracheobronchial tree. Normally, air flows through the airways in an unobstructed pattern. Recognizing sounds of normal airflow, as well as adventitious sounds, is an essential aspect of lung assessment. The nurse assesses a client's lung sounds. Soft, breezy, low-pitched sounds are heard with the stethoscope placed over the periphery of the lung. Which sound does the nurse identify? Vesicular sounds Vesicular sounds are normal breath sounds heard over the periphery of the lung. The sounds are soft, breezy, and low-pitched. The inspiratory is typically three times longer than the expiratory phase. NOT: Wheezes Wheezes are adventitious sounds that can be heard over all of the lung fields. They are high-pitched, continuous, musical sounds heard during inspiration or expiration. Bronchial sounds Bronchial sounds are normal breath sounds heard over the trachea. The sounds are high-pitched with a hollow quality. Expiration is longer than inspiration on a 3:2 ratio. Ronchi Rhonchi are adventitious sounds primarily heard over the trachea and bronchi. The sound is loud, low-pitched, rumbling, and coarse. They can be heard during inspiration or expiration. Rhonchi can be caused by muscle spasm or by fluid or mucus in larger airways. It can also be associated with a growth or pressure from an external source.

Bacterial meningitis

Bacterial meningitis is very contagious and can be deadly if not recognized and treated right away. These factors contribute to panic in the parent of a child who may have been exposed to the condition. The way meningitis spreads depends on the type of bacteria, though close contact with others is a common way the condition is spread. Once a potential exposure is identified, the local health department works with the CDC to determine who should receive prophylactic antibiotic treatment. Vaccination is the best way to prevent bacterial meningitis, though vaccination does not allow absolute protection against the condition. One classic symptom of bacterial meningitis is photophobia, or an extreme sensitivity to light. An elementary school nurse receives dozens of frantic phone calls from parents after a note went home indicating a child at the school tested positive for bacterial meningitis. The nurse creates and distributes an educational flyer on the transmission and prevention of meningitis to the parents of the child's classmates. Which statement made by a parent indicates that the teaching is effective? "I will call the health department to see if my child needs treatment." Depending on the level of exposure and risk to the individual, a health care provider may recommend treatment with prophylactic antibiotics. The CDC recommends contacting the local health department in order to determine if an individual should receive prophylactic antibiotic therapy. NOT: "I will keep my child home from school just in case." While it makes sense to avoid exposure to disease, a child who has been diagnosed with bacterial meningitis was contagious prior to the diagnosis. This means that all of the child's classmates were exposed during the contagious period. Keeping the child home from school is not going to prevent the development of the disease. "My children have been vaccinated so they are protected." Like any vaccine, the vaccines that protect against meningitis are not 100% effective. "I will call my child's health care provider immediately if my child has sensitivity to loud noises." Photophobia, or sensitivity to light, is a symptom of meningitis. While it is acceptable for the child's parent to contact the health care provider, sensitivity to loud noises is not classic symptom of meningitis.

chest tubes

Chest tubes used to drain fluid or blood after a thoracotomy require the nurse to inspect and observe hourly to ensure sterility and patency of the drainage system. The insertion site should be secured in order to prevent dislodging. Lung re-expansion may be impeded if the system does not drain effectively due to kinks or loops in the tubing and if the system is not maintained below the level of the client's chest. The nurse should assess the respiratory status and check drainage hourly for the first 24 hours. As much as 500 to 1,000 mL may be drained in the first 24 hours. After 24 hours, the drainage should be assessed every eight hours. The chamber is usually not emptied unless it is in danger of coming in contact with the chest drainage tube. The nurse marks the drainage chamber at each measurement. If at any time the measurement is greater than 100 mL/hr, the nurse should contact the primary provider. If chest tube drainage is greater than 100 mL/hr, it should be reported to the physician. A nurse receives a client from the operating room after placement of chest tubes due to a chest injury. The nurse assesses 75 mL of dark red fluid flowing into the collection chamber when the client changed positions. Which action does the nurse take? Select All That Apply Mark the chest tube reservoir by amount with date and time. The amount of drainage should be marked and noted on the chest tube reservoir with date and time. Document the drainage amount, color, and client activity. The nurse should document the drainage amount, color, and client activity in the client's electronic health record. NOT: Call the healthcare provider who performed the procedure. Drainage is expected with position change and may be higher in the first 24 hours. Auscultate the client's chest for adventitious sounds. There is no indication for assessing lung sounds. Clamp the tubing closest to the client on the drainage system. The tubing should not be clamped. Chest tubes used to drain fluid or blood after a thoracotomy require the nurse to inspect and observe hourly to ensure sterility and patency of the drainage system. The insertion site should be secured in order to prevent dislodging. Lung re-expansion can be prevented if the system does not drain effectively due to kinks or loops in the system and by keeping the system below the level of the client's chest. The nurse should assess respiratory status and check drainage hourly for the first 24 hours. As much as 500 to 1000 mL may be drained in the first 24 hours. After 24 hours, the drainage should be assessed every 8 hours. The chamber is usually not emptied unless it is in danger of coming in contact with the chest drainage tube. The nurse marks the drainage chamber at each measurement. If at any time the measurement is greater than 100 mL/hr, the nurse should contact the healthcare provider (HCP). A nurse cares for an adult client post-thoracotomy with a chest tube placed to help drain the blood and fluid from the pleural space. Which hourly measurement requires the nurse to take additional action? Select All That Apply 0 mL With no drainage, the nurse would check to be certain the system is functioning correctly. 125 mL Drainage greater than 100 mL/hr should be reported to the provider. NOT: 100 mL Expected drainage is up to 100 mL/hr. 75 mL Expected drainage is up to 100 mL/hr. 50 mL Expected drainage is up to 100 mL/hr.

Rapid change in mental status

When there is a rapid change in mental status of a client, the nurse must act fast to prioritize interventions. Using the nursing process as a framework, assessment comes first to gather information. After the nurse performs an assessment, including a focused neurological assessment, the next action is to notify a member of the healthcare team. By doing so, the nurse is able to offer a comprehensive overview of the client's status and take prescriptions for additional interventions. The nurse monitors the client's airway and breathing status, then ensures that emergency equipment is available. The nurse cares for a client who suddenly becomes drowsy, is easily arousable, and has an acceptable breathing rate and pattern. In which order does the nurse perform the required interventions? (Place each option in order, from first priority to last.) Correct Answer Perform a neurologic assessment. Notify a member of the healthcare team. Monitor the client's airway and breathing. Have emergency equipment readily available.

Blood Pressure (BP) Cuff

Blood pressure cuffs, whether cloth or vinyl, have an inflatable bladder and come in different sizes to accommodate the varying sizes of the arms of children and adults. For best measurement, the bladder of the cuff should encircle at least 80% of the upper arm of an adult. The lower edge of the cuff should be placed close to the antecubital space but allow enough room to place the bell or diaphragm of the stethoscope. A cuff that does not fit properly results in inaccurate blood pressure readings. When obtaining a blood pressure on a client for the first time, the nurse should palpate the radial or brachial artery while inflating the cuff. When the pulse disappears, inflate the cuff with an additional 30 mmHg or more. This allows for an accurate reading. The client should be in a comfortable seated position with the arm level with the chest. The cuff should be applied directly to skin and not over clothing for an accurate measurement. A nurse is assigned the task of completing routine vital signs on the unit. Which actions does the nurse take when obtaining client blood pressure readings? Select All That Apply Palpate the radial pulse while inflating the cuff to determine how high to inflate. Once the radial pulse disappears with inflation, the nurse can inflate an additional 30 mmHg in order to obtain an accurate reading. Ensure the bladder of the cuff encircles at least 80% of the upper arm in adult clients. The bladder should encircle at least 80% of the upper arm. NOT: When obtaining an abnormal finding, retake the blood pressure after ten seconds to confirm. If there is a concern with an inaccurate reading, the nurse should wait five to ten minutes before reassessing. Assist the client to stand by the side of the bed prior to obtaining the blood pressure reading. The preferred position is for the client to be seated with the arm level with the heart, unless an orthostatic blood pressure reading is needed. Wrap the cuff around the forearm when the size of the upper arm does not allow the cuff to fit. The forearm is not recommended as it may provide an inaccurate measurement. The nurse should obtain a cuff of appropriate size for the client's arm measurement. Blood pressure cuffs, whether cloth or vinyl, have an inflatable bladder and come in different sizes to accommodate the varying sizes of the arms of children and adults. For best measurement, the bladder of the cuff should encircle at least 80% of the upper arm of an adult. The lower edge of the cuff should be placed close to the antecubital space but allowing enough room to place the bell or diaphragm of the stethoscope. A cuff that does not fit properly will result in inaccurate blood pressure readings. A nurse assesses a client's vital signs. Which statements regarding cuff placement when obtaining upper extremity blood pressure measurement are correct? Select All That Apply The bladder of the cuff should encircle 80% of the arm circumference. This is the correct amount that should be on the arm for an accurate blood pressure reading. The bottom of the cuff should be about 2 cm above the antecubital space. A difference of 2 cm will allow placement of the stethoscope bell or diaphragm to allow for an accurate blood pressure reading. NOT: The bottom of the cuff should be as close to the antecubital space as possible. The bottom of the cuff should allow placement of the stethoscope bell or diaphragm. The bladder of the cuff should cover the area from the elbow to the shoulder. The bladder should encircle at least 80% of the upper arm. The bladder of the cuff should be at least 16 cm in length. The length of the bladder is dependent on the size of the client's arm.

cultural competency

Culture shapes beliefs, including beliefs related to treatment for illness and response to health. Assessment of a client's and family's beliefs based on health is an important part of the process in determining client needs prior to communicating with providers or others involved in client care. Parents present to the emergency department with a school-age Chinese-speaking child who is febrile and hypotensive. During the assessment of the client, the nurse notes red, circular markings covering the child's back. Which action does the nurse take? Discuss health-related cultural practices with the parents. The nurse should recognize that a family from a different cultural background may have varying beliefs regarding health and treatment for illness. These should be explored with the family. NOT: Contact the local authorities and report suspected abuse. The nurse does not need to contact the local authorities until she has asked the parents about cultural practices which may have been used prior to bringing the child to the hospital. Notify the primary provider of suspected infection. The nurse has no reason to suspect an infection and should discuss the child's condition including any cultural treatments tried before coming the the hospital. Contact poison control for suspected exposure to a toxin. Before the nurse begins to make a plan of care, a complete assessment, including cultural concerns, is required.

Identifying an Unconscious Client

In order to correctly identify an unconscious client, the nurse should match and confirm the client's information on the identification bracelet with the information found in the client's medication record. This information is the best source of verified information and provides the best confirmation of the client's identification. The nurse administers medication to an unconscious client. How does the nurse correctly confirm the client's identity? Match the client's identification bracelet to the information on the medication record. The best way to identify an unconscious client is to match and confirm the client's information on the identification bracelet to the information on the medication record. NOT: Ask the client to state his or her identifiers while the nurse looks at the client's identification bracelet. The client is unconscious and unable to state his or her identifiers. This is not the correct choice. Read the client's identification bracelet and ask the family member at bedside if it is correct. Asking the family member for identification is not the most appropriate action by the nurse because this does not best identify the client. Have a second nurse read the client's identification bracelet to the nurse giving medications. Asking a second nurse to read the client's information on the identification bracelet is not the most appropriate action and is not necessary.

primary prevention

Primary prevention comprises efforts that are taken to prevent a disaster, such as a fire, from occurring. Secondary prevention includes efforts to reduce the intensity and duration of the crisis that has already happened and removing clients from harm. Tertiary prevention involves reducing injury and damage after a crisis, providing treatment to clients with injury. A staff nurse reviews disaster prevention and preparedness during annual hospital orientation. Which are examples of primary prevention related to fires in the hospital? Select All That Apply Assessing each client room for hazards that could result in fire, such as frayed cords Primary prevention includes efforts that are taken to prevent a disaster, such as fire, from occurring. Instructing family members who use essential oils and scented candles of their prohibited use in the hospital Primary prevention comprises efforts taken to prevent a disaster (fire) from occurring. NOT: Removing a client from a room where an electrical fire has started and pulling the fire alarm Secondary prevention includes efforts to reduce the intensity and duration of the crisis that has already occurred—such as, in this case, a fire—and removing clients from harm or working to put out the fire. Assessing clients removed from a hallway where a fire was initiated and determining the care needed Tertiary prevention involves reducing injury and damage after a crisis and providing treatment to clients with injury from the fire. Taking three clients who have second-degree burns to the emergency room for treatment Tertiary prevention involves reducing injury and damage after a crisis and providing treatment to clients with injury from the fire.

braden scale

The Braden scale is an assessment tool for predicting the development of pressure injuries. It measures six parameters: sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Each parameter is scored based on the client's situation. The maximum score possible is 23 and indicates little or no risk for developing pressure injuries. A score of 18 or less indicates at risk status. The lowest possible score is 6. •< 9 very high risk, 10-12 high risk, 13-14 moderate risk, 15-18 mild risk. •Sensory perception is scored from completely limited-1, very limited-2, slightly limited-3, and no impairment-4. •Moisture is scored from constantly moist-1, often moist-2, occasionally moist-3, and rarely moist-4. •Activity is scored from bedfast-1, chairfast-2, walks occasionally-3, and walks frequently-4. •Mobility is scored from completely immobile-1, very limited-2, slightly limited-3, and no limitations-4. •Nutrition is scored from very poor-1, probably inadequate-2, adequate-3, and excellent-4. •Friction and shear is scored from problem-1, potential problem-2, and no apparent problem-3. The nurse assesses a client for pressure injury risk using the Braden scale. The client scores a 6 on the scale. Which intervention does the nurse implement? Turn the client every one to two hours. A score of 6 is the lowest score possible on the Braden scale. The client receives one point for each of the six categories indicating the client has completely limited sensory perception, is constantly moist, is confined to bed, is completely immobile, has poor nutrition, and experiences friction or shear. The client needs complete assistance to prevent the development of pressure injuries. NOT: Provide a specialty chair pad. A score of 6 indicates the client is completely immobile and confined to bed. A chair pad is not needed at this time. Assist to standing every shift. A score of 6 indicates the client is completely immobile and confined to bed. The client is not able to stand at this time. Ambulate in the hallway daily. A score of 6 indicates the client is completely immobile and confined to bed. The client is not able to ambulate at this time.

Tuning fork tests

Tuning fork tests are used to assess for hearing loss. Both the Rinne and the Weber test use tuning forks to test how sounds or vibrations are responded to. The Rinne test compares air conduction to bone conduction. The Weber test evaluates conductive and sensorineural hearing losses. The Weber test is performed by holding the vibrating tuning fork on the midline vertex of the client's head or in the middle of the forehead. The client is then asked if the sound is heard equally in both ears or better in one ear. The sound is heard equally in both ears if the hearing is normal. In conduction deafness, which is a loss of hearing when there is interference with the conduction pathway, the sound is heard best in the impaired ear; in sensorineural hearing loss, the sound will be heard best in the normal ear; thus, the exam is able to differentiate between sensorineural hearing loss and conduction deafness. The nurse performs an ear assessment on a client with suspected hearing loss. Which result from the Weber tuning fork test indicates sensorineural hearing loss? The client hears the sound better in the normal ear. Sound heard better in the normal ear indicates sensorineural hearing loss. NOT: The client hears the sound equally in both ears. Sound heard equally in both ears indicates normal hearing. The client hears bone conduction longer than air conduction. Assessing air and bone conduction is associated with the Rinne tuning fork test, not the Weber test. The client hears air conduction longer than bone conduction. Assessing air and bone conduction is associated with the Rinne tuning fork test, not the Weber test.