ASSESSMENT 1 PRE PROCTORIO FUNDAMENTALS (NURS 100)

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. (The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.)

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints. (The use of restraints without padding can abrade the client's skin, resulting in client injury.)

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make?

"Let's talk about how the change in your job status will affect you." (This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.)

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries. (The first action the nurse should take when using the nursing process is to assess the client for injuries.)

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?

A mole with an asymmetrical appearance (An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.)

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief. (During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis.)

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take?

Turn the client every 2 hr. (The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.)

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching?

"I will hire someone to trim the tree that hangs low over the stairs of my front porch." (Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.)

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

-obtain the death pronouncement from the provider -remove tubes and indwelling lines -wash the client's body -ask the family members if they wish to view the body place a name tag on the body

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

Pupil clarity Visual fields Visual acuity -Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. -Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. -Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Exhibit 1 Nurses' Notes Day 1: Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2: IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.

The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. -Stop the IV infusion. -Elevate the client's left arm. -Apply heat to the client's left hand. (*Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. *Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. *Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.)

A nurse is caring for a client who has a new diagnosis of seizure disorder. -Exhibit 1 Nurses' Notes 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. -Exhibit 2 Medication Administration Record Carbamazepine ER 200 mg PO twice per dayLorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min

The nurse should first address the client's *Physical safety* followed by the client's *Positioning* -Physical safety is correct. The greatest risk to the client is injury from the seizure. Therefore, the first action the nurse should take is to ensure the client's physical safety by protecting the client's head. The nurse should cradle the client's head in their lap or place a pad underneath the head. -Positioning is correct. The nurse should attempt to turn the client on their side with their head tilted slightly forward. This position will protect the client's airway from the aspiration of any secretions that may occur. Therefore, this is the second action the nurse should take.

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping?

"I am relying on support from our family during this time." (This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis.)

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) Crackles Rhonchi Friction rub Normal breath sounds

Normal breath sounds (These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.)

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position. (The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.)

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 mEq/L (This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.)

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it. (This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.)

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body. (The client should hold the cane on the stronger side of her body to increase support and maintain alignment.)

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area. (An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.)

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. (Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).)

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output. (The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.)

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Determine the reasons why the client is refusing to use the incentive spirometer. (The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.)

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make?

"We would give you oxygen through a tube in your nose." (Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.)

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Decrease in heart rate (Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.)

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

Droplet (Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.)

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves. (The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate.)

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?

The client identifies the location of a fire extinguisher. (The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.)

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

Use tracheostomy covers when outdoors. (Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.)

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?

Administer the medication into the abdomen. (The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.)

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?

Advocacy ensures clients' safety, health, and rights. (Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.)

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take?

Examine personal values about the issue. (Nurses should examine their own personal values about the issue in question in order to provide care that is without bias.)

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?" (Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.)

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

** IMAGE OF NURSE HITTING THE KNEE** The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage. (A second nurse must witness the disposal of any portion of a dose of a controlled substance.)

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Compare the client's home medications with the provider's prescriptions. (The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.)

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?

Use the planning step of the nursing process to prioritize client care delivery. (Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.)

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness." (Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.)

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind." (When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client.)

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while I'm lying in bed." (Listening to music is an effective nonpharmacological intervention for the management of mild pain.)

A nurse in a provider's clinic is caring for a client who has heart failure. -Exhibit 1 Nurses' Notes *First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. *Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide.​ -Exhibit 2 Vital Signs *First Clinic Visit: Temperature 36.7° C (98° F) Heart rate 106/min Respirations 26/min BP 162/88 mm Hg Oxygen saturation 93% on room air Weight 83.9 kg (185 lb) *Second Clinic Visit: Temperature 36.7° C (98° F) Heart rate 86/min Respirations 22/min BP 142/78 mm Hg Oxygen saturation 94% on room air Weight 81.6 kg (180 lb)

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? -"I am limiting my sodium intake to 2 grams daily." -"I am eating fewer potato chips and more fruit for snacks." -"I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

During the admission process (Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.)

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?

Hydrocolloid (Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.)

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?

Notify the nursing manager. (The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.)

A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

X mL/hr= 750 mL / 7 hr= 107 answer 107 (rounded to nearest whole #)

A nurse is caring for a client who has COPD. -Exhibit 1 Nurses' Notes 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. -Exhibit 2 Vital Signs 1000: Temperature 38.6° C (101.5° F) BP 114/56 mm Hg Heart rate 99/min Respirations 32/min Oxygen saturation 85% on room air -Exhibit 3 Diagnostic Results 1200: Chest x-ray shows lung hyperinflation and left upper lobe pneumonia.

Select the 3 findings that require follow-up -Breath sounds -Oxygen saturation -Temperature (1.-Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. 2.-Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. 3.-Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.)

A nurse is caring for a client who is postoperative following abdominal surgery. -Exhibit 1 Nurses' Notes 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200: Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. -Exhibit 2 Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN pain Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting -Exhibit 3 Vital Signs 1100: Temperature 36.2° C (97.2° F) Heart rate 76/min Respirations 18/minBP 122/68 mm Hg Oxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F) Heart rate 116/min Respirations 20/min BP 112/68 mm Hg Oxygen saturation 93% on room air

Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. -Urinary output -Reported pain level -Vital signs

A nurse is caring for a client who is receiving a unit of packed RBCs. -Exhibit 1 Nurses' Notes 0800:Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815:Client reports itching and anxiety. Client's face is flushed and has hives. -Exhibit 2 Vital Signs 0800:BP 112/64 mm HgHeart rate 80/minRespirations 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air 0815:BP 106/54 mm HgHeart rate 100/minRespirations 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air

Complete the following sentence by using the list of options. The client has manifestations of *ALLERGIC REACTION* as evidenced by the client's *ITCHING* -Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Itching is correct. The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?

Use a bed exit alarm system. (The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.)

A nurse is admitting a client to a health care facility. -Exhibit 1 Nurses' Notes 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. -Exhibit 2 Vital Signs 1100: BP 138/72 mm Hg Heart rate 80/min Respirations 22/min Temperature 38.3° C (101.1° F) Oxygen saturation 90% on room air -Exhibit 3 Diagnostic Results 1400: Chest x-ray positive for inflammation and infiltrates in upper lobes QuantiFERON-TB positive (negative) Tuberculosis culture positive (negative)

*Wear an N95 mask when caring for the client *Place a container for soiled linens inside the client's room *Place the client in a negative airflow room *Remove mask after exiting the client's room -Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. -Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. -Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. -Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR) (SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.)

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions (Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.)

A nurse is caring for a client who has pneumonia. -Exhibit 1 Vital Signs 0800: Heart rate 109/min Respirations 26/min BP 125/65 mm Hg Temperature 39.2° C (102.6° F) Oxygen saturation 95% 1200: Heart rate 94/min Respirations 18/min BP 115/65 mm Hg Temperature 37.8° C (100° F) Oxygen saturation 96% -Exhibit 2 Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough -Exhibit 3 Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.​

Complete the following sentence by using the list of options. The nurse should identify that the client might be experiencing **Extravasation** as evidenced by the client's **IV catheter site.** (Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation.)

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus. (Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.)

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?

Role overload (The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.)

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate." (The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.)

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?

Acupuncture (The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.)

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

Administer the medication with the needle at a 45° angle. (The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.)

A nurse in an emergency department is caring for a client. -Exhibit 1 Physical Examination 1200: Influenza with nausea, vomiting, and diarrhea for 3 days.Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria.Plan: Admit for IV fluids. -Exhibit 2 Vital Signs 1200: Temperature 38.4° C (101.1° F) Pulse rate 126/min Respirations 28/minBP 92/54 mm Hg Oxygen saturation 93% -Exhibit 3 Nurses' Notes 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. -Exhibit 4 Medication Administration Record Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hrPromethazine 25 mg IV bolus every 4 to 6 hr PRN nausea and vomitingDiphenoxylate 5 mg PO four times dailyAcetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F)

Complete the following sentence by using the list of options. The nurse should first *Review medications that might be causing confusion* followed by *Using other methods to keep the client safe* (Review medications that might be causing confusion is correct. Using the nursing process, the first step the nurse should take is to assess for a cause of the client's confusion. Using other methods to keep the client safe is correct. After assessing for the cause of the client's confusion, the nurse should attempt alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible.)

A nurse is caring for a client who has pancreatitis. -Exhibit 1 Nurses' Notes 1000:Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. -Exhibit 2 Vital Signs 1000: BP 96/52 mm Hg Heart rate 110/min Respirations 22/min Temperature 38.4° C (101.1° F) Oxygen saturation 92% on room air -Exhibit 3 Prescriptions 1100: • CT of abdomen • NG tube to low wall suction • Serum amylase level

Select the 3 tasks the nurse should delegate to an assistive personnel (AP). -Document the client's vital -Measure the client's intake and output -Transfer the client from wheelchair to bed (*Document the client's vital signs is correct. The nurse should identify that documenting the client's vital signs is a task that is within the AP's range of function. *Measure the client's intake and output is correct. The nurse should identify that measuring the client's intake and output is a task that is within the AP's range of function. *Transfer the client from wheelchair to bed is correct. The nurse should identify that transferring the client from wheelchair to bed is a task that is within the AP's range of function.)

A nurse in a provider's clinic is caring for a client who has diarrhea. -Exhibit 1 Vital Signs Temperature 36.2° C (97.2° F) Pulse rate 116/min Respiratory rate 24/min BP 102/68 mm Hg Oxygen saturation 95% Weight 52.2 kg (115 lb) -Exhibit 2 Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea. -Exhibit 3 Physical Examination 1015: Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount.

The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. -Eat probiotic foods, such as yogurt. -Avoid alcohol while experiencing diarrhea. -Avoid caffeine while experiencing diarrhea. -Follow a low-fiber diet.