ATI
in contributing to the plan of care for a client who has prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?
Compare the clients pedal pulse bilaterally every 4hr The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities.
Atropine
-Muscarinic antagonist -Used in bradycardia and for ophthalmic applications -Also used as antidote for cholinesterase inhibitor poisoning -Actions include increase pupil dilation, cycloplegia, decreased airway secretions, decreased acid secretions, decreased gut motility, decreased bladder urgency in cystitis -Toxicity: increased body temp (due to decreased sweating), rapid pulse, dry mouth, dry and flushed skin, cycloplegia, constipation, disorientation; -Can cause acute angle-closure glaucoma in elderly (due to mydriasis), urinary retention in men with prostatic hyperplasia, and hyperthermia in infants
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following finding as indication that the client has fluid volume deficit?
-Orthostatic hypotension indicates fluid volume deficit. -Flate neck vein indicates fluid volume deficit. -Cool extremities can indicate fluid volume deficit.
The nurse is providing handoff Report for a client who has a chest tube in place. WHICH OF THE FOLLOWING INFORMATION SHOULD THE NURSE INCLUDE IN THE REPORT?
-The amount and characteristics of drainage . For a client who has a chest tube, the amount and characteristics of the drainage provide important information about the client's current respiratory and immune status and are an essential component of change-of-shift report.
Heparin IV
-prevents further clot formation -does not affect the existing clot -Dosed based on weight, and PTT **[[Protamine Sulfate = antidote]]
amoxicillin 875 mg every 12 hr. available amoxicillin oral suspension 400mg/5ml how many ML should nurse administer per dose ? round to nearest whole number?
10.93 round to 11 Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 5 mL X mL = 400 mg Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 5 mL 875 mg X mL = × 400 mg 1 Step 4: Solve for X. X mL = 11 mL Step 5: Round if necessary. 10.9375 mL = 11 mL Step 6: Determine whether the amount to administer makes sense. If there are 400 mg/5 mL and the prescription reads amoxicillin 875 mg PO every 12 hr, it makes sense to administer 11 mL. The nurse should administer amoxicillin 11 mL PO every 12 hr.
Nasal cannula flow rate
6 L/min provides a low oxygen concentration.
Digoxin
Cardiac glycoside prototype: positive inotropic drug for CHF, half−life 40 h; renal excretion; inhibits Na+/K+ ATPase, also a cardiac parasympathomimetic. Tox: calcium overload arrhythmias, GI upset
Maslow's hierchy
According to Maslow's hierarchy of needs, supporting environmental conservation helps fulfill the client's self-actualization needs. Therefore, another activity is the priority.
IN assisting with a planning palliative care for a client who has stage IV cancer and is in the active stage of dying. Which of the following interventions should the nurse include in the plan of care? a. Position the client on the left side if nausea occurs b.Provide intramuscular pain medication to ease the client's pain. c Administer atropine to reduce the client's respiratory secretions. d. Encourage the family members to speak in a loud tone of voice to the client.
Administer atropine to reduce the client's respiratory secretions. The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle.
Pertussis (whooping cough)
An airborne bacterial infection that affects mostly children younger than 6 years. Patients will be feverish and exhibit a "whoop" sound on inspiration after a coughing attack; highly contagious through droplet infection.
Ps coughing red tinged mucous during suctioning of tracheostomy
Coughing of red tinged mucous during suctioning is non urgent because it is an expected finding for a client who has a new tracheostomy. The nurse should reassure the client and monitor for hypoxia
expected motor skills for a 9 month old infant
Creeping on hands and knees is an expected gross motor skill for a 9-month-old infant
autonomy
(n) self-government, political control
BP
120/80
Venturi mask
A Venturi mask can be adjusted to provide a consistent lower oxygen concentration.
According to Maslow's hierarchy of needs
According to Maslow's hierarchy of needs, supporting environmental conservation helps fulfill the client's self-actualization needs. Therefore, another activity is the priority.
which pulse is located on the top of the foot ?
Dorsalis pedis The nurse should document palpating the dorsalis pedis pulse on the top of the foot.
The reduced muscle tone has relaxed the jaw muscles."
Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth.
motor skills for a 7-month old infant?
Sitting and leaning forward using both hands for support is an expected finding for a 7-month-old infant.
Accoutability
The expectation that employees will perform a job, take corrective action when necessary, and report upward on the status and quality of their performance
What should a nurse do when taking vitals for pulse oximetry ?
The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading
High potassium foods
bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish and salt substitutes
BUN
blood urea nitrogen 10-20 mg/dL
The client's body will be adorned with amulets.
It can be a Hispanic and Latino cultural practice to adorn the body of a deceased person with amulets or rosary beads.
The client's body should be placed on the floor.
It can be a practice of the Hindu faith to place the body of a deceased person on the floor.
A nurse is contributing to a plan of care for a pt receiving continuous bladder irrigation following a transurethral resection of the prostate . which of the following interventions should the nurse include? Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color. Use clean technique when removing clots from the bladder irrigation. Add the amount of fluid instilled for irrigating when calculating the total output. Use tap water for the bladder irrigation
Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color. MY ANSWER The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding.
A client who has a prescription for rang of motion exercises of the shoulder. which of the following exercises should the nurse recommend to promote shoulder hyperextension? a. Move the arm behind the body with the elbow straight. b. Move the arm in a full circle. c. Raise the arm out to the side and reach it above the head with the palm facing away from the head. Raise the arm from the side straight forward and then up above the head.
Move the arm behind the body with the elbow straight. Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight.
The client is receiving Heparin via IV infusion. Which of the following medications should the nurse ensure is readily available? Vitamin K Epoetin Protamine sulfate Calcium gluconate
Protamine sulfate The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin.
positive throat culture streptococci
Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room.
When treating a patient with Clostridium difficile
The CDC recommends using soap and water for hand washing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants.
wound care irrigation
The nurse should hold the syringe 2.5 cm (1 in) above the upper end of the wound and over the area they are cleaning to prevent syringe contamination and unsafe pressure of flowing solution.
Bone pain
The nurse should identify bone pain as a finding associated with hypercalcemia
Reinforcing preoperative teaching with a client about how to turn, cough and deep breath (nausea)
Turning, coughing, and deep breathing can reduce the risk of developing a pulmonary embolus, rather than prevent nausea.
Reinforcing preoperative teaching with a client about how to turn, cough and deep breath (regarding heart beating to fast )
Turning, coughing, and deep breathing can reduce the risk of developing a thrombus formation, rather than tachycardia.
expected motor skills for a 12 month old infant
Walking with one hand held is an expected finding for a 12-month-old infant.
decanulated tracheostomy tube
When using the urgent vs non urgent approach to client care, the nurse should stay with the client and call immediately for assistance to replace the old tracheostomy tube or place a new tube down the stoma, if available. The nurse should monitor and prepare to manually ventilate if the client becomes hypoxic.
Young adult females should have a routine physical examination every ?
Young adult females should have a routine physical examination every 1 to 3 years.
Young adult males should have a testicular examination every?
Young adult males should have a testicular examination annually.
Young adult females should have a routine physical examination every?
Young adults who have an increased risk of exposure should receive a tuberculosis skin test every 2 years.
delusion
a false belief, often of persecution or grandeur, that may accompany psychotic disorders
In performing wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? a. Administer an analgesic 30 min before starting the procedure. b. Hold the syringe 5 cm (2 in) above the upper end of the wound. c. Place the irrigation solution in a basin of cool water. d. Perform the wound irrigation with a 10-mL syringe with an angiocatheter.
a. Administer an analgesic 30 min before starting the procedure. The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure.
In discussing about STIs with a group of adolescents at a health fair. Which of the following statements the nurse make? a.Men and women are at equal risk for acquiring STIs." b. "Females who have chlamydia are at increased risk for cervical cancer. c. "An infection with gonorrhea can result in infertility." d. "Human papillomavirus infections must be reported to the local health department.
a. Men and women are at equal risk for acquiring STIs." The nurse should not include this statement, because females are at greater risk for acquiring an STI due to the increased vascularity of the vagina, vaginal pH, the epithelial lining of the cervix, and the contact time of semen on the vaginal and cervical mucosa. b. "Females who have chlamydia are at increased risk for cervical cancer." The nurse should not include this statement, because chlamydia does not increase the risk for cervical cancer. c. "An infection with gonorrhea can result in infertility." Gonorrhea can lead to pelvic inflammatory disease and tubal scarring, which can result in infertility in female clients. d. "Human papillomavirus infections must be reported to the local health department." The nurse should not include this statement, because human papillomavirus infections do not require reporting to the local health department.
a nurse is caring for a client who is actively dying from cancer. Which of the following actions should the nurse take? a.Administer the lowest dose of prescribed pain medication to the client. b. Moisten the client's conjunctiva with sterile normal saline. c.Provide oral care for the client using glycerin swabs. d. Perform nasotracheal suctioning for the client frequently to clear secretions.
b. Moisten the client's conjunctiva with sterile normal saline. If the client's eyes are open, the nurse should moisten the conjunctiva with sterile normal saline, artificial tears, or an ophthalmic lubricating gel. Provide oral care for the client using glycerin swabs. The nurse should provide oral care using a soft moist brush or swab. Glycerin or lemon swabs promote drying of the mucous membranes. Petroleum jelly should be applied to the lips to maintain moisture.
in reinforcing preoperative teaching with a client about how to turn, cough and deep breath. Which of the following statements by the client indicates an understanding of the teaching? a. "This can help prevent nausea." b. "This can help prevent pneumonia." c. "I should do this every 4 hours." d. "I should do this to keep my heart from beating too fast.
b. This can help prevent pneumonia." The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions.
which of the following interventions should a nurse follow for a client with urinary diversion? a.Assist the client to perform the Credé maneuver to empty the bladder. b.Review information about Kegel exercises with the client. c.Secure an ostomy pouch on the client's abdomen to collect urinary drainage. d.Use intermittent urinary catheterization for the client at regular intervals.
b. Use intermittent urinary catheterization for the client at regular intervals. A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch.
A nurse is in care of a patient that refuses medication what action should the nurse take ? a. Explain the negative consequences of the refusal. b. Discuss with the client's partner why the treatment is necessary. c. Document the client's refusal of the treatment. d. Try to convince the client that the treatment is needed.
c. Document the client's refusal of the treatment. The nurse is responsible for notifying the provider when a client refuses a treatment or procedure and documenting the client's decision.
Benefiecence
do good and promote the best interest of your client
Hypersomnia
excessive sleepiness
According to Maslow's hierarchy of needs,
finding an enjoyable hobby helps fulfill the client's self-esteem needs. Therefore, another activity is the priority
A puncture wound that is sutured
healing by primary intention.
viral meningitis
meningitis caused by a virus and not as severe as pyrogenic meningitis
Pulse oximetry
noninvasive technique that measures the oxygen saturation (SaO2) of arterial blood greater or equal to 95%
heart rate
number of beats per minute 60 to 100/min
Hypoxic
pertaining to a low level of oxygen
ethical dilemmas and ethical choices
situations in which individuals are required to define right and wrong conduct
bilateral mastectomy
surgical removal of both breasts tissue
Confidentiality
the act of holding information in confidence, not to be released to unauthorized individuals
a nurse is reinforcing teaching about using crutches with a client who has a fractured ankle. Which of the following client statements indicates an understanding of the instructions? a. "I'll place my weight on the crutch pads at my armpits." The client should use their arms, not their axillae, to bear their body weight. Pressure on the axillae can damage the radial nerve and cause weakness and partial paralysis below the elbows. b. "I'll wear my leather-sole shoes when I am using my crutches." The client should wear rubber-sole shoes to reduce the risk for slipping or skidding c. "I'll bend my elbows to about 25 degrees when I walk with my crutches." The client should have 20° to 30° of flexion at the elbows when using their crutches. The nurse should verify that the client understands the correct amount of elbow flexion to have when using crutches. d."When I go down stairs, I will put my crutches and my right leg on the lower step first." The client should shift their weight to their right leg and then advance the crutches and their left leg down to the next step. Then, they should transfer their weight to the crutches and move their right leg down to the step that their left leg and the crutches are on.
. c. "I'll bend my elbows to about 25 degrees when I walk with my crutches." The client should have 20° to 30° of flexion at the elbows when using their crutches. The nurse should verify that the client understands the correct amount of elbow flexion to have when using crutches.
Full bounding pulse.
A full bounding pulse indicates fluid volume excess. The nurse should expect a weak peripheral pulse in a client who has fluid volume deficit.
is Hematocrit 42% within range ?
A hematocrit of 42% is within the expected reference range of 37% to 47% for females and 42% to 52% for males. With fluid volume excess, the nurse should expect the client's hematocrit to be below the expected reference range due to
***Tracheostomy dressing with dark red drainage?
A moderate amount of dark red drainage on a new tracheostomy dressing is non urgent because it is an expected finding. Drainage should subside as healing of the client's stoma occurs.
Is a Urine output of 200 mL over 8 hr be reported ?
A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.
is a Urine pH 6.5 level with in range ?
A urine pH of 6.5 is within the expected reference range of 4.6 to 8. Hydration status does not affect pH levels.
Is Urine specific gravity of 1.015 within range?
A urine specific gravity of 1.015 is within the expected reference range of 1.005 to 1.030. With fluid volume excess, the nurse should expect the urine specific gravity to be below the expected reference range due to dilution of the urine.
Venturi mask flow rate
Flow Rate; Approximate Amount Delivered (F i O2): 4 to 8 L / min = 24, 28, 31, 35 and / or 40%
The client's face should be turned toward Mecca.
Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca.
Isopropyle alcohol
Isopropyl alcohol is an active ingredient in the alcohol-based cleansing solutions nurses use to perform hand hygiene when in contact with bacteria, fungi, and viruses. However, alcohol does not kill C. difficile
The client's oldest child will bathe the body.
It can be a Chinese cultural practice for the oldest child to bathe the body of a deceased person under the direction of an older relative or priest.
Moist crackles in the lungs .
Moist crackles in the lungs indicate fluid volume excess. The nurse should expect clear lungs in a client who has fluid volume deficit.
glasgrow coma scale
The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviors make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive). This score is used to guide immediate medical care after a brain injury (such as a car accident) and also to monitor hospitalized patients and track their level of consciousness. Lower GCS scores are correlated with higher risk of death. However, the GCS score alone should not be used on its own to predict the outcome for an individual person with brain injury. Contents 1Scoring1.1Eye response (E)1.2Verbal response (V)1.3Motor response (M) 2Scoring (Pediatrics) 3Interpretation 4History 5Controversy 6See also 7References7.1Citations7.2General sources
signs of hypokalemia
The nurse should identify decreased bowel motility as a finding associated with hypokalemia.
Lung expansion
The nurse should instruct the client to turn, cough, and deep breathe every 1 to 2 hr to promote lung expansion
Which of the following interventions should the nurse include in the plane of care to treat the fever?
The nurse should limit the client's physical activity to decrease body heat production
Which of the following interventions should the nurse include in the plane of care to treat the fever?
The nurse should maintain the room temperature between 21.1° to 26.7° C (70° to 80° F). A room temperature that is too low can lead to shivering, which increases the client's body temperature
Which of the following interventions should the nurse include in the plane of care to treat the fever?
The nurse should not apply ice packs to the client's axillae or groin because this measure can lead to shivering, which increases the client's body temperature
wound care irrigation solution
The nurse should place the irrigation solution in a basin of hot water to warm the solution to body temperature. This action will reduce vasoconstriction of the tissues.
wound care irrigation syringe size
The nurse should use a 35-mL syringe with a 19-gauge needle or an angiocatheter to ensure an irrigation pressure within the correct range.
A nurse is collecting data from a client who has a NG tube to low intermittent suction. Which of the following findings indicates hypomagnesemia? a. Bone pain b.Drowsiness c.Bowel hypomotility d.Positive Chvostek's sign
d. Positive Chvostek's sign To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels.
An abdominal surgical wound with intact staples
healing by primary intention.
Nurse is preparing to removing a peripheral, after performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? a. Clamp the infusion tubing. b. Remove the dressing. c. Withdraw the catheter from the vein. d. Ensure the catheter is intact.
a. Clamp the infusion tubing. Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal.
Which of the following wound should the nurse identify as healing by secondary intention ? a. A stage 3 pressure injury on the coccyx b. A contaminated wound that is closed after 72 hr c. A puncture wound that is sutured d.An abdominal surgical wound with intact staples
a. A stage 3 pressure injury on the coccyx The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention
In assisting with a plan of care for a Pt who has bacterial infection and persistent oral temperature of 38.9 (102 F). Which of the following interventions should the nurse include in the plane of care to treat the fever? a.Administer acetaminophen. b. Apply ice packs to the client's axillae. c. Maintain the room temperature at 18.3° C (64.9° F). d.Assist the client to ambulate four times a day.
a. Administer acetaminophen. The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever.
A nurse is caring for a postoperative client who is at risk fro thrombus formation. Which of the following intervention should the nurse delegate to an assistive personnele (AP? a. Apply thromboembolic stockings. b. Monitor the circulation in all four extremities. c. Record the condition of the client's skin. d. Reinforce teaching about performing range-of-motion exercises.
a. Apply thromboembolic stockings. The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse. b,c,d are out side of the range of knowledge and skill for an (AP)
Chronic hepatitis
hepatitis inflammation and necrosis for longer than 6 months The client who has chronic hepatitis will experience hepatic tenderness in the upper right quadrant, which is where the nurse should palpate. This is the area where the liver is located.
Chlorhexidine solution
is effective against bacteria and viruses. However, this solution does not kill the spores of C. difficile.
In caring for a client who has an indwelling catheter. Which of the following actions should the nurse take to prevent urinary tract infection? a. Empty the urine drainage bag every 12 hr. b. Drain urine from the tubing before ambulation. c. Use clean technique for urine specimen collection. d. Hang the urine drainage bag at the level of the bladder.
a. Empty the urine drainage bag every 12 hr. The nurse should empty the drainage bag whenever it is half full. Correct b. Drain urine from the tubing before ambulation. Draining urine from the tubing before ambulation will prevent back flow of urine into the bladder. c. Use clean technique for urine specimen collection. The nurse should use sterile technique to collect specimens from the drainage system to prevent contamination. d. Hang the urine drainage bag at the level of the bladder. The nurse should hang the drainage bag below the level of the client's bladder to prevent backflow of urine into the bladder.
A nurse is planning care fro a client who is disoriented and at risk for fall. Which of the following interventions should the nurse include? a. Ensure that the client is wearing nonskid slippers. b. Move the bedside table away from the bedside. c. Place the client in a room near the nurses' station. d. Keep the bed's full side rails in the up position. e. Reinforce teaching about how to use the call bell.
a. Ensure that the client is wearing nonskid slippers is correct. Nonskid slippers provide better traction and can help prevent slipping and falling. Move the bedside table away from the bedside is incorrect. The nurse should keep the bedside table within the client's reach to facilitate access to items they need. Reaching for objects increases the risk for falling out of bed. b. Place the client in a room near the nurses' station is correct. Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls. c. Keep the bed's full side rails in the up position is incorrect. Because the client might attempt to climb over the bed's full side rails and fall, the nurse should keep half side rails up and only when necessary. d. . Reinforce teaching about how to use the call bell is correct. Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls.
which of the following should the nurse identify as the first stage of health behavior change a. Precontemplation b. Preparation c. Maintenance d. Action
a. Precontemplation According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action and the maintenance stage.
in teaching about crutches, which action indicates the understanding of the teaching? a. The client leans on the crutches for support while standing still. b. The client advances the unaffected leg first while climbing stairs. c. The client stands 5 cm (2 in) from the front of a chair before sitting. d. The client bears weight on their axilla while standing in the tripod position.
a. The client leans on the crutches for support while standing still. The nurse should reinforce with the client that it is unsafe to lean on the crutches to support their body weight. b. The client advances the unaffected leg first while climbing stairs. When ascending stairs, the client should first advance the unaffected leg. c. The client stands 5 cm (2 in) from the front of a chair before sitting. The nurse should reinforce with the client that they should stand with the back of their legs placed against the chair for support during the procedure of sitting. d. The client bears weight on their axilla while standing in the tripod position. The nurse should reinforce with the client that their axilla should not bear any weight while in the tripod position because this can cause pressure injury formation. The client should bear their weight with their arms and hands.
Epigastrium
abdominal region above the stomach
Triclosan
an antibacterial and antifungal agent that can be found in a variety of consumer products, including detergents, soap, and toothpaste
Which following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? a. Nasal cannula b. Simple face mask c. Venturi mask d. Nonrebreather mask
d. Nonrebreather mask A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation.
A nurse is reviewing vital signs of four clients. Which one requires further data collection? a. A client who has a respiratory rate of 12/min b. A client who has a blood pressure of 110/74 mm Hg c. A client who has a temperature of 37.3° C (99.2° F) d. A client who has a pulse rate of 110/min
b. A client who has a pulse rate of 110/min This client's heart rate is above the expected reference range of 60 to 100/min. Therefore, the nurse should collect further data to determine the cause of the tachycardia.
In Assisting admission of a client who has active tuberculosis. a. The nurse does not need to restrict visitors, but should ensure that they follow airborne precaution guidelines b.Assign the client to a negative-pressure airflow room. c. The nurse should remove personal protective equipment before leaving the client's room to prevent the spread of bacteria outside the room d. The nurse should have the client wear a surgical mask whenever they leave their room to prevent transmitting bacteria to others
b. Assign the client to a negative-pressure airflow room. The nurse should assign the client to a negative-pressure airflow room to ensure that the air from the client's room is not circulated throughout the facility.
seclusion
isolation from others, solitude
tracheostomy
surgical creation of an opening into the trachea through the neck
in using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client ? a.Volunteer at the local food pantry. b.Attend an exercise program. c.Find an enjoyable hobby. d. Support environmental conservation.
b. Attend an exercise program. When using Maslow's hierarchy of needs, the nurse should determine that the priority activity is to fulfill the client's physiological needs for activity. Therefore, the nurse should recommend exercise and help the client select a suitable exercise program.
Nurse is contributing to a plane of care who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? a. Check that the restraint is tied to a fixed frame of the bed. b. Pad bony prominences on the wrist. c. Remove the restraint every 4 hr to allow movement. d. Tie the restraint with a knot that will tighten when pulled.
b. Pad bony prominences on the wrist. The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin
primary intention wound
wound edges are closed, well-approximated and there is little tissue loss and little scarring examples:
A nurse is caring for a patient with a NG tube in place. Which of the following should the nurse take verify the placement of clients NG tube a. Test the glucose level of the gastric aspirate. b. Instill air through the tube and auscultate the stomach for bubbling sounds. c. Test the pH of gastric aspirate. d. Instill air through the tube and ask the client to speak.
c. Test the pH of gastric aspirate. Prior to administering an enteral feeding, the nurse should aspirate 5 mL of gastric contents through the tube and then test the aspirate's pH. A pH between 0 and 4 indicates gastric placement. A pH higher than 6 indicates that the distal end of the tube is in the intestines or in the pulmonary system.
Which of the following information should the nurse include in promoting with young adult clients ? a.Young adults should receive a dental assessment every 6 months. b. Young adult males should have a testicular examination every 5 years. c. Young adult females should have a routine physical examination every 4 years. d. Young adults should receive a tuberculosis skin test every 3 years
c. Young adults should receive a dental assessment every 6 months. The nurse should include the recommendation for young adults to receive a dental assessment twice per year.
Simple face mask flow rate
can be adjusted for short-term delivery of low to medium oxygen concentration. 6-10L/min
Healing by tertiary intention
contaminated wound that is left open for monitoring and then closed after several days
The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? a. Urine specific gravity 1.015 b. Hematocrit 42% c. Urine pH 6.5 d. BUN 8 mg/dL
d BUN 8mg/dl
A nurse in a long-term care facility is serving as a preceptor to a newly hired nurse. The nurse asks the preceptor, What should i do for my client who has dypnea with oxygen saturation of 92%, Which of the following interventions should the preceptor recommend? a. Apply oxygen using a non rebreather face mask. b. Encourage the client to cough and deep breathe every 4 hr. c. Initiate nasotracheal suctioning. d. Position the client at a 45° angle in bed.
d. Position the client at a 45 angle in the bed The preceptor should recommend for the nurse to position the client at a 45° angle in bed to promote greater lung expansion and decrease pressure from the abdomen onto the diaphragm.
A nurse is contributing to the plane of care for a client who has urinary and fecal incontinence. Which of the following interventions should the nurse implement to help maintain clients skin integrity? a. Use soap and hot water to cleanse the skin. b. Use a cloth incontinence brief to contain urine and feces. c. Keep the head of the bed elevated to 45°. d. Apply a moisture barrier ointment after each incontinence episode.
d. Apply a moisture barrier ointment after each incontinence episode. MY ANSWER After cleansing the skin of urine and feces, the nurse should apply a barrier ointment to help protect the skin from the damaging effects of excessive moisture and bacteria, especially if the client has diarrhea.
In assitsing a plan of care for a client who has aphasia following a stroke . Which of the following interventions should the nurse use to assist the client with communication? a. Provide an artificial voice box. b. Avoid using facial gestures. c. Speak to the client in a louder voice. d. Ask the client close-ended questions.
d. Ask the client close-ended questions. Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding their head.
Which of the following tasks should can be assigned to an assistive personnal (AP)? a.Ensure a client can use crutches before discharge. b. Check a client's ability to swallow following a stroke. c. Obtain a client's pain rating prior to physical therapy. d. Assist a client to get out of bed after a breathing treatment.
d. Assist a client to get out of bed after a breathing treatment. The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function
Allowing a client to make decisions about a treatment is an example of which of the following principles? a. Confidentiality b Nonmaleficence c. Accountability d. Autonomy
d. Autonomy Autonomy is an ethical principle that refers to protecting a client's independence and right to make decisions about care.
A nurse is preparing to administer a topical medication to a client. Which of the following action should the nurse take? a. Show the assistive personnel where to apply the medication. b. Ask the client when the previous nurse last applied the medication. c. Identify the client by comparing the medication administration record with the client's room number. d. Compare the label of the medication container with the medication administration record three times.
d. Compare the label of the medication container with the medication administration record three times. When preparing medication from a bottle or container, the nurse should compare the label of the medication container with the medication administration record three times to ensure it is the correct medication.
