EAQ Corrections - Test 2 prep
Which information would the registered nurse provide to a student about the importance of nursing documentation for risk management
"a nurses documentation is the evidence of care that a client receives.", "the nurses would note assessments and significant changes the the client's health.", "nurses would always document the primary health care providers' responses whenever they are contacted"
To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis
Carina
Which step should the nurse take to alert the risk management system after notifying the primary health care provider of a client's fall
Document the incident in the occurrence report tool
Statement regarding an interpreter is correct
Interpreting not only the language but also the culture is important
after reviewing information about oxygenation for 4 clients with COPD, which client will the nurse plan to teach about the use of home long-term continuous oxygen therapy
PaO2 of 55; SpO of 88
Assessment
The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client
Implementation
The nurse is performing nurse care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation
Validation
The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking?
Irrigate the would with 100 mL normal saline until clear: 6 AM - 2 PM - 8 PM
The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning
Sequence of steps used to meet the client's needs
Which definition is correct to explain the nursing process
which term describes synovial joint movement away from the midline of the body
abduction
which client muscle strength assessment data is consistent with a a score of 3 on the muscle-strength scale
active movement against gravity but not against resistance
which clinical finding enables the nurse to conclude that the heparin therapy is effective in a client who has atrial fibrillation with rapid ventricular response and is started on a continuous heparin infusion
an activated partial thromboplastin time (aPTT) is twice the usual value
a client returns from the post-anesthesia care unit after a rotator cuff repair. Which action would the nurse take?
assess for capillary refill in the nail beds
which client assessment data would correspond to a muscle-strength rating of 3
can complete ROM against graviy
Which factor would elevate a clients oxygen saturation
carbon monoxide
how would the nurse determine if a client is experiencing the therapeutic effect of valsartan
check the blood pressure
which nursing interventions would provide safe oxygen therapy
checking for tubing kinds, post 'no smoking' signs in the clients' rooms
Which pathophysiological changes in the lungs occur with emphysema?
collapse of alveolar walls, trapping of air in distal lung structures, increases in pulmonary artery pressures
a client who has a fractured femur with buck traction keeps slipping down in bed. Which action would the nurse take?
elevate the foot of the bed
to prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care
encourage early mobility
which synovial joint movement is described as turning the sole away from the midline of the body
eversion
which level of Maslow's hierarchy of needs does the nurse fulfill by fitting a client who nearly died of asphyxiation with an oxygen mask
first level the first level of Maslow's hierarchy of needs includes the most basic and physiologic needs like air, water, and food. the second level includes safety and security needs, which involve physical and psychological needs the third level includes love and belonging needs like interpersonal relationships the fourth level encompasses self-esteem needs
which therapeutic effect of digoxin would the nurse expect
increased contractile force of the myocardium
which assessment finding would the nurse consider abnormal
joint crepitation, muscular atrophy, tenderness of the spine
which actions could the registered nurse assign to an LPN caring for the client with traction or a cast
monitoring skin integrity around the cast, marking circumference of any drainage on the cast, checking color, temperature, capillary refill, and pulses distal to the cast
the nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise
promotes elimination of CO2
which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain
providing oxygen, assessing vitals, obtaining a 12-lead EKG, drawing blood for cardiac enzymes, auscultating heart sounds, administering nitroglycerin
which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain
relieved by sublingual nitroglycerin
Which instruction will the nurse include in a teaching plan for a client taking a calcium channel blocker such as nifedipine
report peripheral edema, avoid drinking grapefruit juice, change to a standing position slowly
which example is classified as flat bone
scapula, sternum
which statement describes a nurse's correct understanding about skeletal muscles
skeletal muscle accounts for about half of a human being's body weight
which action would the nurse take to determine a client's pulse pressure
subtract the diastolic from the systolic reading
which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective
triglycerides
which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks
diuretics, low-salt diet, daily weight checks, fluid restriction, intake and output, oxygen administration
A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse assesses the recorded vital signs. Which vital sign assessment requires reassessment?
respiratory rate of 14 breaths/minute, blood pressure of 120/80 mm Hg, oxygen saturation of 95%
which symptom will the nurse include as a reason to withhold the medication when teaching a client about digoxin therapy
yellow vision
the nurse teaches a client about wearing thigh-high antiembolism elastic stockings. Which instruction would be correct to include
you will need to apply them in the morning before you lower your legs from the bed to the floor
Continuity of care by the nursing staff, collection of data about the client's clinical condition, engagement in a caring relationship without assumptions
Which factors enable the nurse to know a client better
which statement would the nurse identify as the purpose of the nitroglycerin patch
decreased cardiac preload reduces cardiac workload
how would the nurse instruct a client with arthritis to take aspirin when the client states that the aspirin causes stomach irritation
with food and a full glass of water
which instruction will the nurse provide about an angiotensin II receptor blocker (ARB) prescribed to a client with hypertension
"Stop the medication if swelling of the mouth, lips, or face develops", "Have blood drawn for potassium levels 2 weeks after starting the medication"
the client can complete range of motion with gravity eliminated. Which grade would the nurse assign to the client's muscle strength?
2; grade 1 indicates no joint motion and slight evidence of muscle contractility, grade 2 indicates complete range of motion with gravity eliminated, grade 3 is indicated by complete range of motion against gravity only, grade 4 is complete range of motion against gravity with some resistance
Actual nursing diagnosis
A client with bilateral oral swelling, pain, and trismus underwent surgical extraction of an impacted tooth 5 days ago. The documentation supports utilizing which type of nursing diagnosis for the client's acute pain
"I identified impaired skin integrity in a pressure ulcer document upon finding redness in the client's hip"
Which example demonstrates clinical decision-making by the nurse
Global health informatics, community health informatics
Which example illustrates public or population health informatics
Nursing diagnoses involve the client when possible, N.D involve the sorting of health problems within the nursing domain, N.D involve clinical judgement about the client's response to health problems
Which feature distinguishes nursing diagnosis from medical diagnosis
Ensure that the three principles of the Joint Commission's Universal Protocol are adhered to before starting a surgery on a client, refrain from depending on the use of electronic monitoring devices completely because they are not always reliable, file an occurrence report in case of an error in technique when administering medication intravenously
Which information would the registered nurse provide to the nursing student regarding identifying and eliminating potential hazards
which tissue connects the clients tibia to the femur at the knee joint
ligaments
while caring for a client in traction, which action would the nurse delegate to a licensed practical nurse (LPN)
padding traction connections, assisting the client with passive and active range-of-motions (ROM) exercises
which exercises would the nurse incorporate into the plan of care while the client is on bed rest after a cerebrovascular accident resulted in right hemiplegia
passive rang of motion exercises
which therapeutic effect is associated with digoxin prescribed to a client with HF
slows and strengthens cardiac contractions
which instruction would the nurse give a client while performing mcmurray's test
to flex, rotate, and extend the knee
a client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen
to increase oxygen concentration to heart cells
Which explanation would the nurse give about the purpose of the procedure when a client with angina is scheduled to have a cardiac catheterization
to visualize the disease process in the coronary arteries
a client has a stage III pressure injury. Which nursing intervention can prevent further injury by eliminating shearing force
use lift sheets to pull up, transfer, and position the client
the nurse is caring for a client admitted with chronic obstructive pulmonary disease(COPD). which laboratory test would the nurse monitor for hypoxia
which action would the nurse take to obtain subjective data about a client's respiratory status