Fund. of Nursing Final

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety? a."I will start an IV, which should not cause you too much pain." b."I will start an IV that will add fluids directly to the blood stream." c. "It will not take too much time to insert the IV." d. "You should not feel anxiety about a simple procedure."

"I will start an IV that will add fluids directly to the blood stream." The nurse should explain the procedure and its purpose. The nurse telling the client that it should not take much time does not convey the purpose of the procedure. It is unnecessary for the nurse to inform the client about the technical details of the catheter. Additionally, the nurse should not give false reassurance by telling the client that the procedure will not be painful.

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy? a. It is okay to cry, sometimes that helps soothe you. b. I understand. I had to take care of my father before he died of cancer. c. Just take your time. I am listening. d. Take some time for yourself, and get yourself together.

"Just take your time. I am listening." The response, "Just take your time. I am listening." allows the client permission to collect thoughts while also expressing emotion and lets the client know the nurse is there for the client. Using appropriate periods of silence rather than "talking away" the client's feelings is empathetic. The response "I know how you feel" does not focus on the client's feelings. Stating "It's okay to cry" or "Take some time for yourself" suggests that the nurse is granting the client permission to experience the client's own feelings, which the client does not need.

Place the following examples of interventions to meet human needs in order from the most basic, high-priority needs to the lower-priority needs based on Maslow's hierarchy. Use all options. a.A nurse places a No Smoking sign on the door of a client who is receiving oxygen. b.A nurse provides nutrition for a client through a feeding tube. c.A nurse prepares a room for a clerical visit requested by a client. d.A nurse includes family members in the care of a client. e. A nurse helps a client focus on the client's strengths following a diagnosis of breast cancer.

1. A nurse provides nutrition for a client through a feeding tube. 2. A nurse places a No Smoking sign on the door of a client who is receiving oxygen. 3. A nurse includes family members in the care of a client. 4. A nurse helps a client focus on the client's strengths following a diagnosis of breast cancer. 5. A nurse prepares a room for a clerical visit requested by a client. Maslow's hierarchy provides a framework for nursing assessment and for understanding the needs of clients at all levels, so that interventions to meet priority needs become a part of the plan of care. A nurse would first prioritize the nutritional needs of the client. This is Level 1, physiological needs. The next task to be prioritized would be placing a No Smoking sign on the door of a client who is receiving oxygen. This is Level 2, safety and security needs. The next task would be including family members in the care of the client. This is Level 3, love and belonging needs. The next task would be helping a client focus on the client's strengths following a diagnosis of breast cancer. This is Level 4, self-esteem needs. The last task would be preparing a room for a clerical visit requested by the client. This is Level 5, self-actualization needs.

The nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. Calculate the intake for the shift. Record your answer using a whole number rounded to the nearest 10 mL. 550 mL of urine ¼ cup of grapes 200 mL of liquid stool 4 oz of Jell-O 250 mL of IV normal saline 1 cup of apple juice

610 The nurse would include all items that are liquid or turn to liquid at room temperature in the calculation. Jello, IV normal saline, and apple juice are calculated as intake. Urine and stool are calculated as output. Grapes will not be included as intake. Convert all units to mL, rounded to the nearest 10 mL: 4 oz of Jello = 120 mL 1 cup of apple juice = 240 mL 120 mL + 250 mL IV fluid +240 mL = 610 mL

A nurse is caring for a client diagnosed with pancreatitis. Which is a priority need for nursing management of this client? a. acute pain in the abdomen b. depression c. inability to care for family after diagnosis d. lack of self-confidence

Acute pain in the abdomen Acute pain in the abdomen is a physiologic need of the client that receives attention on a priority basis. According to Maslow's hierarchy of human needs, physiologic needs are the most important. These needs are to be fulfilled before others. The client may experience depression, lack of self-confidence, and inability to care of the family after diagnosis from the pancreatitis, which are psychological issues. Physiologic needs need to addressed before psychological needs, which are needs for safety and security, love and belonging, esteem and self-esteem, and self-actualization.

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. a. Demonstrate the correct use of crutches to the client prior to discharge b.The client will know how to dress the wound after receiving a demonstration c.After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. d. By 4/5/20, the client will demonstrate how to care for a colostomy. e. After counseling, the client will describe two coping measures to deal with stress. f. The client will list the dangers of smoking and qui

After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. By 4/5/20, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. The above goals that have these characteristics are: "After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn"; "By 4/5/20, the client will demonstrate how to care for a colostomy"; and "After counseling, the client will describe two coping measures to deal with stress." "Demonstrate the correct use of crutches to the client prior to discharge" is a nursing intervention, not an outcome. "The client will know how to dress the wound after receiving a demonstration" is not measurable. The client demonstrating a technique is measurable, but "will know" is not measurable. "The client will list the dangers of smoking and quit" is not timebound.

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply. a. collecting data b. identifying patterns c. identifying indicators of potential dysfunction d. organizing data

Analyzing data Identifying patterns Identifying indicators of potential dysfunction During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? a. provide written materials b. delegate to a colleague that has expertise in the education c. boost client morale d. assess for cultural differences

Assess for cultural differences. When the client is having difficulty learning, it may be possible that the client does not understand the language that the nurse speaks. In such a case, the nurse should take the necessary steps to break the cultural barrier and then proceed with the education. Written materials can enhance many clients' learning, but will not necessarily overcome many of the common barriers to understanding, including cultural and linguistic factors. The nurse should take action to overcome any barriers to the learning process before delegating to a colleague. The client's morale is not pertinent to the client's difficulty understanding the teaching.

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply. a. communicator b. advocate c. financier d. statistician e. teacher f. counselor

Communicator Counselor Teacher The roles and functions of the nurse are many and include caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse.

A father, mother, grandmother, and three school-age children have immigrated to the United States. The nurse needs to provide medication education to the grandmother, who does not speak the dominant language. Which strategy will the nurse use to convey health information to the client? a. engage the services of a trained interpreter b. rely on family members to interpret c. ask someone from the office to translate d. communicate nonverbally with hand gestures

Engage the services of a trained interpreter. Engaging the services of a trained interpreter is the best way to convey health information to clients who have difficulty understanding and speaking the dominant language. Relying on family members to interpret could result in medical terms being mistranslated or misunderstood. Asking someone in the office to translate does not ensure client privacy and confidentiality, Hand gestures may have different connotations across cultures and can easily be misinterpreted.

Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment? a. Florence Nightingale b. Sister Callista Roy c. Dorothea Orem d. Lydia Hall

Florence Nightingale Florence Nightingale conceptualized the nurse's role as manipulating the environment to facilitate and encourage the reparative process. This would be accomplished by attending to ventilation, warmth, light, diet, cleanliness, and noise. Sister Callista Roy, CSJ is an American nun, nursing theorist, professor and author. She is known for creating the adaptation model of nursing. Dorothea Orem was a nursing theorist and creator of the self-care deficit nursing theory, also known as the Orem model of nursing. Lydia Hall was a pioneer in nursing autonomy and nurse-driven care.

The nurse offers a client two possible times to ambulate, as prescribed by the health care provider. The nurse is acting in which nursing role? a. Communicator b. Manager and coordinator c. Advocate d. Caregiver

Manager and coordinator While the nurse is acting in many roles, the nurse is managing and coordinating the care for the client by giving choices for when care may be implemented. The nurse is not acting simply as a communicator, advocate, or caregiver.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which data collected can be classified as subjective data? a. blood pressure b. heart rate c. nausea d. respiratory rate

Nausea Subjective data are those that only the client can experience and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case? a. nursing standards b. nursing process c. nurse practice acts d. nursing orders

Nursing process Devising a plan of care is based on the nursing process. This process identifies the client's health care needs and strengths to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes. Nursing standards allow nurses to carry out professional roles, serving as protection for the nurse, the client, and the institution where health care is given. Nurse practice acts are laws established in each state in the United States to regulate the practice of nursing. Nursing orders prescribe the nursing care to be given to assist the client to meet health goals.

Which accurately identify the characteristics of effective client goals represented in the acronym SMART? Select all that apply. a. s= specific b. m= measureable c. a= accurate d. r= regimented e. r= realistic d. s= statistically proven e. t= timebound f. t= therapeutic

S = specific M = measurable R = realistic T = timebound S: specific; M: measurable; A: attainable; R: realistic; T: timebound.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data?

Subjective Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by anyone else. Examples are feeling nervous, nauseated, or chilly, to name a few. Objective data from the client are measurable, such as vital signs. Intuition is the ability to understand something immediately, without the need for conscious reasoning. A hunch is a feeling or guess based on intuition rather than known facts. The client verbalized a statement and expressed a feeling but did use reasoning as a basis for the feeling.

Which example may illustrate a breach of confidentiality and security of client information? a. documenting a patient's care in the health record then logging off. b. providing information to a caregiver assigned to the patients care c. the nurse provides information over the phone to the client's family member who lives in a neighboring state. d. telling a nurse talking about a patient's condition in the cafeteria is a breach of confidentiality

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A client who does not speak the dominant language has been admitted to the health care facility reporting chest pain. Because the assigned nurse does not know the client's language, what would be the most appropriate solution for communication until a professional interpreter can be obtained? a. the nurse should get a language dictionary and attempt to translate basic information in order to obtain consent for treatment. b. The nurse should request the help of a family member if available, if not care should be administered that is in the best interest of the client. c. ask for a different assignment or ask for a different nurse that is fluent in the client's native language d. communicate to the client nonverbally, using gestures and facial expressions

The nurse should request the help of a family member if available, if not care should be administered that is in the best interest of the client. The nurse should request the help of a professional interpreter to communicate effectively with the client who does not speak the same language as the nurse. If this is not readily available in an emergency situation, the nurse can ask a family member to help in basic communication if available. The nurse is responsible for providing care to stabilize the client regardless of language barriers. Trying to use a language dictionary to help communicate may be troublesome and time-consuming. The nurse cannot shun nursing responsibilities by asking for a different assignment or asking for a different nurse to take the case. Asking the client to communicate nonverbally may lead to a break in communication or misinterpretations.

The nurse is completing documentation for a newly admitted client. Which entries should the nurse include in charting? Select all that apply. a.The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. b."I feel something is going on the client isn't telling me." c.The client was overheard telling a family member about more bleeding than reported d. The dressing has a 5 cm area of bloody drainage e.The client's pupils are equal, reactive, to light and accommodation

The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. The client was overheard telling a family member about more bleeding than reported The dressing has a 5 cm area of bloody drainage The client's pupils are equal, reactive, to light and accommodation Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

Which are purposes of the evaluation phase of the nursing process? Select all that apply. a. To determine the client's responses to nursing interventions b. To appraise the extent to which client goals were attained c. To determine the involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions d. To collect subjective and objective data to make judgments about nursing care delivered

To determine the client's responses to nursing interventions To appraise the extent to which client goals were attained To determine the involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions To collect subjective and objective data to make judgments about nursing care delivered Purposes for carrying out evaluation include: to examine the client's behavioral responses to nursing interventions; to compare the client's behavioral responses with predetermined outcome criteria; to appraise the extent to which client goals were attained or problems resolved; to appraise involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions; to provide a basis for the revision of the plan of care evaluation; to collect subjective and objective data to make judgments about nursing care delivered; and to monitor the quality of nursing care and its effect on the client's health status. Nursing care is dynamic, so the nurse should not expect the plan of care to remain unchanged from the time it was originally prepared.

A nurse tells a client, "Are you going to get out of bed, or are you just going to sleep all day and night?" This is an example of which barrier to communication? a. probing questions b. leading questions c. comments that give advice d. Using judgmental or belittling language

Using judgmental or belittling language A nurse making judgmental comments tends to impose the nurse's moral standards on the client. In this case, the nurse judges the client as being lazy, and the nurse's apparent hostility could end effective communication. Leading questions are usually open ended and allow for the client to finish a sentence or to provide direction in the form of oral communication. Probing questions are follow-up questions when a response is not fully understood or when answers are vague or ambiguous to obtain more specific or in-depth information. Comments that give advice provide guidance to the client.

Which are examples of objective assessment information? Select all that apply. a. vital signs, height, weight b. marital status and occupation c. smoking and alcohol history d. list of medications e. findings on palpation of the abdomen

Vital signs, height, and weight Findings on palpation of the abdomen Objective data are information that the nurse can gather through direct assessment, including what can be seen, heard, felt, or measured. These include vital signs, height, weight, and findings on palpation of the abdomen. Subjective data are those that the client reports or describes, such as marital status, occupation, smoking and alcohol history, and a list of medications.

A nursing student is studying the normal physiologic changes of older adults. The faculty member knows that the student comprehends the information when the student makes which statements? Select all that apply. a. "Height may decrease 1 to 3 in (2.5 to 8 cm)." b. "There is an increased sensitivity to glare." c."Fluids and electrolytes remain within normal ranges." d. "There is is an increase in reflexes." e. "Sour tastes diminish first."

a. "Height may decrease 1 to 3 in (2.5 to 8 cm)." b. "There is an increased sensitivity to glare." c."Fluids and electrolytes remain within normal ranges." Normal physiologic changes of older adults include height may decrease 1 to 3 in (2.5 to 8 cm), there is an increased sensitivity to glare, and fluids and electrolytes remain within normal ranges. Rate of reflex responses decrease and the senses of taste and smell are decreased. Sweet and salty tastes diminish first.

Which topics should be included in an education plan for preventing falls in the home? Select all that apply. a. Avoid climbing on a chair or table to reach items that are too high. b. Use a nightlight. c. Remove clutter from walkways. d. Keep electrical and telephone cords against the wall and out of walkways. e. Encourage the pt to use an electronic personal alarm f. Consider the use of a raised toilet seat.

a. Avoid climbing on a chair or table to reach items that are too high. b. Use a nightlight. c. Remove clutter from walkways. d. Keep electrical and telephone cords against the wall and out of walkways. f. Consider the use of a raised toilet seat. Nurses should teach older clients ways to prevent falls at home. They include the following: Clean up clutter. Repair or remove tripping hazards. Install grab bars and handrails. Avoid wearing loose clothing. Lighting should be bright. Wear shoes and make them nonslip. Live on one level. The use of an electronic personal alarm is not a product that would prevent falls.

The nurse is performing assessments for an assigned client. Which methods are appropriate ways for the nurse to gather objective data related to a client's pain? Select all that apply. a. By checking vital signs b. By observing facial expressions c. By asking about the intensity and type of pain d. By using a pain assessment questionnaire e.By diagnostic tests and procedures

a. By checking vital signs b. By observing facial expressions e.By diagnostic tests and procedures Physical assessment is a mode of gathering objective data about a client's pain perception. It involves assessing the client's vital signs and observing facial expressions of pain. Diagnostic tests and procedures can provide objective data by validating painful events and identifying the source of pain. Eliciting factual information, such as the intensity and type of pain, as well as use of pain assessment questionnaires, are strategies to obtain subjective data about the client's pain perception.

A nurse is teaching a family member how to bathe the female bedbound client. What information should the nurse tell the client about perineal care? a. Clean, using a washcloth, from the pubic area toward the anal area. b. Clean the area surrounding the labia and anal area with washcloth before cleaning the labia and anus. c. Flush the labial area when cleaning the perineal area d. Clean the surrounding area and then wash the vagina

a. Clean, using a washcloth, from the pubic area toward the anal area. The nurse should teach the caregiver to proceed from the least contaminated area to the most contaminated area. For a female client, the caregiver will spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over to the genital area. This direction of movement will decrease contamination. Flushing the labial area is not needed when cleaning the perineal area. Likewise, the surrounding area should not be washed before the labia and anus with the same washcloth as contamination can occur.

A nurse is caring for clients with alterations in mobility. Which nursing interventions are recommended for these clients? Select all that apply. a. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. b. For ineffective breathing patterns, encourage shallow breathing and coughing. c. For constipation, increase fluid intake and roughage. d. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 e. For impaired physical mobility, perform ROM exercises every 2 hours

a. For orthostatic hypotension, have the client sleep sitting up or in an elevated position. c. For constipation, increase fluid intake and roughage. d. For impaired skin integrity, reposition the client in correct alignment at least every 1 to 2 The nurse would implement the following nursing interventions when caring for clients with alterations in mobility: Have the client sleep sitting up or in an elevated position for orthostatic hypotension; have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns; reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns. Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility.

The nurse is caring for a client who developed pneumonia while hospitalized. How will the nurse document this condition? a. Health care-associated infection (HAI) b. Infectious disease c. Contagious disease d. Community-Aquired Infection (CAI)

a. Health care-associated infection (HAI) HCAI, the most common adverse event in hospitals, are acquired within healthcare facilities. Community-acquired infections occur in the community. Infectious and contagious can be acquired in any setting.

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply. a. Heart rate is 64 beats/min b. Mucous membranes are pink and moist c. Oxygen saturation reads 88% on 5L of oxygen d. Client is able to state the date, time, and location e. A respiratory rate of 33 breaths/min

a. Heart rate is 64 beats/min. b. Mucous membranes are pink and moist. d. Client is able to state the date, time and location. A normal resting heart rate indicates a tolerable work of breathing. When in respiratory distress, clients will also experience tachycardia or a heart rate higher than 100 beats/min. Skin color and mucous membranes are another indicator of the client's oxygenation status. When hypoxic, a client will present as pale skinned, sometimes with bluish-ness around the mouth called cyanosis. Mucous membranes can also appear pale or blanched due to poor circulation. A client with normal work of breathing will have pink and moist mucous membranes. Level of consciousness is another indicators or normal oxygenation. If the client is oriented to day, time and place, the client has an intact level of consciousness, a sign of normal oxygenation. A respiratory rate of 33 breaths/min indicates tachypnea related to increased work of breathing. This is a sign of hypoxia. The nurse will oxygenate the client with an aim to bring the client's oxygen saturation above 90%, to ease the work of breathing. An oxygen saturation of 88% with oxygen supplementation is too low and the nurse will need to re-evaluate the effectiveness of the intervention.

A nurse is caring for a client who has a large, hardened mass of stool that is interfering with defecation, making it impossible for the client to pass feces voluntarily. Which recommendation(s) will the nurse provide the client to prevent future fecal impaction from occurring? Select all that apply. a. Increasing fluid intake b. Increasing daytime exercise c. Increasing fat in the diet d. Limit fluids after bedtime e. Call the HCP for an order of laxatives

a. Increasing fluid intake b. Increasing daytime exercise The client has fecal impaction because the large, hardened mass of stool is interfering with defecation, making it difficult for the client to pass stool voluntarily. The client will need to prevent constipation by increasing fluid intake, exercising, and toileting at regular intervals. While laxatives can be effective in the short term, they can also cause dependence. Increasing fat in the diet will not help to prevent constipation. Limiting fluids after bedtime will help the client to not have the urge to urinate throughout the night.

The nurse has received an order to catheterize a female client. What action should the nurse perform? a. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). b. Advance the catheter until slight resistance is felt d. Indicate correct placement by advancing the catheter while there is resistance e. Insert one catheter into the vagina to mark the spot

a. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). The nurse should lubricate 1 to 2 in (2.5 to 5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 in (5 to 7.5 cm) from the tip and insert slowly into the urethra. The nurse should then advance the catheter until there is a return of urine (approximately 2 to 3 in [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 in (5 to 7.5 cm). The nurse may encounter slight resistance when advancing the catheter, but this does not necessarily indicate correct placement; further advancement of the catheter may be necessary to obtain urine flow.

A nurse is assessing the stoma of a client who had an ostomy. Which assessment finding(s) necessitates further evaluation of the stoma? Select all that apply. a. Pallor of the stoma b. Purple-blue color of the stoma c. Irritation and dryness at the stoma site d. Yellow discharge at the stoma site e. Bleeding at the stoma site

a. Pallor of the stoma b. Purple-blue color of the stoma c. Irritation and dryness at the stoma site d. Yellow discharge at the stoma site e. Bleeding at the stoma site The normal ostomy stoma should be dark pink to red and moist. Abnormal findings that should necessitate further assessment of the stoma include paleness (possible anemia), purple-blue color (possible ischemia), bleeding, irritation and dryness, or a yellowish discharge, which could indicate infection.

What technique should the nurse use to implement infection control in the home? a. Practice hand hygiene when beginning and ending the home visit. b. Wear gloves at all times when in the home or traveling in the car. c. Taking prescribed antibiotics on a regular basis d. Not touching personal belongings when in a client's home

a. Practice hand hygiene when beginning and ending the home visit. Of all the methods used to prevent infection, hand hygiene is the most important and is necessary before and after treating the client (i.e., when beginning and ending the home visit). It would be difficult for a nurse to not touch anything in the client's home. Wearing gloves in a home visit can make a client feel uncomfortable. Gloves should only be worn when potential exposure to blood or body fluids is expected. Taking prescribed antibiotics on a regular basis causes bacterial resistance.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? a. Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. b. Encourage the client to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm. c. Encourage the patient to eat as fast as possible as to not experience constipation d. Speak to the client while they are eating so they have enough time to think while they are chewing.

a. Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. Talking during eating increases the risk of aspiration for a client who has dysphagia. Arranging food on the plate in a clock face pattern is a strategy appropriate for a client who is visually impaired. Clients who have dysphagia need to eat slowly and be continually observed for signs of aspiration. Allow enough time for the client to adequately chew and swallow the food. The client may need to rest for short periods during eating.

Which situation would lead the client's family to suspect onset of dementia? a. The client has increasingly experienced disorientation to familiar surroundings. b. The client's air-conditioning is broken and he has not reported it. c. The client has not attended church d. Confusion, or delirium, can be an adverse effect of medications

a. The client has increasingly experienced disorientation to familiar surroundings. Dementia is a progressive cognitive disorder in older adults, characterized by increased forgetfulness, impaired judgment, progressive confusion, and disorientation. Other reasons may exist for the client not reporting a broken air-conditioner (e.g., financial) or not attending church (e.g., time or transportation). So these situations may not necessarily be related to dementia. Confusion, or delirium, can be an adverse effect of medications. This condition is temporary and can be resolved by stopping the use of the medication.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? a. a 26-year-old client who is exhibiting a crowing sound b. a 30-year-old client who is drowsy and reporting pain c. A pediatric client requesting a parent d. A client with disorientation

a. a 26-year-old client who is exhibiting a crowing sound A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.

The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply. a. asking questions repeatedly b. socially inappropriate behavior c. wandering d. irritability

a. asking questions repeatedly b. socially inappropriate behavior c. wandering d. irritability Behavioral findings associated with dementia include: asking questions repeatedly, emotional lability, socially inappropriate behavior, wandering and irritability.

The "rights" of medication administration help to ensure accuracy when administering medications. What are some of these rights? Select all that apply. a. medication b. client c. pharmacy d. dosage e. physician f. route

a. medication b. client d. dosage f. route To prevent medication errors, always ensure that the right medication is given to the right client in the right dosage through the right route at the right time, followed by the right documentation. The physician and pharmacy are not part of the "rights" of medication administration for nurses.

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? a. phlebitis b. pulmonary embolus c. air embolism d. thrombus formation

a. phlebitis The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is a stationary blood clot. Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system.

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply. a. situational low self-esteem b. reflex urinary incontinence c. risk for infection d. impaired urinary elimination

a. situational low self-esteem c. risk for infection The client with a new urostomy may be at risk for impaired skin integrity and infection if the client does not care properly for the ostomy. The client may experience a change in self-esteem due to this different way of eliminating. The client will not experience reflex incontinence, because the urostomy will continually drain urine. As long as the urostomy functions appropriately, the client should not experience impaired urinary elimination.

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain? a. the client's pain based on a pain rating b. the nurse's impression of the client's pain c. nonverbal clues of pain by the client d. pain relief after nursing intervention

a. the client's pain based on a pain rating The client's assessment of pain, based on a pain rating, is the most appropriate assessment data. The pain is rated on a 0 to 10 scale and nursing actions are then implemented to reduce the pain. The nurse's impression of pain and nonverbal clues are subjective data which should be considered, but which are not more important than the pain rating. Pain relief after nursing intervention is appropriate, but is a part of evaluation.

The health care provider writes a prescription for ampicillin 1 gram every 6 hours for a client. What would cause the nurse to question this medication prescription? a. the route is missing b. the amount is missing c. the dose is missing d. the time is missing

a. the route is missing The rights of medication administration include client, drug, route, dose, time, reason, and documentation. This medication prescription does not identify a route. Ampicillin can be administered intravenously, intramuscularly, or orally.

A client with no significant medical history reports constipation for the past week. Which assessment information will the nurse collect? Select all that apply. a. whether the client is taking new medication b. the client's normal bowel habits c. characteristics of loose stools d. if the client feels a sensation of rectal fullness e. if the client has used laxatives in the past

a. whether the client is taking new medication b. the client's normal bowel habits d. if the client feels a sensation of rectal fullness e. if the client has used laxatives in the past The nurse will ask about new medications, because these can often cause constipation; what the client's normal bowel habits are like to establish a baseline; and whether the client has used laxatives to pass stool in the pass. A sensation of rectal fullness is associated with constipation. Loose stool is associated with diarrhea.

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. a.proper client nutrition b.2-hour turn schedule c.pressure redistribution support surfaces d.position client with head of the bed at 45 degrees e. client repositioning with a lift

a.proper client nutrition b.2-hour turn schedule c.pressure redistribution support surfaces e. client repositioning with a lift To protect clients at risk for the adverse effects of pressure, the nurse will implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Use of a pressure redistribution support surface can be expensive, but it is an effective way to prevent a pressure injury. The nurse will also keep heels from pressing on the bed for immobile clients and advise against prolonged sitting. While sitting or lying, the client will use positioning devices or pillows to keep boney prominences from rubbing on each other or pressing onto a surface. Placing pillows under the knees while supine puts pressure on the heels against the mattress. The nurse will protect the client's skin from friction and shear by lifting the client when moving or repositioning and keep the head of bed at 30 degrees or less. Positioning at client on a bed while the head of the bed is at a 45 degree angle could cause the client to have a skin shear or friction injury. The nurse will provide adequate calories and nutrients.

The nurse is caring for a client who has had a total knee replacement and not has not had a bowel movement on postoperative day three. Which action(s) taken by the nurse is part of the implementation step of the nursing process? Select all that apply. a. administrating laxative medications b. auscultating bowel sounds to listen for activity c. reviewing client history d. encouraging more frequent mobilization e. checking the client's nutritional status for the daily fiber intake

administrating laxative medications encouraging more frequent mobilization Implementation is the fourth step in the nursing process, and it means carrying out the plan of care. The nurse implements medical orders as well as nursing orders, which should complement each other. This step in the nursing process is where the nurse takes action based on the client's plan of care. For a client who is experiencing constipation, interventions the nurse will carry out in the implementation step of the nursing process can include administering medications such as laxatives and encouraging the client to mobilize more frequently as this action can promote bowel motility. The nurse will auscultate bowel sounds to listen for activity in the bowel during the assessment step of the nursing process. Reviewing the client history is part of collecting objective data during the database assessment stage of the assessment. Information obtained during a database assessment serves as a reference for comparing all future data and provides the evidence used to identify the client's initial problems. Comparisons of ongoing assessments with baseline data help determine whether the client's health is improving, deteriorating, or remaining unchanged. When checking the client's nutritional status specifically for the amount of daily fiber intake. the nurse is also collecting objective data in the assessment step of the nursing process.

A client inquires about the use of herbal therapy. Which statement by the nurse is most accurate? a. "Be sure to pay attention to the packaging's therapeutic and prevention information." b. "Herbs can have side effects and can interact with prescription medications." c. Consider the licensing body for herbalists d. Research the standardization of the herb's constituents

b. "Herbs can have side effects and can interact with prescription medications." It is important for clients to understand that herbs can have side effects and can interact with prescription medications. Standardization of the herb's constituents is useful, but also limited because not all the compounds or the required levels are known. Thus, the purity and dosage contents may not be equal between herbs. Herbal products cannot make therapeutic and prevention claims. There is no current licensing body for herbalists.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? a. Fluid Volume Excess b. Cardiac dysrhythmia c. Pulmonary emboli d. Tetany

b. Cardiac dysrhythmia Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The nurse is caring for an older adult client who has a cognitive impairment and frequently wanders. The nurse will implement which action(s) into the client's plan of care? Select all that apply. a. Encourage the client to walk outdoors when weather permits. b. Check that all exit doorways have a STOP sign posted. c. Place a bell over the client's room and other facility doors. d. Call security personnel to monitor the patient

b. Check that all exit doorways have a STOP sign posted. c. Place a bell over the client's room and other facility doors. For older adult clients with cognitive impairment, such as when clients are diagnosed with dementia or Alzheimer disease, the tendency to wander can pose a serious risk to the client's safety. In the nurse's plan of care for this client, it is necessary to ensure the client's environment is assessed for and adapted to prevent the client from exiting the care facility unaccompanied. The nurse will place STOP signs on all exit doors to communicate to the client that the client should not open exit doors. The nurse can ensure there is a bell over the client's room door so there is an audible signal to care providers when the client is out of the room. Physical restraint is an intervention that is used sparingly with clients with cognitive impairment because it is invasive and traumatizing. The application of physical restraint is reserved for situations in which the client is placing one's own safety in danger. An intervention such as this would not be used periodically throughout the day. The nurse will implement nonviolent crisis intervention such as therapeutic communication, redirection and, occasionally, chemical restraints if the client is sufficiently agitated to place oneself or others at risk. Security personnel can be perceived as threatening by the client, and their presence could lead to further agitation and long-term harm to the client. The presence of security is required only on a case-by-case basis. The client should only take a walk outdoors if accompanied by a care provider or family member.

Which client should the nurse determine to be at the greatest risk for hospital-acquired infection (HAI)? a. Client with a diabetic foot ulcer b. Client with a urinary catheter c. Client with an intravenous catheter d. Client who has a surgical incision

b. Client with a urinary catheter While all of the clients are at risk for infection, the client at the greatest risk is the one with a urinary catheter. This is because catheter-associated urinary tract infections are the most common type of hospital-acquired infections, accounting for more than 30% of HAIs in acute care hospitals. Most hospitalized clients receive an intravenous catheter. Clients go to the hospital for surgery so a surgical incision is expected. Clients with a diabetic foot ulcer may be admitted to the hospital for intravenous antibiotics.

An 84-year-old client has returned from the postanesthesia care unit. The client is oriented to name only. The client's family is very upset because before having surgery the client knew the family. The client is diagnosed with delirium. Which action should the nurse take to help the family with their emotions? a. Explain that delirium is a state of confused thinking and usually lasts only a short time. b. Coordinate a family meeting to make sure everyone has the same information. c. Recommend that the HCP alleviate family concerns d. Utilize the hospital chaplain may help to provide emotional support but not all people are interested in religious counseling

b. Coordinate a family meeting to make sure everyone has the same information. By explaining what delirium is and that it usually is short-term provides the family with information that can decrease the family's worry. The hospital chaplain may help to provide emotional support but not all people are interested in religious counseling. The health care provider can be a good resource for information but the nurse should provide teaching to alleviate family concerns. It is not the nurse's place to coordinate a family meeting.

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply. a. Use powder or lotion when cleansing the perineal area b. Encourage fluid intake, unless contraindicated. c. Record volume and character of the urine. d. Maintain a closed urinary catheter system. e. Change the indwelling catheter regularly

b. Encourage fluid intake, unless contraindicated. c. Record volume and character of the urine. d. Maintain a closed urinary catheter system. The client with a Foley catheter should maintain a closed drainage system to prevent introduction of pathogens into the system, and should have the urinary output monitored closely to determine adequate volume. The client can have natural irrigation of the catheter with an increased intake of fluid, if not contraindicated, which also reduces potential for infection. The character of the urine should also be monitored to determine any signs of urinary tract infection. The indwelling catheter should not be changed regularly but only as needed. Powder or lotion should not be used in the perineal area, but the area should be cleansed daily (or after each bowel movement).

A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of her stethoscope in this assessment? a. In the center of the upper back b. Over the space between the fifth and sixth ribs on the left midclavicular line c. Over the radial artery, below the hand on the wrist d. Over the clients heart, on the left side

b. Over the space between the fifth and sixth ribs on the left midclavicular line The apical pulse is measured over the apex of the heart, which is located approximately in the area of the space between the fifth and sixth ribs on the left midclavicular line.

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for reinforcement of the principles of asepsis? Select all that apply. a. The nurse's back is facing the sterile field. b. The nurse keeps hands above waist level while donning sterile gloves. c. The nurse touches an unsterile object to the instrument tray. d. The nurse is talking with the scrub nurse over the sterile field.

b. The nurse keeps hands above waist level while donning sterile gloves. c. The nurse touches an unsterile object to the instrument tray. d. The nurse is talking with the scrub nurse over the sterile field. Principles of surgical asepsis include never turning one's back on a sterile field. The nurse should avoid talking, coughing, or sneezing over the field and keep sterile objects above waist level. Sterile objects may only be touched by other sterile objects. Most solutions are considered sterile for 24 hours after they are opened.

A nurse is assessing the bowel elimination patterns of hospitalized clients. Which nursing actions related to the assessment process are performed correctly? Select all that apply. a. Ask the client to empty their bladder before their exam as to not have the client uncomfortable b. The nurse places the client in the supine position with the abdomen exposed. c. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. d. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft e. Place the client's legs flat against the bed

b. The nurse places the client in the supine position with the abdomen exposed. c. The nurse uses a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. d. The nurse notes the character of bowel sounds, which are normally high-pitched, gurgling, and soft The nurse would place the client in the supine position with the abdomen exposed. The nurse would use a warmed stethoscope to listen for bowel sounds in all abdominal quadrants. The nurse would note the character of bowel sounds. The nurse would first inspect, then auscultate, then palpate the abdomen. The nurse would not place the client's legs flat against the bed, rather flex the knees slightly. The nurse would not ask the client to drink fluids to fill the bladder before the exam. The nurse would ask the client to empty the bladder before the exam so as not to have the client uncomfortable from a full bladder.

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students? a. The exercise will have minimal effect on fluid and electrolytes. b. The student should drink large amounts of water on practice days. c. The hot weather will not prepare the student for the marching season d. The student's endurance will increase as practice continues,

b. The student should drink large amounts of water on practice days. It is important for the nurse to caution the student about the potential dangers of excessive exercise without adequate fluid replacement, especially in hot weather. Dehydration can lead to muscle damage and fluid and electrolyte imbalances. Exercise will have a major impact on the student's fluid, and electrolytes balance and replacement needs to be accomplished. The student's endurance will increase as practice continues, but fluid replacement needs to occur. The hot weather will not prepare the student for the marching season; practice will prepare the student.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly? a. Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke. b. Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe. c. Assist the client into the prone position for the procedure d. Cleanse the perineal area with a gauze pad and alcohol

b. Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe. The nurse would use the dominant hand to inflate the catheter balloon, and inject the entire volume of sterile water supplied in the prefilled syringe. The nurse would not hold the catheter 1 ft (0.3 m) from the tip. This would result in the nurse having little control over the tip of the catheter and the catheter could easily become contaminated. The nurse would not cleanse the perineal area with a gauze pad and alcohol. Iodine swabs are used to clean the perineal area prior to catheter insertion. The nurse would assist the client into the supine position, not the prone position for the procedure.

For which clients would the nurse be required to use droplet precautions? Select all that apply. a. a client with tuberculosis b. a client with rubella c. a client with mumps d. a client with methicillin resistant staphylococcus aureus (MRSA) e. a client with diphtheria prioritization

b. a client with rubella c. a client with mumps e. a client with diphtheria prioritization Droplet precautions would be used for clients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. For tuberculosis and SARS, airborne precautions would be used. Contact precautions would be the primary method of precautions with MRSA.

A nurse is caring for a client with orthostatic hypotension. Which nursing interventions are appropriate to decrease the risk of falls? Select all that apply. a. encourage slow movement from the bed to the chair b. encourage oral fluid intake c. encourage the client to use the call light prior to getting out of bed d. encourage the use of the call light for help to the bathroom e. encourage the client to eat protein rich foods

b. encourage oral fluid intake a. encourage slow movement from the bed to the chair c. encourage the client to use the call light prior to getting out of bed d. encourage the use of the call light for help to the bathroom The nurse can reduce the fall risk associated with postural hypotension by restoring adequate hydration, making sure the client stays seated and moves slowly from sitting to standing, and encouraging the client to use the call light for help when ambulating. Protein-rich foods have no bearing on postural hypotension. Compression stockings should be applied to reduce the pooling of blood in the extremities when the client is standing.

A 75-year-old man was admitted to the hospital for altered mental status. He had been in his usual state of good health until this morning when a nurse at the long-term care facility where he lives noticed that he was confused. Shortly after being admitted to the hospital, he became combative and had to be restrained. His bed linens have to be changed frequently because of urinary incontinence. Which nursing diagnosis best describes this client's condition? a. total urinary incontinence b. functional incontinence c. reflex incontinence d. urge incontinence

b. functional incontinence Functional incontinence is the inability of a normally continent person to reach the bathroom in time to avoid the unintentional loss of urine. Stress incontinence is a state where the client loses small amounts of urine with increased pressure on the abdomen. Urge urinary incontinence is when a client experiences an involuntary loss of urine when a specific bladder volume is reached. Total urinary incontinence is when a client experiences continuous, unpredictable loss of urine

The nurse is transferring a client who has dementia from the bed to a wheelchair. Which instructions will the nurse use? Select all that apply. a. scoot onto the wheelchair b. i am going to put your shoes on you c. don't lock your knees d. stand up by the bed e. sit down in the wheelchair

b. i am going to put your shoes on you d. stand up by the bed e. sit down in the wheelchair The nurse should use direct, one-action statements. The client may be confused by the direction to "scoot" and by the two actions in the statement. Instructions should be stated in the positive, rather than started with the negative "don't."

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action? a. call the HCP b. perform a respiratory assessment c. give the client oxygen d. raise the head of the bed

b. perform a respiratory assessment As the nurse enters the room, he or she will immediately begin an assessment of respiratory efforts, vocalizations, chest symmetry or lack thereof, and auditory lung sounds. Other actions can take place subsequent to the assessment.

A client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment? a. duration b. quality c. onset d. pain intensity e. pain threshhold

b. quality The client is describing the quality of pain in his head. Quality refers to how the pain feels to the client or words that describe the pain's nature. Pain intensity indicates the magnitude or amount of pain perceived. It is described on a numeric scale or by terms such as none, mild, moderate, severe, or excruciating. Onset and duration are components of temporal pain pattern. Pain threshold is the amount of pain stimulation a person requires before feeling it.

The nurse is holding a cholesterol screening at a local pharmacy this Saturday morning. What level(s) of health promotion is this screening an example of? a. primary b. secondary c. tertiary d. quaternary

b. secondary Screenings, such as those for blood pressure, cholesterol, glaucoma, HIV, and skin cancer, are considered nursing activities that fall under the category of secondary health promotion. Secondary health promotion and illness prevention focus on screening for early detection of disease, with prompt diagnosis and treatment of those found. Secondary health promotion involves measures that actually help prevent disease from occurring in the first place, such as a presentation to school children about healthy food choices and the importance of being active. Tertiary health promotion involves rehabilitation following the development of a chronic condition, to help prevent further progression and associated complications of the condition, such as cardiac exercise classes for clients recovering from a heart attack.

While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger clients. What should the nurse do? a. document that the client experiences symptoms consistent with dementia b. slow the pace and allow extra for answers c. ask the client's family members to answer questions to speed up the process d. ask the client's family members if dementia is present

b. slow the pace and allow extra for answers Cognition does not change appreciably with aging. It is normal for the older adult to take longer to respond and react. The nurse should slow the pace of care and allow older clients extra time to answer questions or complete activities. The nurse needs to ask the questions to complete the assessment. Not all older adults have dementia, thus the nurse should not assume this is the case. It is not appropriate to ask family members to answer the questions to speed up the process. Family members should be asked if dementia is present or if the client cannot recall information, but that is not the first intervention.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? a. comatose b. somnolence c. asleep d. stuporous

b. somnolence When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. a. a respiratory rate that ranges from 12 to 16 breaths/min is normal for the adult and order adult b. the client demonstrates restlessness c. the client's capillary refill is assessed at 4 seconds d. the client has uneven movements of the chest respirations e. the client has flaring nostrils

b. the client demonstrates restlessness c. the client's capillary refill is assessed at 4 seconds d. the client has uneven movements of the chest respirations e. the client has flaring nostrils Careful assessment of older adults who demonstrate restlessness or confusion is imperative for accurately differentiating signs of inadequate oxygenation from signs of delirium or dementia. While the nurse may be observing signs of cognitive impairment, restlessness is commonly accompanies respiratory distress. The nurse will not dismiss this sign and will consider it as part of the respiratory assessment. A prolonged capillary refill time (any time longer than 3 seconds) is indicative of poor perfusion secondary to poor oxygenation. This is a sign that the client may be experiencing respiratory complications. The nurse observes for paradoxical (uneven) chest movement that would indicate possible flail chest. These complications may require insertion of a chest tube or other surgery, blood transfusion or artificial ventilation. Flaring nostrils indicate increased work of breathing related to poor gas exchange. A respiratory rate that ranges from 12 to 16 breaths/min is normal for the adult and older adult.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? a. taking prescribed medications b. thorough hand hygiene c. proper intake of fluids and fiber d. adequate sleep and res

b. thorough hand hygiene The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began measuring the BP after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client? a.This is called hypotension and may be caused by your medications. b.You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. c. This is called Hypertension and you may want to reduce you red meat intake d. This is called bradycardia and you must make sure you are receiving adequate nutrition

b.You may have orthostatic hypotension and should be seen by your health care provider as soon as you can. Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls

The nurse has completed an assessment of a client's typical hygiene practices. How should the nurse best document the findings of this assessment in the client's chart? a. "Client prioritizes personal hygiene in her daily routines and is proactive with skin care." b. "Client's level of personal hygiene is acceptable and age-appropriate" c. "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." d. "Client prioritizes personal hygiene in her daily routines and is proactive with skin care"

c. "Client normally bathes and washes her hair every other day; applies moisturizer to dry areas on her elbows and forearms." When documenting the nursing or health history, it is best to be specific, clearly describing the client's typical hygiene practices and any complaints. Judgments such as "bathes more often than necessary and consequently experiences dry skin" regarding cause and effect are likely premature in this context and may be inaccurate. The statements such as "client's level of personal hygiene is acceptable and age-appropriate" and "client prioritizes personal hygiene in her daily routines and is proactive with skin care" are not specific and generalized.

A nurse is planning hygiene for a client with dementia. The nurse understands the need to provide an environment that will aid her in the care of this client. Which action will she perform? a. Refuse to bathe the client because the nurse and client have not established a rapport. b. Delegate care to the UAP c. Create a calming environment with little stimuli. d. Play music for the client

c. Create a calming environment with little stimuli. Bathing sometimes increases stimulation in clients who are confused or have dementia. Reducing the stimuli and providing a calm environment will decrease agitation. Turning down the lights, ensuring the adequacy of the environment where the client is being bathed and playing soft, relaxing music are possible interventions to calm the client. Nurses are responsible for the care of their clients and the staff that care for them. Delegating care of a client with dementia may require special instructions for the UAP.

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? a. Administer Naloxone to discontinue the client's pain control b. Discontinue the client's pain medication until his or her level of consciousness improves c. Report this finding to the PCP and seek a decrease in the client's opioid dosing d. Administer stimulants to help keep the client awake

c. Report this finding to the PCP and seek a decrease in the client's opioid dosing The sedation score for this client is 3. This requires collaboration with the primary care provider to decrease the analgesic dose. Naloxone is not likely necessary, nor is it appropriate to completely discontinue the client's pain control.

A client's partner expresses concern to the nurse about the client's snoring. Which assessment parameters will the nurse teach the couple to observe for the possibility of sleep apnea? a. Varying patterns of snoring b. A period of deep sleep c. Snoring with periods of irregular silence d. Irregular silence while sleeping

c. Snoring with periods of irregular silence Snoring is caused by an obstruction of airflow through the nose and mouth. When snoring changes from the characteristic sawing wood sound to a more irregular silence followed by a snort, this indicates obstructive apnea. Snoring does have varied patterns, but the irregular silence is different from snoring. A client with sleep apnea would experience regular arousal, rather than deep sleep.

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition? a. depression b. disorientation c. delirium d. dementia

c. delirium Delirium is a temporary state of confusion that is often precipitated by drug interactions or the effects of new drugs. Dementia is rooted in organic brain changes and rarely has a sudden onset. The client is not showing signs or symptoms of depression. Disorientation is a manifestation of a problem rather than a cause.

A client with cancer pain is taking morphine for pain relief. Knowing constipation is a common side effect, what would the nurse recommend to the client? a. only take morphine when you have the most severe pain b. administer an enema every third day of taking morphine c. increase fluids and high-fiber foods, and use a mild laxative d. wait it out, as the constipation usually gets better after a few doses

c. increase fluids and high-fiber foods, and use a mild laxative The most common side effects associated with opioids (e.g., morphine) are sedation, nausea, and constipation. If constipation persists, it usually responds to treatment with increased fluids and fiber, and use of a mild laxative. For many clients, constipation makes the client irritable, so instructing about this side effect is important for the nurse. Taking the medication only for severe pain is not appropriate to instruct the client. Administering an enema every third day is inappropriate.

The Z-track technique is utilized during drug administration by which route? a. subcutaneous b. intradermal c. intramuscular d. Intravenous

c. intramuscular The Z-track technique is used for intramuscular injections to prevent leakage of medication into the needle track, thus minimizing discomfort.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing? a. presence of sputum in the trachea b. inflammation of pleural surfaces c. presence of fluid in the lungs d. air passing through narrowed airways

c. presence of fluid in the lungs Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury? a. stage I b. stage II c. stage III d. stage IV e. unstageable

c. stage III Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV exposes muscle and bone

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? a. bradycardia b. dysrhythmia c. tachycardia d. myocardial infarction

c. tachycardia Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate or less than 60 beats/min. Dysrhythmia is an irregular pulse rate.

While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude? a. the observations are not typically found in older adults b. additional education is necessary as these could lead to complication c. these are normal physiologic changes of aging d. contact the HCP

c. these are normal physiologic changes of aging Dry wrinkled skin, gray hair, and needing glasses to read are all commonly occurring and normal physiologic changes of aging. They are not abnormal and no additional education is necessary as the changes observed do not lead to complications.

Potassium is needed for neural, muscle, and:

cardiac function Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? a. Continue use of prophylactic antibiotics b. Frequently irrigate the catheter c. Use clean technique when inserting the catheter d. Ensure that the catheter is removed as soon as possible

d. Ensure that the catheter is removed as soon as possible To prevent UTIs, the nurse should leave the catheter in place for as short a time as possible. Strict aseptic technique is used for insertion, not clean technique. Frequent irrigation increases the risk of UTIs. For most clients with intact immune systems, prophylactic antibiotics are not used.

A client with dysphagia prepares to eat dinner. How does the nurse best help this client? a. Play the client's favorite music or video. b. talk to the patient whil they are eating c. Assist the patient by setting up their meal tray d. Ensure the head of the bed is high-Fowler.

d. Ensure the head of the bed is high-Fowler. The nurse must ensure that the client is sitting up well enough to safely eat, whether that is high-Fowler or in the chair. The nurse may assist in setting up the meal tray or play something the client enjoys for background noise. The client with dysphagia should have minimal conversation while eating due to the increased risk of failure to correctly swallow.

The nurse is assessing a client who was seen 7 days ago with strep throat. The client states, "I felt better after 2 days of the antibiotic the provider prescribed, so I quit taking it." What would the nurse do to address this situation? a. Allow the patient to discontinue use because they feel better b. Consult the HCP for alternative treatment c. Call the HCP to add another antibiotic d. Provide education on taking all antibiotics for effective treatment

d. Provide education on taking all antibiotics for effective treatment Although benefits of antibiotics may be felt in a few days after starting therapy, the nurse will teach the client that the entire course of medication must be taken to rid the body of infection. Discontinuing the antibiotic prematurely may cause the infection to reoccur. The incomplete use of an antibiotic is one factor that contributes to the evolution of resistant microbial organisms so the nurse would not instruct the client to returning to the previous regimen. Consulting the health care provider for alternate treatment options may or may not be applicable and also is not particularly the most important. The mixture of antibiotics would typically not be prescribed in this client.

A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply. a. Alternatives to restraints and less restrictive interventions must have been implemented and failed. b. A physician or licensed independent practitioner must reevaluate and assess the client every 48 hours. c. Restraints may be used to prevent a client from falling if the facility is short-staffed. d. The client's family must be involved in the decision and care plan. e. The benefit gained from using a restraint must outweigh the known risks for that client.

d. The client's family must be involved in the decision and care plan. a. Alternatives to restraints and less restrictive interventions must have been implemented and failed. e. The benefit gained from using a restraint must outweigh the known risks for that client. The client has the right to be free from restraints that are not medically necessary. Restraints are not used for the convenience of staff or to punish a client. The client's family must be involved in the care plan and must be consulted when the decision is made to use restraints. Alternatives to restraints and less restrictive interventions must have been implemented and failed, and all alternatives used must be documented. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 24 hours. The client's vital signs must be assessed and the medical client must be visually observed every 2 hours.

A nurse delegates a specific intervention to an unlicensed assistive personnel (UAP). What implications does this have for the nurse? a. the UAP can function independently b. the UAP is responsible for outcome because they are delivering the care c. When delegating care, the responsibility for care shifts to the UAP d. The nurse transfers responsibility but is accountable for the outcome.

d. The nurse transfers responsibility but is accountable for the outcome. UAPs are trained to function in an assistive role to the registered nurse (RN) in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome. Nurses can delegate tasks to the UAP, but the UAP cannot function independently. Accountability for the action lies with the nurse.

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? a. temporal b. femoral c. radial d. apical e. popliteal

d. apical The apical pulse is assessed when a client is being given medications that alter heart rate and rhythm.

The nurse is delegating tasks to the unlicensed assistive personnel (UAP) prior to beginning the shift on the acute care unit. Which task would be appropriate to delegate to the UAP? a.inserting a nasogastric tube b.starting an IV c. performing an assessment for a newly-admitted client d. assisting an older adult client with using the bedside commode

d. assisting an older adult client with using the bedside commode When delegating tasks to UAPs, the nurse should perform the rights of delegation prior to delegating. Assisting the client with activities of daily living such as transfers, assisting with toileting, and feeding are some of the tasks that are able to be performed by the UAP. Inserting a nasogastric tube, starting an IV, and performing an assessment for a newly-admitted client are tasks that the nurse must perform and are outside of the scope of practice for the UAP.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a. muscle weakness b. increased intracranial pressure c. metabolic acidosis d. cardiac irregularities

d. cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? a. narcotic overuse b. delusion c. dementia d. delirium

d. delirium Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: a. hyperkalemia b. hypokalemia c. hypernatremia d. hyponatremia e. hypercalcemia

d. hyponatremia Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced? a. stress b. urge c. reflex d. total

d. total Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. Other types of incontinence have different causative factors.

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound? a. stage I b. stage II c. stage III d. stage IV e. suspected deep tissue injury f. unstageable wound

e. suspected deep tissue injury A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial-thickness loss of dermis that often presents as an open blister. A stage III pressure injury is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

The following are prescriptions on a client's chart. Which prescriptions would the nurse question because they are written incorrectly? Select all that apply. a. CXR tonight b. heparin 5000U subcutaneously every day c. vancomycin 750 mg IV qod d. metoprolol 25 mg po daily, hold if BP <100 mm Hg e. lytes in AM f. 1000mL NS q12h every other day

heparin 5000U subcutaneously every day metoprolol 25 mg po daily, hold if BP <100 mm Hg vancomycin 750 mg IV qod The prescriptions written incorrectly, which the nurse would question, are the heparin, metoprolol, and vancomycin orders. The U in the heparin option should be written as units. U could be mistaken as the numbers 0 or 4, causing a severe overdose. U could also be mistaken for cc. The < symbol means less than. However, people have misinterpreted < as greater than. Qod is meant as every other day. The "o" has been mistaken for "i." It is best to write out these symbols. NS means normal saline, lytes means electrolytes, and CXR means chest x-ray. These are acceptable abbreviations.