fundamentals

A nurse is providing discharge teaching. Which response indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

NG tube removal

- disconnect tube from suction - inject 50 mL air to clear contents - instruct client to hold breath - pinch tube

tracheostomy suctioning

- hyperoxygenate w 100% O2 for at least 2 minutes prior to suctioning - perform max of 3 passes - give 1 min in bt/wn suctioning passes to hyperoxygenate - pull suction catheter back 0.5 inch if client starts coughing

NG tube feeding

- keep HOB elevated for 1 hour after feeding - flush 30 mL water before & after - inject 10-30 mL air before checking residual to clear of any food - to assess placement prior to admin, check residual & verify pH (want less than/equal to 4)

Hold dropped ___ inches above ear to administer otic meds

0.5

hold irrigator ___ inches away from the eye

1

normal gastric pH

1-4, can be up to 6

magnesium

1.3-2.1 mg/dL

BUN

10-20 mg/dL

Infant should be able to use utensils to feed themselves by

12 months

sodium

135-145 mEq/L

move cane

15-30 cm forward before each step

How long to wait between inhalations of bronchodilating inhalers?

20-30 seconds

HCO3- range

21-28 mEq/L

how often to use ROM to improve mobility

2x daily

Do not take oral temp on children less than

3 yo

phosphorus

3.0-4.5 mg/dL

potassium

3.5-5.0

1 oz

30 mL

PaCO2 range

35-45 mmHg

BP cuff bladder should be

40% arm width

WBC

5,000-10,000/mm3

ABG pH range

7.35-7.45

blood glucose levels

70-110 mg/dL

BP cuff should be

80% arm circumference

PaO2 range

80-100 mmHg

Infant should be expected to use pincher grasp at

9 months

calcium levels

9-10.5 mg/dL

calcium

9.0-10.5 mg/dL

Angle to use when capillary blood glucose testing (finger prick)

90

hypomagnesemia

<1.3 mEq/L

hyponatremia

<135 mEq/L

hypokalemia

<3.5 mEq/L

hypocalcemia

<9 mg/dL

hypercalcemia

>10.5 mg/dL

hypernatremia

>145 mEq/L

hypermagnesemia

>2.1 mEq/L

hyperkalemia

>5.0 mEq/L

A nurse is administering meds to a client who asks the nurse to leave the med at the bedside to be taken at a later time. What should the nurse reply? A. "Call me when you are ready and I will return with the med." B. "Since you were taking this med at home, I will leave it for you to take." C. "I will come back in 30 mins to check that you took the med so I can chart the time." D. "If you refuse to take the med now, I can't give it again until your next scheduled time."

A. "Call me when you are ready and I will return with the med." - other answers incorrect; B - nurse responsible for med admin, C - nurse can't verify med was taken, D - med can generally be given w/in 1 hour of prescribed time

+1 pitting edema bilaterally. mm indentation? A. 2 B. 4 C. 6 D . 8

A. 2 mm - +2 = 4 mm, +3 = 6 mm, +4 = 8 mm

A nurse is planning a training session about nutrition. Which statement should she include in the teaching? A. Fats provide energy B. Carbs repair body tissue C. Fats regulate fluid balance D. Carbs prevent interstitial edema

A. Fats provide energy - this is true, the rest are false (A, B, & C relate to protein)

A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take A.) Explain that it is against policy to share access codes and refer the resident to his supervisor. B.) Access the client's online data and monitor the resident as he reads it. C.) Access the online client data system and allow the resident to locate the client's data. D.) Ask the client to give permission for the resident to access his medical records.

A. explain that it is against policy to share access codes & refer the resident to his supervisor - allowing unauthorized access is a breach of federal guidelines for data security & client confidentiality

A nurse is providing teaching to a client with HF about reducing his daily sodium intake. Which factor is most important in determining the client's ability to learn new dietary habits? A. the involvement of the client in planning B. the emphasis the provider places on the dietary changes C. the learning theory the nurse uses to teach the dietary changes D. the extent of the dietary changes planned for the client

A. the involvement of the client in planning - according to EBP, client involvement is the most important factor in the client's ability to learn new habits

A nurse is caring for a client who has injuries resulting from a motor vehicle crash. Which statement should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."

B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." - Maslow's hierarchy; need for comfort, pain management

Which client is eligible for hospice services at this time? A. a client who has MS and uses a wheelchair B. a client who has end-stage liver cirrhosis C. a client who has hemiplegia due to a stroke D. a client who has cancer and receives weekly radiation therapy

B. a client who has end-stage liver cirrhosis - likely has life expectancy of <6 months

A nurse is performing an admission assessment for a client who has asthma and reported several food allergies. Which action should the nurse take first? A. document the client's food allergies in the medical record B. ask the client to identify the specific food allergies C. monitor the client for indications of anaphylaxis D. have epinephrine available for administration

B. ask the client to identify the specific food allergies - data collection/assessment before developing a plan of action

A nurse is teaching about pain management in clients age 65 and older. Which piece of info should she include? A. clients who are age 65 and older experience a decreased ability to perceive pain B. clients who are age 65 and older are reluctant to report pain C. clients who are age 65 and older should not receive opioid narcotics D. clients who are age 65 and older experience a shorter duration of action with medications

B. clients who are age 65 and older are reluctant to report pain - other answers incorrect; 65+ clients are frequently reluctant to report pain bc they might not want to bother/anger caregivers & might believe pain is expected

A client has terminal illness. What indicates that their death is imminent? A. urinary retention B. cold extremities C. hypotension D. tachycardia

B. cold extremities

A HHN is visiting an older client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working and caring for his mother at home. Which option should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility

C. Respite care - respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance

A nurse is inserting an IV catheter for a client that results in blood spilled on her gloved hand. The client has no documented blood infection. Which action should the nurse take? A. wash the gloved hands, then throw the gloves away B. prepare an incident report C. carefully remove the gloves and perform hand hygiene D. ask the provider to order a blood culture to determine the risk of infection

C. carefully remove the gloves and perform hand hygiene - standard precautions

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which action should the nurse take first? A. obtain the prescribed irrigation solution B. don personal protective equipment C. check the client's pain level D. place a waterproof pad under the client's extremity

C. check the client's pain level - collect data/assess before intervening; A is incorrect bc you should have the solution prior to performing the procedure

A nurse is administering a cleansing enema to a client before a diagnostic procedure. What action should she take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. position client on the right side C. insert the tip of the tubing 8 cm (3.1 in) D. hold the enema container 61 cm (24 in) above the rectum

C. insert the tip of the tubing 8 cm (3.1 in) - nurse should insert tip of tube 7-10 cm (3-4 inches) along the rectal wall to prevent tube dislodging during the procedure/ A - lubricate 5-8 cm (2-3 in); B - Sims'; D - hold container a max of 45 cm (18 in) above the rectum to prevent painful distension of the colon

A nurse is caring for an inmate. The inmate is brought in by a guard who asks about the client's HIV status. What should the nurse do? A. inform the guard that the warden must request this info B. ask the guard to sign a release of info form C. instruct the guard to ask the inmate D. complete an incident report

C. instruct the guard to ask the inmate - rest incorrect, client consent !!!

A nurse is caring for an adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which action should the nurse take? A. tie the restraints to the side rails B. perform ROM exercises to the wrists every 3 hrs C. remove the restraints one at a time D. obtain a PRN prescription for the restraints

C. remove the restraints one at a time - remove restraints one at a time for a violent/noncompliant client

A nurse is preparing to irrigate a client's wound. Which action should she take? A. use a 10 mL syringe B. attach a 22 gauge catheter to the syringe C. warm the irrigating solution to 37 Celsius D. administer an analgesic 10 min before the irrigation

C. warm the irrigating solution to 37 Celsius - rest are incorrect

A nurse is performing a spiritual assessment of a client. Which question should the nurse ask? A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?"

D. "What is your source of strength and hope?" - broad, open-ended question, does not assume

A nurse is discussing fire safety with newly hired nurses. Which action is the priority if a fire occurs in a health care facility? A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit

D. Evacuate clients from the unit - the greatest risk during a fire is injury to clients; therefore the nurse's priority action is to evacuate clients from the unit

Client has head of the bed at 45 degrees with his knees slightly flexed. Which position is he in? A. Sims B. Prone C. Supine D. Fowler's

D. Fowler's - aka Semi Fowler's, which is between 45 -60 degrees

A nurse is preparing to administer a TB skin test. After performing hand hygiene, which action should the nurse take? A. select a 23 gauge needle B. insert the needle into the skin at a 25 degree angle C. massage the area of injection following removal of the needle D. circle the injection area with a pen

D. circle the injection area with a pen - circling the area ensures the nurse will examine the correct site when reading the test 48-72 hours later

A nurse is caring for a client who is unstable and has vital signs measured every 15 mins by an electronic BP machine. The nurse notices the machine begins to measure the BP at varied intervals and the readings are inconsistent. What action should the nurse take? A. turn on the machine every 15 min to measure the client's BP B. record only the BP readings needed for 15 min intervals C. obtain manual & automatic readings & compare them D. disconnect the machine & measure the BP manually every 15 mins

D. disconnect the machine & measure the BP manually every 15 mins - malfunctioning equipment can pose a safety risk

A nurse is performing a mental-status exam on a client who has manifestations of dementia. What directions should the nurse give the client to evaluate their ability to think abstractly? A. subtract by 7 serially, starting at 100 B. describe a previous illness C. explain what to do if a fire happened in his bedroom D. discuss the meaning of a common proverb

D. discuss the meaning of a common proverb - A. evaluates attention span, B. evaluates remote memory, C. judgement

While admitting a client to the unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which document? A. informed consent form B. living will document C. DNR directive D. durable power of attorney document

D. durable power of attorney document - AKA health care proxy, names surrogate who can make health care decisions if client is unable to do so

A nurse manager is providing teaching to a group of nurses about ways that clients acquire health care associated infections (HAIs). Which route of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. infection acquired from a diagnostic procedure - iatrogenic HAIs result from diagnostic/therapeutic procedures

sodium regulates

ECF volume

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea & bronchi. What should the nurse do?

Encourage the client to cough - rhonchi typically caused by obstructions/excretions

What should a nurse wear when in contact with a client with AIDS?

Gown & gloves

hyponatremia s&s

N/V, headache, confusion, muscle cramps, seizures, coma, DEPRESSED DTRs, hypothermia, tachycardia, high HR, hypotension

Should you let the family/friends of a patient who speaks a different language than the nurse relay medical info to the client?

NO, medical interpreters are federally mandated

4 clients on oxygen therapy. Partial rebreather, transtracheal oxygen cannula, tracheostomy collar, nasal cannula; priority?

Partial rebreather client - if bag doesn't inflate properly, client will rebreathe CO2

fluid volume excess symptoms

Peripheral edema, weight gain, bounding pulse, elevated BP, distended veins, dyspnea, crackles, confusion, altered LOC

temporal artery temperature

Temperature taken on either side of the head, where the temporal arteries are located

Placed soiled linen in

a single linen bag

Before suctioning a client's tracheostomy, the nurse should

administer high-flow O2 - reduces risk of hypoxia

use PC for

after meals

Muscle group responsible for knee movement

antagonistic

A nurse is taking vitals. This action is which component of the nursing process?

assessment - collecting data = assessment

Infant should be able to crawl on hands and knees

at 9 months

2+

average

don't BT for

bedtime

Brain's respiratory control center

brainstem, medulla, pons

3+

brisk

ecchymosis

bruise

salivary amylase breaks down

carbohydrates

balance/coordination problems r/t

cerebellum

A client is having difficulty with coordination after a head injury. The nurse should suspect damage to which area of the brain?

cerebellum - coordinates voluntary movements

difficulty w/ expression r/t

cerebral cortex

Clean blood spills with

chlorine bleach

clubbing of nails is caused by

chronic hypoxemia

What food can cause a false negative guaiac test

citrus

example of concrete operational thought

collecting and trading game cards - requires seriation (what to collect, what to trade, what has value)

MRSA precautions

contact (gloves - if splashing, mask, gown)

after using IS

cough deeply

most accurate measurement of fluid status

daily weight

reduce orthostatic hypotension/fall risk by

dangling legs on edge of bed for 60 seconds

Client has calcium level of 12.7 mg/dL. What finding should the nurse expect?

depressed DTRs, NV, bone pain, lethargy, weakness

St. John's wort

depression

1+

diminished

xerostomia

dry mouth due to lack/absence of saliva

Symptoms of protein malnourishment

dry, brittle hair, edema, poor wound healing

How often to move extremities to promote circulation

every 1-2 hrs

pap smear

every 3 years, starting at 21

A nurse is called away for an emergency. She returns promptly to the client as promised. Which ethical principle is she demonstrating?

fidelity - keeping promise

positive pressure airflow

filters the air going into the room; used in patients who have compromised immune systems

kidneys regulate

fluid volume, electrolytes, acid-base balance

Clean surgical wound

from the wound toward the surrounding skin (least to most contaminated/dirty)

obstruction of the flow of the vitreous humor in the eye is a manifestation of

glaucoma

don't use HS for

half-strength

chamomile

has anti-inflammatory properties

metabolic alkalosis

high pH, high HCO3

respiratory alkalosis

high pH, low CO2; hyperventilation

urticaria

hives (allergic reaction)

Dressing to put on stage II pressure ulcer

hydrocolloid - absorbs exudate, provides moist environment that facilitates healing

4+

hyperactive

Prolonged exposure to stress can cause

hyperglycemia and hypertension

metabolic acidosis r/t

hyperkalemia

hypoactive DTRs

hypermagnesemia, hypernatremia, hyponatremia, hyperkalemia, hypokalemia, hypercalcemia

positive Chovstek

hypocalcemia

metabolic alkalosis r/t

hypokalemia

hyperactive DTRs

hypomagnesemia, hypocalcemia

sleep difficulty r/t

hypothalamus

strabismus

improper alignment of the eyes

concrete operational stage

in Piaget's theory, the stage of cognitive development (from 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events

garlic, ginger, & ginkgo biloba

increase risk of bleeding; DON'T use w/ anticoagulant

edema at infusion site

indicates IV infiltration, fluid entering SQ tissue

Use half-strength hydrogen peroxide to clean

inner cannula of tracheostomy

spooning of nails (koilonychia) is caused by

iron deficiency

Raising all 4 side rails

is considered a physical restraint; prescription from provider needed for nurse to employ

When ambulating with a cane, the client should

keep 2 points of support on the ground at all times

4 point crutch gait

keep 3 points on the ground at all times

To maximize heat loss in a client with a fever, the nurse should

keep their bed linens dry

Client position for enema

left Sims'

rhonchi

loud coarse or snoring sounds; caused by obstructed airways

respiratory acidosis

low pH, high CO2; hypoventilation

metabolic acidosis

low pH, low HCO3

Where to anchor catheter tube on a male

lower abdomen/upper thigh (with tape)

black cohosh

mimics estrogen; may be used in pts going thru menopause

A nurse is caring for a client who had a stroke and is at risk of falling. What should the nurse do?

monitor the client at least once every hour, keep bed in low position, create elimination schedule, use gait belt when client is ambulating

A client reports SOB. After repositioning, which action should the nurse take next?

observe the rate, depth, & character of the client's respirations - before an intervention, nurse needs to collect data (assess)

To assess for pulse deficit

obtain apical & radial pulses simultaneously; subtract the difference

insensible fluid loss

occurs daily through lungs and skin; cannot be measured for accurate output

When feeding a client with dysphagia, the nurse should

offer the client sour/tart foods first - stimulates saliva production

What equipment should be at the bedside of an seizure patient?

oxygen

To check for strabismus, the nurse should

perform a corneal light reflex test

Procedure education can ONLY be done by

physician

A client reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes the wound has eviscerated. What should the nurse do?

place the client in a supine position with hips and knees flexed; cover wound and intestine with a sterile, moistened dressing; monitor client for manifestations of shock

Dextran and albumin are

plasma volume expanders (correct hypovolemia)

postural drainage

positioning a patient so that gravity aids in the drainage of secretions from the lungs

negative pressure airflow

prevents contaminated air from inside the room from flowing outside the room

iatrogenic

produced by a treatment

valerian

promotes sleep

saw palmetto

prostate

How to straighten ear canal in children younger than 3 yo

pull auricle back and down

When mixing regular insulin w/ NPH

pull regular 1st bc it's short acting while NPH is intermediate

8-10 month old can

pull self to standing position

hypertension screening is an example of

secondary prevention

Braden scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

postop client should use IS

several times an hour

4 month old

should be able to sit up w/ support w/ no head lag

What nutrient regulates extracellular fluid volume?

sodium

echinacea

stimulates immune system

The nurse is caring for a client with a peripheral IV catheter. He notes that the area surrounding the insertion site is red and warm. What should the nurse do?

stop infusion, remove IV catheter, apply warm compress to site

don't use SC for

subcutaneously

Infiltration S/S

swelling, discomfort, burning, tightness, cool skin, blanching

An assessment reveals a client has a temp of 39.2 C (102.6), HR of 105, soft nontender abdomen, and menses overdue by 2 days. Which finding should be the nurse's priority?

temperature of 39.2 C - elevated HR could be caused by fever, therefore fever is 1st priority

When providing oral care for an unconscious client, the nurse should

test for client's gag reflex - determines aspiration risk; many clients w/ decreased LOC do NOT have gag reflex

Tape a catheter on a female client to

the inner thigh

Never use a client's room number to ID them because

they can change rooms

How often to wash feeding bag

twice a week

safest injection site

ventrogluteal

Which breath sound should the nurse expect to hear over the periphery of the major lung fields?

vesicular

3 point gait is used

when patient is non-weight bearing on a leg

Change smoke detector batteries every

year