Fundamentals Exam 2

The nurse is reviewing dental care with a client who is edentulous (lacking teeth) and wears dentures. What statement indicates an understanding of proper dental care:

"I will remove my dentures before bed & keep them in my labeled denture cup covered with water"

ISBAR-R (used for end of shift report)

-Identify -Situation -Background -Assessment -Recommendation -Read Back

The nurse on a behavioral health unit is having a theraputic discussion with a client and recognizes that which communication techniques would be non-theraputic?

-Minimizing feelings -Asking "why" questions -Changing the subject

The nurse is educating an LPN on where to find mucous membranes in the body. The LPN knows that mucous membranes are located:

-Respiratory tract -Stomach -Nostrils

What is calculated: -gelatin -ice cream -applesauce -broth -soup

-gelatin -ice cream -broth -soup (only soup) (anything that turns into liquid)

When you have 10 oz of ice cream you are going to calculate it by 30mL

10 x 30 = 300 mL of ice cream

You have a patient that has an IV and they're getting fluids at 100 ml an hour for a 12 hr shift, how do you figure out how many mL they got just from that IV?

100 x 12 = 1200 mL

How many mL are in 1 oz?

30 mL

How many oz are in a cup?

8 oz = 1 cup

The nurse is providing directions to the assistive personnel (AP) regarding clients hygiene needs. Based on the client needs, the nurse instructs the AP to bathe which client first:

A confused client who is incontinent of stool and urine

When admitting a client to a long term care facility whats 1 thing we need to assess them for to understand what they can do as far as ADL's:

Assess for mobility & the things they can do

What do we clean dentures with?

Denture paste, denture brush, & cold water

How often do we reposition:

Every 2 hours

How often do we want to provide oral care for an unconscious patient:

Every 2 hours

How often do we care for a mouth breather:

Every 4 hours

How do you care for a client who is unresponsive & you're doing oral care :

Lay them on their side

What do we use to facilitate us when we are repositioning a patient:

Lift sheet

Know what modifiable and non-modifiable is:

Modifiable- things that can be changed (smoking) Non-modifiable- things that can't be changed (age)

A nurse is caring for a patient who was diagnosed with cancer. The patient states "I don't know why I need to do chemotherapy. I'm just going to die anyways". The nurse responds with "No you won't, we will help you get better as long as you take your medication". What type of nontheraputic communication is the nurse responding to:

Offering false reassurance

How do you calculate if you give your patient 1000 mL and at the end of shift 300mL is left:

PT drank 700 mL

Using the SOAP method of documentation, which nursing note belongs in the subjective portion of the patient's chart?

Patient reports pain of 7 out of 10

When you have a patient that is capable of doing some activities but may need a little help (ex: pt is contracted but has some type of movement how can we help provide some type of care)

Providing an electric toothbrush

What's 1 way we can provide our patient privacy:

Pulling privacy curtain

How would you describe a stage 1 pressure ulcer:

Red, nonblanche, & irritated

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse knows that which is not part of the five rights of delegation:

Right Documentation

A spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No english, only spanish". Which action should the nurse take?

Seek an interpreter from the hospital's interpreter services

The nurse inspects a pressure injury on a client's sacrum and notes that the site has partial-thickness loss and the formation of a blister. The nurse would document the pressure injury as which category:

Stage II

A nurse is preparing to communicate with an older client who is hearing impaired. Which intervention would be implemented initially:

Stand in front of the client

What's the first thing you do when you have a patient with hearing loss?

Stand in front of them

A nurse is assessing a patient and evaluating their nonverbal behavior. The nurse understands this about nonverbal communication:

The client cultural background can influence nonverbal communication

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented:

The skin when pinched immediately fell back into normal when released

If it's in oz convert into:

mL (1 oz = 30 ml)

How do you care for a stage 1 pressure ulcer:

pat clean don't rub around it

What is a theraputic type of communication that is really awkward but not a bad thing?

silence

subjective data

what someone tells you (ex: "I have pain in my elbow")

objective data

what you observe (ex: patient has a pressure ulcer)