Fundamentals: josphine, kim, mona

A patient demonstrates correct use of the incentive spirometer when the patient places the mouthpiece in the mouth and does which of the following? A. Inhales slowly and deeply B. Exhales quickly and forcefully C. Exhales slowly and deeply D. Inhales quickly and forcefully

A. Inhales slowly and deeply

The nurse is providing patient education on self-catheterization. What statement by Ms. Johnson indicates the need for additional teaching?

I can use either an indwelling or intermittent catheter.

The nurse is performing an assessment of Ms. Morrow's wound. What should be included in the documentation? (Select all that apply.)

Odor Drainage Tunneling Location

Ms. Morrow's daughter asks the nurse why it is necessary to irrigate her mother's wound. What is the appropriate response by the nurse? The procedure helps remove drainage and debris from the wound. What is the appropriate response by the nurse?

The procedure helps remove drainage and debris from the wound.

Ms. Johnson asks: Why do I need to self-catheterize at regular intervals? What would be the appropriate response by the nurse?

This helps prevent your bladder from being over-distended.

the nurse has an order to check a patients post void residual urine. how would the nurse carry out this order?

measure the amount of urine in the bladder using a bladder scanner

The nurse titrates the patient's oxygen to 3L per nasal cannula in order to maintain an oxygen saturation of at least 94%, per the provider's orders. What is the rationale for this order? (Select all that apply.) A. Allows the body to meet metabolic demands B. Promotes a decrease in respiratory effort C. Promotes a decrease in myocardial workload D. Allows the patient to receive 100% oxygenE. Prevents atelectasis in a patient with pneumonia

A. Allows the body to meet metabolic demands B. Promotes a decrease in respiratory effort

Expected assessment findings of a patient with pneumonia may include which of the following? (Select all that apply.) A. Malaise B. Fever C. Tachypnea D. Enuresis E. Use of accessory muscles

A. MalaiseB. FeverC. TachypneaE. Use of accessory muscles

Identify the following potential problems or actual problems that the nurse should include when planning care for the patient diagnosed with pneumonia? (Select all that apply.)

Acute pain.Ineffective respiratory gas exchange.Difficulty breathing.Not able to tolerate activity.

The nurse is performing a sterile dressing change. After donning sterile gloves the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time?

Ask the patient to press the call bell to summon a co-worker to obtain another dressing

Upon entering the room, the nurse observes Mona Hernandez slumped over in a semi-Fowler's position, struggling to catch her breath. What is the priority nursing action at this time?

Assist the patient into a high Fowler's position.

Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen saturation is 95% per the pulse oximeter. Which interventions should the nurse provide? (Select all that apply.)

Assist the patient with adequate ventilation.Provide supplemental oxygen as ordered.Promote voluntary coughing activities to clear secretions.Ensure the patient is well hydrated.

A patient in semi-Fowler's position is having difficulty breathing. What is the priority action of the nurse? A. Call respiratory therapy B. Conduct a pain assessment C. Raise the head of the bed D. Auscultate the lungs

C. Raise the head of the bed

The nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. What would be the appropriate action by the nurse?

Call for a co-worker to help hold the patient's legs in position.

A nurse rounding on a patient with pneumonia notices the patient is more confused than at the beginning of the shift. What is the best response by the nurse?

Check oxygen saturation level.

A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on room air, an increased respiratory rate, and an increased pulse. The patient is pale and anxious. The nurse questions the oxygen saturation results and looks up which of the following test results? A. White blood cell count B. Chest X-ray C. Gram stain D. Hemoglobin

D. Hemoglobin

While completing discharge with a patient, the nurse notices the patient is short of breath. What is the priority nursing action at this time? A. Ask if the patient has support at home. B. Determine if the patient has any questions. C. Reassure the patient. D. Listen to the patient's lung

D. Listen to the patient's lungs.

Mona Hernandez complains of shortness of breath with activity and does not want to exacerbate her condition by moving to the chair or ambulating three times a day as ordered. How should the nurse respond?

Even short activities such as moving to the chair will help you cough mucus out of your lungs.

The nurse assess a wound and documents it as stage IIi. What did the nurse observe when the would was assessed.

Full-thickness tissue loss, possibly with visible subcutaneous fat.

The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. What question would be appropriate for the nurse to ask the patient

Have you noticed any swelling on your feet, ankles or fingers - do you have some areas of your skin that seem warmer or colder than others - have you used pads of special pants because you cant control your urine - do you have any sores on your body

The nurse is conducting a skin assessment using the Braden Scale. How would the nurse interpret a score of 12?

High risk. 10-12 score is high risk.19-23 is not a risk15-18 is low risk13-14 is moderate risk

The nurse is providing Ms. Johnson discharge education about intermittent self-catheterization. What statement, if made by the patient, would indicate the need for further instruction?

I should maintain sterile technique throughout the procedure.

Nurse is preparing to irrigate a wound. Which statement if made by the nurse indicates an understanding of the procedure

I will gently direct a stream of fluid into the wound, keeping the syringe tip at least on inch from the upper tip of the wound

Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer when she is already having difficulty breathing. What is the best response by the nurse?

It helps prevent atelectasis or collapsing of the alveoli in the lungs.

The nurse is preparing to irrigate a patient's wound. Upon assessment, the wound appears be healing and the wound bed is beefy red. What solution should the nurse select for this procedure?

Normal saline

The nurse has created a sterile field and is preparing to catheterize a patient. While using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. What is the correct action of the nurse at this time? Obtain a new catheter kit and restart the procedure.

Obtain a new catheter kit and restart the procedure.

The nurse has received an order to collect a urine sample. Which characteristics would the nurse observe for when assessing the patient's specimen? (Select all that apply.)

Odor Color Clarity Sediment

During her hospitalization for pneumonia, the provider orders arterial blood gases for Mona Hernandez. What is the best explanation for why this is ordered?

Patient has shallow, ineffective breathing.

The nurse is completing an admission assessment on a patient admitted for an infected, non-healing wound. Which factors in the patient's history may contribute to this condition? (Select all the apply.)

Poor hygieneDiabetes mellitusPoor circulationObesity

The nurse is reviewing the patients laboratory results. Which lab test most accurately represent current nutritional status?

Prealbumin- has a shorter half life and is more sensitive measurement of current nutritional status

The nurse is caring for a patient with lower extremity edema resulting from chronic venous insufficiency. What should the nurse include in the plan of care for this patient? (Select all that apply.)

Provide meticulous skin care.Perform neurovascular checks to look for changes.Monitor patient for signs of skin breakdown.Assist with range of motion exercises to lower extremities.

The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding

Purulent- yellow foul drainageSerous drainage- clear and waterySanguineous is bring red and looks like blood Serosanguineous is light pink to blood tinged

The nurse is preparing to discharge Mona Hernandez from the hospital. Which of the following instructions should the nurse include in the discharge education? (Select all that apply.)

Quitting smoking will improve your recovery.Use the incentive spirometer every one to two hours to move secretions out of your lungs.Take your antibiotics as directed, even if you are feeling better.Continue to focus on ambulating several times per day.

After completing an intermittent catheterization, what information concerning the procedure will include in Ms. Johnson's medical record? (Select all that apply.

Size of catheter usedCharacteristics of the urine obtainedTime procedure was performedDescription of the patient's tolerance to the procedure

The nurse is irrigating a patient's wound when the patient complains of pain. What is the appropriate action by the nurse?

Stop the procedure and administer the ordered analgesic.

The nurse has received an order to apply a hydrocolloid dressing to Ms. Morrow's right lower extremity. Which statement, if made by the nurse, would indicate the need for further education?

The dressing will need to be held in place by surgical tape.

Mona Hernandez's laboratory work indicates an elevated white blood cell count with a left shift in the differential. The nurse interprets this to mean which of the following?

There is a high number of white blood cells and immature white blood cells present to fight the infection.

Ms. Johnson is being discharged with an order to continue the medication oxybutynin. What information should be included in the teaching session?

This medication helps reduce bladder spasms.

The nurse is recording fluid intake for Ms. Johnson. Which items on the dinner tray should the nurse include when completing this documentation? (Select all that apply.) Tomato soupIce creamIced tea

Tomato soup Ice cream Iced tea

The nurse is caring for a patient admitted with bilateral lower extremity edema. What questions should the nurse ask when completing a health history

When did the edema start? -Can you describe the edema? - What were you doing just before you noticed the edema? -Do you have a recent history of surgery or illness? -What are your usual daily activities? -Do you stand alot? -What medications do you take? -Do you have heart disease or blood vessel disease

As the nurse administers Mona Hernandez's prescribed medication, guaifenesin, the patient states: "I don't like this medication. It makes me cough too much." How should the nurse respond?

When you cough out secretions, oxygenation is more effective.

the nurse is caring for a patient who is unable to urinate voluntarily since a gunshot injury. patient data associated with which intervention will provide information regarding the patients kidney function?

daily serum creatinine levels

the nurse is caring for a patient experiencing the effects of paraplegia. what urinary condition is associated with this diagnosis?

neurogenic bladder

The nurse is providing education to Ms. Morrow and her daughter on nutrition. What is the best dietary choice to promote wound healing? Baked chicken

Baked chicken

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg

Dark discoloration of the skin surrounding the wound site.shiny skin on lower extremities with hair loss would be indicative of peripheral arterial disease.Pale white toes and decreased sensation are descriptive of Reynauds disease.

The nurse is completing documentation following the insertion of an intermittent urinary catheter. What should be included in the documentation? (Select all that apply.)

Date the procedure was performedPatient's tolerance of the procedureSize of the catheterTime the procedure was performed

the nurse is preparing to catheterize a female patient and is positioning the patient. which position(s) would be appropriate for this procedure? (select all that apply)

dorsal recumbent side lying

A patient states he does not want to use the incentive spirometer because it makes the patient cough up too much sputum, and it is difficult to breathe. What is the correct information to teach the patient about the incentive spirometer? A. The incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis. B. You should wait to use your incentive spirometer until you are not coughing up so much sputum. C. The incentive spirometer will cause you to cough less because you are moving more air through your lungs D. You have to use your incentive spirometer because your provider has ordered it for you.

A. The incentive spirometer helps you to maximize lung function and minimize the risk of atelectasis.

The nurse is providing education to Ms. Morrow and her daughter on management of venous stasis in the lower extremities. What would be appropriate for the nurse to include in the teaching sessions?

Put an anti embolism stockings as soon as you get up in the morning and wear them all day.

the nurse is completing a focused assessment on a female patient admitted for altered urinary elimination. what questions would the nurse include when assessing the patient? (select al that apply)

have you noticed any change in your usual voiding pattern?do you ever leak urine?how often do you urinate?

while inserting an intermittent urinary catheter in a female patient, the nurse accidentally inserts the catheter into the vagina. what is the appropriate action by the nurse?

leave the catheter in the vagina as a landmark and begin the procedure again with new supplies

which information presented to a patient concerning a bladder scan will assist in addressing anxieties about the procedure? (select all that apply)

the scanner is moved over the skin of the patients lower abdomen the scan typically does not cause the patient any pain the patients body is draped to promote modesty

the nurse is providing discharge education on complications associated with intermittent self catheterization. which possible complications should the nurse include in the teaching session? (SATA)

urinary tract infections urethral strictures bladder spasms bladder perforation