Fundamentals Quizes
what nutrient supports bone and tooth formation and facilitates nerve impulse transmission?
calcium
what patients are able to get a deltoid IM injection?
children 18 months or older, risky choice
nurse is collecting a sample from a urinary catheter, which of the following actions should the nurse take?
clamp the tubing below the collection port
middle-aged adult should be evaluated toward which developmental tasks?
ceasing to compare personal identity with others
If the patient is experiencing difficulty with expression, what part of the brain may be injured?
cerebral cortex contains the neural networks that facilitate complex behaviors like learning, memory, and language
nurse is implementing cold therapy to a patient with an ankle sprain, what action should the nurse take?
check capillary refill before applying an ice pack to the affected area -applying cold therapy decreases blood supply to the affected area, if the patient is showing poor circulation it will further exacerbate the decrease in bloodflow/circulation -fill ice pack with 2/3 crushed ice to mold around affected area, apply for 30-minute intervals to anesthetize (to subject to anesthesia, loss of sensation) and prevent further swelling
patient has a prescription for collection of a sputum specimen for culture sensitivity, what action should the nurse take when obtaining the specimen?
collect the specimen when the client rises in the morning -client will be able to cough up secretions that have accumulated during the night, before breakfast; rinse mouth, take a deep breath, and cough prior to expectorating into the sterile container, 4-10ml
a nurse is doing vital signs and notices an irregularity in the pulse, what action should the nurse take?
count the apical pulse rate for 1 full min and describe the rhythm in the chart -the nurse should auscultate the apical pulse for 60 seconds to obtain accurate rate. Nurse should document the irregularity in the medical record
A nurse is caring for a patient who is postoperative following abdominal surgery, what actions should the nurse perform first after discovering the wound has eviscerated (to protrude through a surgical incision)?
cover the incision with a moist sterile dressing an open wound increases the risk of peritonitis and any exposed organ tissue could dry out
nurse is caring for a patient who has an Ng tube for intermittent enteral feedings, what action should the nurse take?
elevate the head of the bed 45degrees before feeding -elevate 30-45 degrees to prevent aspiration
cancer patient is experiencing pain, what nursing intervention can the nurse implement to assist with pain relief?
encourage the patient to listen to soft music -reduce anxiety, provide distraction and relieve pain
Middle-aged female client should have which diagnostic test routinely?
eye examination every 2 years -checking for glaucoma, 65+ should have annual exam -women 45+ should have annual mammogram, 55+ Q 2 years, Colonoscopy Q 10 years
What is a weber test?
hearing screening that uses a tuning fork
metabolic alkalosis
high pH (percent hydrogen 7.35-7.45), high PaCO2 (Bicarbonate 22-26), normal PaCO2 (carbon dioxide 35-45)
respiratory alkalosis
high pH (percent hydrogen 7.35-7.45), low PaCO2 (percent carbon dioxide 35-45), normal HCO3 (Bicarbonate 22-26)
teaching about nutritious diets to a group of adult women, what should the nurse include?
include 2.5 cups of vegetables in your diet daily -2 cups of fruit, AHA recommends 1.5g sodium, one alc drink per day, 2-3L H2O daily to maintain homeostasis (based on health)
secondary-source data:
information provided by someone other than the client
where do you insert a deltoid injection?
insert 2-3 finger width below the acromion process, above the axillary line, middle of the triangular-shaped deltoid (midline of lateral aspect of the arm) *potential injury due to proximity to the brachial arty and radial nerve. Do not use this injection site for toddlers younger than 3 yo
what is the definition for recommended dietary allowance (RDA) ?
level of nutrient intake that meets the needs of healthy people in various groups
what actions indicate the nurse and AP understand how to transfer a client from a bed to a wheelchair?
locking the brakes on the bed and the wheelchair before moving the client -ensure they are both stationary and will not shift when the client moves into the chair -AP lower the plates after the transfer (lift the feet onto them), place wheelchair parallel to the bed, place wheelchair on stronger side to allow the client to move toward the stronger side
hypoxemia
low oxygen in the blood
hypoxia
low oxygen in the tissues
metabolic acidosis
low pH (percent Hydrogen 7.35-7.45), low PaCO2 (Bicarbonate 22-26), and normal PaCO2 (carbon dioxide 35-45)
patient having tonic-clonic seizure, what action should the nurse take?
lower the client to the floor -prevent injury
what nutrient affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles?
magnesium
the client's radial pulse is 55/min, what action should the nurse take next?
measure the client's apical pulse rate -the nurse and a coworker should measure the apical and radial pulse simultaneously; if radial pulse rate is lower than the apical pulse rate, the client might have a cardiovascular disorder
patient has 2 Penrose drains near an abdominal incision, what adhering device is best for the nurse to decrease skin irritation?
montgomery straps -adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced and the ties are secured again without removing the adhesive strips
nurse notes patient has a loss in height from the previous year, the nurse should identify that as manifestation of what musculoskeletal system disorder?
osteoporosis -loss of calcium in vertebrae which can cause them to fracture and collapse
A nurse is initiating seizure precautions for a client who has a seizure disorder. What piece of equipment should the nurse have readily available at the client's bedside?
oxygen equipment - the nurse should be able to apply oxygen via mask or nasal cannula to a client who experiences a seizure --the nurse should NOT restrain the client, hold flailing limbs loosely and loosen the client's clothing, do not place anything in the mouth or airway, protect client's head by holding it in the lap, placing head on pillow or pad under client' bed, pad the guard rails prn
religious practices for deceased patients: Islamic, Judaism, Hindu, Buddhist
people who practice Judaism stay with the body of the deceased until burial, Islamic faith the body of deceased is washed and wrapped during a ritual then buried as soon as possible following death, Hindu faith may place the body with the head facing north following death then cremation, Buddhist male family members prepare the body following death
what action should the nurse take to assess the client's tissue perfusion?
perform a blanch test -the blanch test is used to check capillary refill, indicator of peripheral circulation and tissue perfusion
nurse is doing peripheral pulses, what description should the nurse use to document the findings?
peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
nurse is employing a thorough, systemic method while obtaining objective data about a client. through which method should the nurse collect this information?
physical examination -objective data
nurse is obtaining blood pressure in a client's lower extremity, what action should the nurse take?
place the bladder of the cuff over the posterior aspect of the right thigh -the nurse should auscultate the BP of the popliteal artery and position the cuff 1 in above the artery; patient should be in prone or supine with knee flexed
what nutrient stores glycogen, nerve impulse transmission, cardiac conduction and smooth muscle contraction?
potassium
when a nurse is inserting an NG tube, the client begins to gag and cough, what action should the nurse take?
pull the NG tube back slightly -instruct the client to breathe slowly, once client is relaxed, the nurse should gently advance the tube as the client swallows. -should not remove the NG tube if the client begins to cough and gag, this can result in discomfort, should not advance while coughing because this can result in inserting the tube into the client's trachea, tilt head forward to help aid insertion into esophagus
how to properly use crutches when going up the stairs
put weight on the crutches, place the unaffected leg/foot on the first step, transfer weight to the unaffected foot, move the crutches to the next step and bring up the affected foot/leg
2 ways to test cane is appropriate height for the patient:
reaches the greater trochanter, bony prominence of femur even withe the wrist crease
a nurse is caring for a client who requires wrist restraints, what action should the nurse take?
remove the restraints every 2 hours -reposition the patient every 2 hours, provide fluids and nutrients, assist with ROM, and evaluate client's overall wellbeing -attach the restraint with a quick-release buckle, do not attach to bedside rails, make sure 2 fingers fit under the restraints
how do you help a patient with an IV remove their gown?
remove the sleeve of the gown from the arm without the IV line -nurse will be able to remove the gown from the patient before stopping the system to remove the gown from the line resulting in minimal interruption of the IV flow
the nurse should ensure written consent form for what procedures?
risky procedures/surgeries like transfusion of packed red blood cells -radiation, anesthesia, chemotherapy, biopsy, some blood tests, most vaccines
when should the nurse apply proteolytic enzyme wound dressing?
unstageable pressure ulcer -facilitate debridement and to soften eschar
how to withdraw a solution from a vial (5 steps)
*check expiration and the label two times while preparing injection* 1. pressurize vial: draw air into syringe (same amount of solution to withdraw) 2. cleanse the rubber stopper with an alcohol swab, when it is dry insert the needle in the center and inject air into the vial 3. invert the vial, keep the needle below the fluid, draw solution 4. tap or flick syringe prn to move air bubbles to the top of syringe for ejection, remove all air bubble 5. return vial upright, withdraw needle from vial, recap needle with one-handed scoop technique
a laboratory result within the expected reference range for what substance indicates adequate protein uptake and synthesis?
Albumin -levels protein status, they are useful for identifying long-term protein depletion rather than short-term or acute changes in nutritional status
A nurse is caring for a client who requires ventilatory assistance with breathing following a car accident, the nurse should suspect an injury to what part of the brain?
Brainstem nurse should identify an injury to the medulla and pons of the brainstem for a client experiencing difficulty breathing. Brainstem serves as respiratory control center, and a neurological injury can impair this center and inhibit respiratory effort
patient has a stage 2 pressure ulcer, what type of wound dressing should the nurse apply?
Hydrocolloid -reabsorbs exudate and produces a moist environment that will facilitate health while preventing maceration of surrounding skin
If a patient is having difficulty sleeping, what part of the brain is suspected to be injured?
Hypothalamus serves as the sleep center in the body by secreting hypocretins, which promote rapid eye movement (REM)
what is an indication of bleeding at the IV insertion site?
IV system is not intact -check to determine in IV system is intact and if the catheter is within the client's vein, possibly need to start a new line in another location is bleeding does not stop after interventions
Patient has an increased convex curvature in the thoracic region of the spine, what is the abnormality?
Kyphosis
respiratory acidosis
Low pH (percent hydrogen 7.35-7.45), high PaCO2 (percent carbon dioxide 35-45), normal HCO3 (Bicarbonate 22-26)
a nurse is performing a neurological assessment, to promote safety during the examination, the nurse stands nearby as the client follows the instructions for what test?
Romberg -evaluates standing balance, first with eyes opened then closed. nurse should be nearby incase the client falls.
patient has an S-curved spine, this is a manifestation of which of the following abnormalities?
Scoliosis -s-shaped or c-shaped spinal column and uneven shoulder or hip heights are manifestations of scoliosis
Patient has IV for fluid replacement, what findings would the nurse identify as infiltration of the IV infusion site?
Taut skin around the IV catheter site is cool to the touch -stop IV infusion, elevate the extremity, and apply a warm moist compress or cold compress according to type of infiltration
nurse is caring for a client who in unconscious, what action should the nurse take when providing oral care?
Test for the presence of the client's gag reflex -determining the risk for aspiration
patient's head is inclining toward the affected spinal side with contraction of the sternocleidomastoid muscle, what is the abnormality?
Torticollis
when should the nurse use a doppler ultrasound on pulses?
Use a doppler ultrasound for a pulse that is non-palpable or difficult to palpate
IM injection for a young adult client, which injection site is the safest for the client?
Ventrogluteal -safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels
patient with chills and aching joints, which is an identification of an infection?
WBCs 15,000 mm^3, above 5,000-10,000 mm^3 reference range; indication of infection
after inspecting the abdomen, what should the nurse do next?
auscultate
patient reports feeling a pop after coughing without properly splinting an abdominal incision, on assessment, the nurse notes that the client's wound has eviscerated. What actions should the nurse take?
1. place the client in supine position with hips and knees flexed (prevent further tearing of incision and wound evisceration by lessening the tension on the wound) 2. cover the protruding intestine with a sterile dressing that is moistened (0.9% sodium chloride to prevent further contamination and keep intestine from drying out), 3. monitor for manifestations of shock (bleeding, patient seeing the intestine outside the body, increased HR and RR, changes in BP or mentation (mental activity/unconscious), cool clammy skin
patient semiconscious had a small-bore NG tube placed for administration of enteral feeding, what methods should the nurse use to verify correct placement?
1. verify the initial X-ray examination 2. measure the length of the exposed tube 3. determine the PH of aspiration fluid -auscultating air injected into the NG tube is NOT a reliable method for determining correct NG tube placement
what position should the patient be when checking for CVA (costovertebral angle) tenderness?
CVA is where the spine and 12th rib intersect; sitting promotes relaxation and allows access to the back for percussion of that region
patient has exaggerated anterior convex curvature in the lumbar region of the spine, what abnormality is present?
Lordosis
a patient is walking along the hallway and bumping into walls and does not respond to his name, what action should the nurse take?
accompany the patient back to his room
nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis, what action should the nurse take?
advise the client to perform ROM exercises while in bed -performing these ROM exercises will help the client maintain mobility until the pain is under control and she is able to ambulate without excessive discomfort. -If the nurse allows the client to remain in bed, it could place the client at risk for complications of immobility (thrombus formation), and having the family perform ADLs for client limits independence
nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume, what action should the nurse take?
apply light pressure to the scanner head once it is in position
when should the nurse assess pedal pulse?
assess pedal pulse to determine circulation in lower extremities
why should the nurse assess peripheral pulses?
assess peripheral pulses to determine equality of blood perfusion to the extremities
a nurse is teaching a middle-aged patient about health promotion and disease prevention, the nurse should inform the client that which of the following changes could occur?
decreased estrogen and testosterone production
Z track method (IM injections)
displace 1-1.5" subQ tissue at the site with non-dominant hand insert needle 90 degrees inject slowly, smoothy; hold 10 seconds withdraw needly quickly at 90 degrees cover with dry gauze and DO NOT massage
nurse is performing otoscopic examination, the light reflex is visible in the right lower quadrant of the tympanic membrane, what action should the nurse take?
document this as an expected finding -the light of the otoscope reflects off the tympanic membrane, which is cone shaped/ triangular, is it visible in the lower R/L quadrant in the R/L ear
nurse is replacing the surgical dressing on a client who had abdominal surgery, what action should the nurse take?
don clean gloves remove the old dressing -use standard precautions coming into contact with secretions. remove the old dressing one layer at a time, loosen tape toward wound to decrease tension, open sterile supplies after removing the old dressings (wash hands don sterile gloves)
what is the most distal pulse?
dorsalis pedis -located on the top of the foots following the groove between the tendons of the great toe. It is best felt by moving the fingertip between the first and second toes and slowly moving up the dorsum of the foot. congenitally absent in some clients
nurse is performing a physical assessment and recognizes that which of the following places a client at risk for impaired skin integrity?
faint pedal pulses -indicates poor circulation and tissue perfusion, puts the client at risk for impaired skin integrity
nutrition training, what should the nurse include in the teaching?
fats provide energy -fat serves as a stored energy source for the body, providing 9cal/g of energy proteins play a role in tissue repair, fluid balance and prevents interstitial edema; appropriate albumin level keeps interstitial edema from occurring
Basic crutch stance
forming a tripod placing crutches 6 in in front and 6 in to the side of the client's foot (1 foot on the ground)
a nurse is caring for a client who requires an X-ray, prior to being transported for the procedure, what action should the nurse take?
identify the patient using 2 identifiers -once the identity of the patient is determined, the nurse can proceed with the other options. It is the priority because it provides for the safety of the client first. the nurse must be certain that each client receives only what has been prescribed and assure that the correct client is being transported for a chest X-ray. *Once patient is identified, the nurse should explain the procedure, help the client before transport, and ask if they have any questions
Erikson's psychosocial development theory for young adults
intimacy vs. isolation establishing friendships outside of the immediate family
how does a TENS (transcutaneous electrical nerve stimulation) unit work?
it modulates the transmission of the pain impulse -applies low-voltage stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief
preparing injectable medications:
keep distractions to a minimum double-check all calculations avoid shortcuts follow 10 rights of medication administration
What teaching should the nurse include about using crutches safely?
keep rubber crutch securely in place -never use crutches without rubber tips, the client should inspect tips regularly and replace them when they show signs of wear or moisture
patient has temperature of 101.7 F, what action should the nurse take?
keep the bed linens dry -maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce the external covering on the client's bed without causing shivering
rationale for cleaning a wound from the least contaminated area to the greater contaminated area (inner wound to outside the wound)?
keeping microorganisms from entering the wound
nutrition education - what are incomplete proteins and an example?
lentils -missing one or more amino acids necessary for the synthesis of protein in the body. examples: lentils, vegetables, grains, nuts, seeds
nurse is caring for a client with left lower lobe atelectasis (lung collapse due to alveoli deflate/filled with fluid), what action should the nurse plan to take?
place the client in Trendelenburg position -right sided Trendelenburg position promotes drainage from client's left lower lobe -perform percussions over a single layer of clothing, cupped hand to provide percussions, chest percussion should not cause pain
What is an indication of palpable cord along the vein on IV site?
possible Phlebitis, inflammation of the inner layer of a vein. -discontinue infusion and start new IV line in another location
what is an indication of redness at IV site?
possible local infection -remove IV, clean site with alcohol, and start a new IV line in another location
a nurse is preparing to perform postural drainage for a patient, what should the nurse take?
postural drainage consists of providing drainage, positioning and turning the client
patient's NG tube's exit mark has moved since the last feeding, what actions should the nurse plan to take?
request and X-ray of the client's abdomen verifies placement of NG tube both after initial insertion and if displacement of the tube is suspected; verify placement prior to administering bolus (injection of nutritional liquid into feeding tube) feeding
10 rights of medication administration
right: patient, medication, dose, route, time, patient education, documentation, refuse, assessment, evaluation
what nutrient regulates extracellular fluid volume?
sodium -sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities
patient with history of dysrhythmias; upon entering the room, the patient is unresponsive to verbal or painful stimuli, has no respirations and is pulseless. What action should the nurse take first?
start chest compressions -nurse should begin CPR which start with compressions followed by opening the airway and breathing for adults and pediatric clients; evidence indicates a great survival rate when chest compressions are started before a breath is initiated
patient with abdominal trauma, what assessment findings should the nurse identify as an indication of hypovolemic shock (plasma is low, severe blood or fluid loss, heart is unable to pump enough blood to the body)?
tachycardia also cool, clammy skin, urine output < or = 30mL/hr, and tachypnea -due to decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiration rate
nurse teaching about straight-legged cane, what actions indicates understanding of the teaching?
the client holds the cane on the unaffected side -provides wide base of support and stability, step with the affected leg before the unaffected leg to maintain stability, place cane 6in to the side of the foot to provide balance, hold cane with elbows slightly flexed. moves the can with the affected leg together
what instructions should the nurse give when palpating the thyroid gland?
tilt your head back and swallow -should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland
when should the nurse apply a collagen wound dressing?
to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing
nurse is administering IM to a 5-month-old infant, what site should the nurse use?
vastus lateralis -over the anterior thigh for IM injections for infants and children
nurse is administering IM to a 8-month-old infant, what site should the nurse use?
ventrogluteal -safe for children over 7 months, place the palm of hand on the head of the trochanter with thumb pointing toward the client's abdomen, extend index finger up to the anterior superior iliac spine, then spread the rest of the fingers along the iliac crest. Insert the needle in the V formed between index and 3rd fingers
nurse is planning to care for a client with a fluid volume excess, what intervention should the nurse include to monitor client's weight?
weigh the client on arising -every day upon arising, after voiding, and before breakfast. most accurate is with the same garments and on the same carefully calibrated scale, accurate daily weights provide easiest measurement of fluid volume status
If the patient is experiencing difficulty controlling balance and coordination, what part of the brain may be injured?
when the cerebellum is injured, patient's movements can become uncoordinated, unsure, and clumsy
