funds 1 exam 1

what is normal respirations

12-20 breathes per min

what is normal pulse

60-100 beats per min

normal pulse oximeter

95-100%

A nurse is obtaining a SpO2 measurement on an infant client. Which site will likely be used by the nurse? Earlobe Adhesive foot sensor Fingertip Bridge of nose

Adhesive foot sensor

The nurse has four clients on the unit with impaired mobility. Which client is at greatest risk of developing complications from immobility? 43-year-old woman who had a hysterectomy 82-year-old woman who has suffered a cerebrovascular accident (CVA) 19-year-old man with external fixation of the left tibia 57-year-old woman following a thoracotomy

Although all clients have some level of risk, the risk of complications increases with age and longer periods of immobility. This can be significant following a cerebrovascular accident (CVA). The clients who had a hysterectomy, a left tibia fixation, and a thoracotomy will typically be up and moving around within a day or two and could be recovered within weeks. These three clients are also younger, ranging in age from 19-57, whereas the stroke client is 82.

A nurse works on an orthopedic surgical floor in a hospital. The nurse understands that clients are at risk of which physiological complication of immobility?​ Reduced cardiac workload Decreased lung expansion Decreased oxygen demand Increased metabolism

Decreased lung expansion Clients with impaired mobility can be at risk for decreased lung expansion, increased oxygen demand, decreased metabolism, and increased cardiac workload.​​

The nurse is preparing to document the client's vital sign measurements in the electronic health record (EHR). What are the correct statements? Select all that apply. Document the route used to obtain vital signs. The route used to obtain vital signs is not typically necessary to document. First document, then analyze the abnormal vital sign findings. Document the client's response to abnormal findings. Document the follow-up actions taken after abnormal findings were obtained. First document, then inform the healthcare provider of abnormal findings.

Document the route used to obtain vital signs. Document the client's response to abnormal findings. Document the follow-up actions taken after abnormal findings were obtained.

A longitudinal record of an individual's interactions with the healthcare system. EHR EMR

EHR

The legal record documenting a single encounter between an individual and a healthcare professional. EHR EMR

EMR

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? (Saunders, 8th edition, pg. 179, #105) a. Gloves and gown b. Gloves and goggles c. Gloves, gown, and shoe protectors d. Gloves, gown, goggles, and a mask or face shield

Gloves, gown, goggles, and a mask or face shield

The nurse is measuring vital signs on a pediatric client. When analyzing the data obtained, the nurse considers that, compared with adults, children tend to have which of the following? Select all that apply. Lower respiratory rates than adults Higher blood pressure than adults Higher respiratory rate than adults Lower blood pressure than adults Higher pulse than adults

Higher respiratory rate than adults Lower blood pressure than adults Higher pulse than adults

contact precaution disease examples SATA Clostridium difficile (C diff) Measles Conjunctivitis Seasonal influenza (flu) Methicillin resistant staphylococcus aureus (MRSA)

Methicillin-resistant staphylococcus aureus (MRSA), conjunctivitis, and Clostridium difficile (C diff)

The nurse is leaving the room after completing tracheostomy suctioning on a client who is on contact and airborne precautions. Put the personal protective equipment (PPE) in the order the nurse will perform the actions, from first to last. Take off the gown. Remove the N95 mask. Perform hand hygiene, if needed. Perform hand hygiene before leaving area. Remove gloves.

Remove gloves. Take off the gown. Perform hand hygiene, if needed. Remove the N95 mask. Perform hand hygiene before leaving area.

An 18-year-old victim of a motor vehicle crash with a fractured femur has been immobilized for six days. The nurse is getting the client out of bed for the first time. Which nursing diagnosis is applicable to this action? Chronic pain Risk for impaired skin integrity Risk for activity intolerance Impaired circulation

Risk for activity intolerance Clients immobilized or on bed rest for an extended amount of time are at risk for activity intolerance when mobility increases. This increases the risk for falls. ​The data from the scenario does not support other diagnoses, including impaired circulation, chronic pain, or risk for impaired skin integrity.​

A nurse prepares to obtain a SpO2 reading on a client. Which factors would impact the nurse's choice of measurement site? Select all that apply.​ The client has been eating ice chips. The client has liver disease. The client is anemic. The client is sleeping. The client has a very light complexion. The client has atherosclerosis. The client's temperature is 35.9⁰C (96.6⁰F).

The client has liver disease. The client is anemic The client has atherosclerosis. The client's temperature is 35.9⁰C (96.6⁰F).

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? (Saunders, 8th edition, pg. 180, #109) a. Private room or cohort client b. Personal respiratory protection device c. Private room with negative air flow pressure d. Mask worn by staff when the client needs to leave the room

a. Private room or cohort client WHY NOT THE OTHERS

If there is a sign on the door of a client's room instructing the nurse to wear a N95 mask, gown, and gloves, then the client is under which type of precautions? Neutropenic Contact Airborne Aerosol

airborne Contact precautions do not require a mask. Neutropenic precautions restrict flowers, fresh fruits, and vegetables, along with restricting others with infections from entering. There are no precautions labeled aerosol precautions.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with suspected diagnosis of pertussis. Which of the following interventions should the nurse include? a. Place the client in a room that has negative air pressure of at least six exchanges per hour b. Wear a mask when providing care within 3 ft of the client c. Place a surgical mask on the client if transportation to another department is unavoidable d. Use sterile gloves when handling soiled linens e. Wear a gown when performing care that might result in contamination from secretions

b. Wear a mask when providing care within 3 ft of the client c. Place a surgical mask on the client if transportation to another department is unavoidable e. Wear a gown when performing care that might result in contamination from secretions

when bp decreases what happens to pulse rate

increases

when bp decreases what happens to resp rate

increases

when temp increases what happens to bp

increases

when temp increases what happens to pulse rate

increases

when temp increases what happens to respiratory rate

increases

low bp levels normal bp levels elevated bp levels

less than 90/less than 60 less than 120/less then 80 120-129/less than 80

diseases that are airborne

measles, chicken pox, purities, covid

Wearing a surgical mask, gown, and gloves should be worn when caring for a client on __________ precautions.

neutropenic precautions.

droplet precaution diseases

pneumonia, influenza, whooping cough, bacterial meningitis, rsv