Nursing 150 Final
serous fluid
clear, watery plasma
A nurse is preparing a presentation about age-related musculoskeletal changes. Which of the following changes Does the nurse plan to include? A.Decreased muscle mass B.Thickened vertebral disks C.Reduced chest width Increased force of isometric contraction
A
A nursing instructor asks a student nurse to identify isolation precautions required for clients with active TB. The student demonstrates understanding of the Disease's mode of transmission by identifying which of the following isolation precautions? A.Airborne B.Contact C.Standard D.Droplet
A
How should the nurse properly instruct a client with right-sided weakness to use a cane? A.Hold the cane in the left hand and 6 inches lateral to the left foot B.Hold the cane in the right hand and 6 inches lateral to the right foot C.Hold the cane in the left hand and place the cane in front of the left foot D.Hold the cane in the right hand and place the cane in front of the right foot
A
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take. Select all that apply. A.Keep the client's room dark at night B.Teach the client to use the call light C.Keep the client's bed in the lowest position D.Place a fall-risk identification band on the client's wrist E.Assess the client every 4 hours
B C D
When communicating with a client who is hearing impaired, the nurse should: A.speak directly into the impaired ear. B.exaggerate lip movements. C.talk very loudly to the client. D.face the client and speak slowly.
D
stage 3 pressure injury
full thickness loss, looks like deep crater extend to fascia, subtaneous tissue damged/necrpticfat visable undermining/tunneling may be present damage to surrounding tissue
vaccination
immunization
Urinary incontinence (UI)
inability to control urination
Stress UI
increased abdominal pressure - cough, sneeze, laughing
stage 1 pressure injury
intact skin with nonblanchable redness warm/firm/soft
Ecchymosis
large bruise
Which nursing interventions decrease risk of pressure ulcer development/shearing injury? Select all that apply. A.Turn/position q 2 hours or more B.Maintain minimum fluid intake of 1000 mL per day (if no fluid restrictions) C.Place incontinent clients on non-absorbent pad D.Use ring cushion on heels E.Float heels off bed surface F.Use an inflatable donut on sacrum G.Massage bony prominences H.Place HOB at 90 degrees while in bed
A, E
A nurse is teaching a client about risk factors for osteoporosis. What factor(s) should the nurse include in the teaching? Select all that apply. A.Sedentary lifestyle B.Obesity C.Aging D.Caffeine intake E.Secondhand smoke
A,C,D,E
Dementia
An abnormal condition marked by multiple cognitive defects that include memory impairment.
pneumonia
An inflammation of lung tissue, wherer the alveoli in the affected areas fill w/fluid
At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at what location? A.Fifth intercostal space just medial to the midclavicular line B.Second intercostal space to the left of the sternum C.Fifth intercostal space to the left of the sternum D.Second intercostal space to the right of the sternum
Correct: D Incorrect: A is mitral valve B is pulmonic valve C is tricuspid valve
Iatrogenic UI
Due to the activity of a physician or therapy. For example, an iatrogenic illness is an illness that is caused by a medication or physician.
UTI
E. coli, Staphylococcus saprophyticus (young women) Tx: Bactrim, Ciprofloxacin
What motion(s) is/are appropriate when assessing range of motion in the:
Elbow - flexion/extension Knee - flexion/extension Hip-flexion/extension, abduction/adduction, internal/external rotation
What are some ways a client can reduce symptoms related to Obstructive Sleep Apnea (OSA)?
Elevate HOB at night Increase activity level during day Run humidifier at bedside Lose weight Sleep in side-lying position Stop smoking and drinking alcohol
Diarrhea treatment
NICE provides the following dietary advice to people with diarrhoea associated with bowel incontinence: •limit fibre intake from wholegrain breads, bran, cereals, nuts and seeds (except golden linseeds) •avoid skin, pips and pith from fruit and vegetables •limit fresh and dried fruit to three portions a day and fruit juice to one small glass a day (make up the recommended 'five a day' with vegetables) •reduce consumption of fizzy drinks and drinks containing caffeine •avoid foods high in fat, such as chips, fast foods and burgers.
What is a nurse's most reliable method for assessing whether pain medication relieved client's pain?
Pain scale! What if the client has severe dementia? PAINAD What if the client is a neonate? CRIES What about children unable to give you a numeric value? Wong-Baker FACES
signs of breast cancer
Skin irritation Different sized breasts Swelling Nipple discharge Lump Nipple inversion Skin dimpling Pain (can't be seen but presumes based on inflammation
ruddiness
a healthy reddish complexion
constipation
difficulty in passing stools
delirium
mental disorder marked by confusion; uncontrolled excitement; ADJ. delirious
Clean Intermittent Catheterization (CIC)
technique that can be used to empty the bladder using a small catheter tube at regular intervals, thus reducing overflow incontinence (also known as chronic urinary retention). In a CIC procedure, a catheter (a thin, hollow tube) is inserted through the urethra into the bladder to help the individual urinate. Urine flows out of the bladder, through the catheter and into the toilet. Good hygiene is extremely important in CIC as it reduces the risk of developing a bladder infection, which is unpleasant and can sometimes lead to more widespread infection.
Icteric
yellowing of the skin
benign prostatic hyperplasia (BPH)
benign growth of cells within the prostate gland
s Sanguineous
bloody
fecal incontinence
the inability to control the passage of feces and gas through the anus
menopause
the time of natural cessation of menstruation; also refers to the biological changes a woman experiences as her ability to reproduce declines
urine test
to detect the presence of HCG, a hormone that is produced when a woman is pregnant
Reflex UI
voiding without feeling any sensation of need to void; e.g. spinal cord injuries
GI Assessment - Auscultation
-normal frequency range of 5 to 30 per minute -diminished or absent after abdominal surgery or in the patient with peritonitis or paralytic ileus. -most reliable method for assessing the return of peristalsis after abdominal surgery is to ask the patient if he or she has passed flatus within the past 8 hours or a stool within the past 12 to 24 hours. -Increased bowel sounds, especially loud, gurgling sounds, result from increased motility of the bowel (borborygmus). These sounds are usually heard in the patient with diarrhea or gastroenteritis or above a complete intestinal obstruction. *-vascular sounds or bruits ("swooshing" sounds) over the abdominal aorta, the renal arteries, and the iliac arteries. *- aneurysm. If this sound is heard, do not percuss or palpate the abdomen. Notify the health care provider immediately of your findings!
process for collecting a 24-hour urine.
1.You will be given 1 or more containers for collecting and storing your urine. A brown plastic container is typically used. A special pan that fits in the toilet or a urinal may be used to collect the urine. You will need to transfer the urine from the collecting container to the storage container. You will need to keep it cold. 2.The 24-hour collection may start at any time during the day after you urinate. But your healthcare provider may tell you when to start. It is common to start the collection the first thing in the morning. It is important to collect all urine in the following 24-hour period. 3.Don't save the urine from your first time urinating. Flush this first specimen, but note the time. This is the start time of the 24-hour collection. 4.All urine, after the first flushed specimen, must be saved, stored, and kept cold. This means keeping it either on ice or in a refrigerator for the next 24 hours. 5.Try to urinate again at the same time, 24 hours after the start time, to finish the collection process. If you can't urinate at this time, it is OK. 6.Once the urine collection has been completed, the urine containers need to be taken to the lab as soon as possible. If you are doing the urine collection at home, you will be given instructions on how and where to take it. 7.Depending on your specific health problem, you may be asked to repeat the collection over several days.
A nurse prepares a client with right-sided weakness to move from a bed to a chair. List the order in which the nurse would assist the client 1.Secure the chair position 2.Instruct the client about the procedure 3.Places the chair at an angle on the side of the bed 4.Assist the client to stand and move the left arm to the armrest 5.Instruct the client to keep the body weight forward and then pivot Assist the client to sit when the back of the legs touch the chai
3,1,2,4,5,6
A client requests that the prescribed enteric coated aspirin be crushed to make it easier to swallow. What response should the nurse provide? A."Crushing the medication might cause you to have a stomachache or indigestion." B."Crushing the medication is a good idea. I can mix it in some ice cream for you." C."Crushing the medication would release all of the medication at once, rather than over time." D."Crushing is unsafe as it destroys the ingredients of the medication."
A
A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further education? A."I'll sit with my knees lower than my hips." B."I'll do exercises that strengthen my abdominal muscles." C."I'll wear low-heeled shoes from now on." D."I'll carry heavy objects close to my body."
A
A nurse is assessing a client who is in the third trimester of pregnancy. What finding is an expected musculoskeletal change? A.Gradual lordosis B.Increased abdominal muscle tone C.Posterior neck flexion D.Decreased mobility of the pelvic joints
A
A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A.Increased heart rate B.Decreased respiratory rate C.Hyperactive bowel sounds D.Decreased blood pressure
A
A nurse is assisting with the routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which disorder? A.Scoliosis B.Kyphosis C.Lordosis D.Torticollis
A
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. What interventions should the nurse use to maintain skin integrity? A.Use a transfer device to move client up in bed B.Apply baby powder to keep sensitive areas dry C.Massage skin over client's bony prominences D.Elevate head of the bed to 45 degrees
A
A nurse is providing teaching to a client about measures to prevent urinary tract infection. What statement by the client indicates the need for further teaching? A.I need to wipe myself from back to front after urinating." B."I need to completely empty my bladder." C."I need to drink apple cider vinegar each day." D."I need to drink 8 cups of liquid each day."
A
The nurse is discussing nutrition with a client who is lactose intolerant. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? A.Dried fruits B.Hard cheese C.Creamed spinach D.Fresh-squeezed orange juice
A
The nurse is preparing to administer a rectal suppository to a client. Which position prevents expulsion of the suppository? A.Flat on back B.Semi-Fowler's C.High-Fowler's D.Upright with hips at 90-degree angle
A
When admitting a client, which information does the nurse record in the client's record first? A.Assessment of the client B.Plan of care for the client C.Nursing interventions performed for the client D.Evaluation of the client's progress
A
A nurse is reviewing a client's CBC findings and discovers that the platelet count is 9,000 mm3. The nurse should monitor the client for what condition? A.Spontaneous bleeding B.Oliguria C.Hyperactive deep tendon reflexes D.Infection
A Normal is 150 to 450,000
A nurse is caring for an older adult client. For which of the following physiological changes is the client at risk? Select all that apply. A.Decreased gastric motility B.Decreased skin elasticity C.Increased vaginal dryness D.Increased metabolic rate Increased cardiac output
A B C
A nurse is teaching a client about constipation. Which causes of constipation should the nurse include? Select all that apply. A.Excessive laxative use B.Ignoring the urge to defecate C.Inadequate fluid intake D.Increased fiber in the diet E.Increased activity
A B C
The nurse understands that personal health information can be disclosed in which situation(s)? Select all that apply. A.Compliance with legal proceedings B.For research purposes in limited circumstances C.To a family member or significant other in an emergency D.To nonessential medical personnel involved in client care E.To appropriate military if a client is a member of the armed forces
A B C E
constipation treatment
A high-fibre diet is usually recommended for most people with constipation-associated bowel incontinence. A GP can confirm whether a high-fibre diet is suitable. Fibre can soften stools, making them easier to pass. Foods that are high in fibre include: •fruit and vegetables •beans •wholegrain rice •wholewheat pasta •wholemeal bread •seeds, nuts and oats •Fluids can help to soften stools and make them easier to pass.
The nurse is assessing respirations per minute. Which factor(s) will affect the character of respirations? select all that apply A.Anxiety B.Exercising C.Smoking D.Acute pain E.Body position F.Musculoskeletal disorders
A, B, C, D, E
An older client has been lying supine in bed for two hours. The nurse who is repositioning this client would be most concerned with examining which area(s) of the client's body? Select all that apply A. heels B. sacrum C. Back of head D. back of knees E. greater trochanter F. palms of hands
A, B, C, E
The nurse educator is conducting a teaching session regarding risk factors for developing pressure ulcers. The nurse plans to include which factor(s) in the teaching session. Select all that apply. A.Immobility B.Moisture on the skin C.Skin pressure and shearing D.Increased sensory perception E.Urinary and bowel incontinence
A, B, C, E
A nurse is caring for a client who is taking lisinopril. What outcome indicates the medication is having? A.Decreased blood pressure B.Increase of HDL cholesterol C.Prevention of bipolar manic episodes D.Improved sexual function
A. The class is ACE inhibitor
A nurse is assessing a client who is experiencing prostatic hypertrophy. What finding(s) should the nurse expect? Select all that apply. A.Report of feeling pressure B.Tenderness over the symphysis pubis C.Distended bladder D.Voiding 30 mL frequently E.Dysuria
AB C D
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE) the nurse should include which of the following data? (Select all that apply.) A.Ability to perform calculations B.Level of consciousness C.Recall ability D.Long-term memory Level of orientation
ACE
What are common symptoms of a Urinary Tract Infection (UTI) in adults and older adult clients? (Select all that apply) A.A burning sensation during urination. B.Confusion in an older adult C.A frequent or intense urge to urinate, even though little urine comes out. D.Cloudy, dark, bloody, or strange-smelling urine. E.Feeling tired or shaky. F.Fever or chills (a sign that infection may be affecting kidneys) G.Pain or pressure in back or lower abdomen.
ALL ARE CORRECT
A client receives a wrong medication. What action should the nurse take first? A. Call the client's provider •B. Assess the client •C. Notify the nurse manager •D. Complete an incident report
B
A home health nurse is performing an assessment on an older adult client with decreased vision due to glaucoma. Which of the following findings should the nurse identify as a safety risk? A.Electrical cords are placed along the walls B.Scatter rugs are present in the kitchen C.Handrails are present in the bathroom D.Uses a microwave for cooking
B
A nurse is assessing a client's circulatory system. For which pulse site should the nurse avoid assessing bilaterally at the same time? A.Brachial B.Carotid C.Femoral D.Popliteal
B
A nurse is caring for a client who has not voided for 8 hours following removal of an indwelling urinary catheter. What action should the nurse take first? A.Increase fluids B.Perform a bladder scan C.Insert a straight catheter D.Provide assistance to the bathroom
B
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium? A.The client wants to know the current time while there is a clock on the wall. B. The client attempts to climb out of bed and repeatedly states she must get home. C.The client requests extra blankets when the thermostat in the room indicates 25.6° C (78° F). D.The client refuses to get out of bed and perform morning hygiene.
B
A nurse is preparing to measure an infant's vital signs. At which location should the nurse assess heart rate? A.Carotid artery B. Apex of the heart C. Brachial artery D. Radial artery
B
A nurse is teaching a client's partner how to obtain a blood pressure reading. What action by the partner indicates the need for further instruction? A.Wraps blood pressure cuff snugly around client's arm B.Places client's arm above level of client's wrist C.Checks instrument gauge to ensure reading starts at zero D.Centers cuff bladder over client's brachial artery
B
A nurse is teaching an older client who has osteoporosis about beginning a program of regular physical activity. What recommendation should the nurse make? A.High-impact aerobics B.Walking briskly C.Riding a bicycle D.Stretching exercises
B
The nurse is auscultating the apical heart rate of a client who is not taking any prescribed medications. The nurse notes the heart rate is regular. To determine beats per minute, the nurse should measure the apical pulse for how many seconds? A.15 B.30 C.45 D. 60
B
The nurse using a Snellen chart to test a client's vision. How far away from the chart should the client stand? A.10 B.20 C.30 D. 40
B
What laboratory result would cause the nurse the place a client on bleeding precautions? A.WBC 5000 cells/uL B.Platelets 50,000 cells/uL C.Hemoglobin 11 g/dL D.Hematocrit 54%
B
While changing a client's bedlinen, the nurse should: A.place soiled linen on a chair while making the bed. B.hold linen away from the body and clothing. C.put linen on the floor until it can be carried to a hamper. D.shake the clean linen to unfold.
B
When obtaining a urine specimen for culture and sensitivity from an indwelling catheter, the nurse should (select all that apply): A.wear sterile gloves B.collect the specimen from the urometer port. C.cleanse the entry port prior to withdrawing urine. D.drain the collection bag, wait 60 minutes and collect sample from the bag.
B C
A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. A.Superficial palpation B.Inspection C.Deep palpation D.Auscultation
B D A C
The nurse prepares to bathe a client with methicillin-resistant Staphylococcus aureus (MRSA) located in an abdominal wound covered by a dressing. Which protective action should the nurse take when bathing this client? A.Wear gloves B.Wear a gown and gloves C.Wear a gown, gloves, and a mask D.Wear a gown and gloves to change the bed linens and gloves only for the bath
B-contact
Where should the nurse palpate for the bladder?
Between the symphysis pubis and the umbilicus
A nurse assessing a client notes the client has a distended, palpable bladder and constant leakage of small amounts of urine. The nurse should associate these findings with which type of urinary incontinence? A.Stress B.Urge C.Overflow D.Reflex
C
A nurse in a long-term care facility is caring for client with dementia who begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for incontinence, what intervention should the nurse initiate to manage this behavior? A.Remind the client to tell the nurse when he/she has to urinate B.Use adult incontinent products (briefs) to prevent frequent clothing changes C.Take client to the bathroom every 2 hours D.Request prescription for an indwelling urinary catheter to prevent skin breakdown
C
A nurse is assessing a client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective to elicit further information from this client about the pain? A."Does the medication you are taking relieve the pain?" B."Can you point to where the pain is worst? C."Tell me how you are feeling right now." D."Changing positions makes your pain worse, right?
C
A nurse is assessing an older client who has osteoporosis. What spinal deformity does the nurse anticipate finding? A.Lordosis B.Ankylosis C.Kyphosis Scoliosis
C
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect what finding? A.Urge incontinence B.Critically elevated PSA level C.Difficulty starting the urine flow Painful urination
C
A nurse is caring for a client who requests pain medication. What action should the nurse perform first? A.Reposition the client B.Administer the medication C.Determine the location of the pain D.Review the effects of the pain medication
C
A nurse is caring for a client with Alzheimer's dementia who was admitted to a long-term care facility following the death of her husband of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which response by the nurse is appropriate? A."This is where you live now." B. "This is a safer place for you to live." C. "Tell me what you like to cook for dinner." D."Your family said there is no one home to care for you."
C
A nurse is caring for a middle-aged adult female client who reports her menstrual periods have become irregular. she has been having hot flashes. Which of the following symptoms should the nurse also anticipate? A.Urinary retention B.Decreased blood pressure C.Dryness with intercourse D.Elevation in body temperature above 37.8 degrees Celsius
C
A nurse is collecting a 24-hour creatinine clearance. During the collection, the client accidentally discards a specimen. What is the appropriate action by the nurse? A.Continue the collection, noting the loss on the lab slip B.Add 1 hour to the collection time C.Discard the previously collected urine and start again D.Discontinue the collection and draw a serum creatinine
C
A nurse is completing a client's history and physical examination. Which of the following data is subjective? A. Blood pressure B. Cyanosis C. Nausea D. Petechiae
C
A nurse is completing a physical examination On a client and notes that laboratory values indicate leukocytosis. Which manifestation is associated with this condition? A.Anemia B.Coagulation disorders C.Inflammation D.Renal disorder
C
A nurse is instructing a group of clients about nutrition. The nurse should include that ______ is a trigger for the formation of Vitamin D in the body. A.calcium B.vitamin A depletion C.exposure to sunlight D.weight-bearing exercise
C
A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? A.Provide a cognitively stimulating environment. B.Rotate staff to prevent caregiver role strain. C. Limit the client's choices of daily activities. D.Use confrontation to manage negative behavior.
C
A nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendation is unnecessary? A.Use of nightlight B.Use of staircase railings C.Removing wall-to-wall carpeting D.Placing handrails in the bathroom
C
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A.Hemoglobin B.Hematocrit C.WBC (leukocytes) D.Platelets
C
The nurse is preparing educational material for a client who has a thrombocytopenic disorder. What information should the nurse include? A."Use a rectal suppository if constipated." B."Swish with a commercial mouthwash after brushing the teeth." C."Notify the dentist of your condition prior to invasive procedures." D."Take aspirin for headaches."
C
The nurse is reviewing a client's urinalysis results and sees that the specific gravity is 1.027. For which physical finding should the nurse assess this client? A.Pedal edema B.Crackles in the lung bases C.Decreased skin turgor D.Increased pulse amplitude
C
The pulse point to use when assessing an infant's pulse is located in which area? A.Radial B.Carotid C.Brachial D.Popliteal
C
A nurse is teaching a client about risk factors for osteoarthritis. What factors should the nurse include in the teaching? Select all that apply. A.Bacteria exposure B.Diuretics C.Aging D.Obesity Smoking
C D E
The nurse is preparing to assist a client who can transfer with two assistants from the bed to the chair. The nurse requests assistance from staff members, but none are available to help. What action by the nurse is most appropriate? A.Ask the client's family member to assist with the transfer B.Assist the client to transfer with the aid of the nurse and a walker C.Use a mechanical lift to transfer the client from the bed to the chair D.Inform the client that it is necessary to wait until someone can assist Note: in local practice, two people are required to move a client using a mechanical lift.
C is listed as correct, but should not operate a mechanical lift with just 1 person
A nurse in a dermatologist's office is planning an educational session about skin cancer. What risk factors should the nurse include in the teaching plan? Select all that apply. A.Dark skin B.Under 40 years of age C.Overexposure to ultraviolet light D.Previous skin injury E.Genetic predisposition
C, D, E
A nurse is developing a plan of care to prevent skin breakdown for a client with paralysis secondary to a spinal cord injury. Which of the following nursing actions are appropriate? Select all that apply. A.Massage over erythematous bony prominences B.Implement turning schedule ever 4 hours C.Use pillows to keep heels off the bed surface D.Keep the client's skin dry with powder E.Minimize skin exposure to moisture
C, E
A nurse is caring for a client with pneumonia. What action should the nurse take to promote thinning of respiratory secretions? A.Encourage the client to ambulate frequently B.Encourage coughing and deep breathing C.Encourage the client to increase fluid intake D.Encourage regular use of an incentive spirometer
C-encourage fluids
A nurse is caring for a client with urinary incontinence. Which of the following actions should the nurse implement to prevent skin breakdown? A.Apply a moisture barrier ointment to the client's skin B.Clean client's skin and perineum with hot water after each episode of incontinence C.Check client's skin every 8 hours for signs of breakdown D.Request an order to insert an indwelling urinary catheter
Correct: A => quality moisture barrier helps prevent urine from softening/breaking skin Incorrect: B - use warm NOT hot water and mild soap C - check skin every 2 hours D - Catheter à increased Risk for infection
A nurse is caring for a client with acute pyelonephritis (kidney infection). What is an appropriate comment by the nurse regarding home care? A"You should complete the entire cycle of antibiotic therapy." B"You should maintain complete bedrest until symptoms decrease." C"You should drink 1,000 mL of fluid each day." D"You should weigh yourself daily."
Correct: A. Always complete the full course of antibiotics even if symptoms of infection are gone Incorrect: B. Bedrest could result in urinary stasis C. Drink 2000-3000 mL/day unless there are comorbidities that Crestrict fluids DWeighing daily is not required.
A client comes to the emergency department reporting diarrhea for 4 days and urinating less than usual. When assessing the client's skin turgor, the nurse should: A.push on a fingernail bed until is blanches, release it, and observe how long it takes for pink to return. B.grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back. C.press the skin above the ankle for 5 seconds, release it, and note the depth of depression. D.Use skinfold calipers to measure the thickness of a skin fold at the upper arm.
Correct: B => checking skin turgor (one assessment for dehydration incorrect: A is capillary refill C is checking for pitting edema; other locations can be used as well D is one assessment used to assess whether person is overweight ; Used to assess % of body fat; Skinfold Calipers- specific sites used vary in men and women.
A nurse is admitting a client who requires transmission-based precautions due to influenza. What action should the nurse take? 1. Place client in a room with negative airflow 2. Wear a mask when providing care to the client 3. Ensure the client's room has HEPA filtration 4. Wear a gown when providing care to the client
Correct: B- Influenza requires droplet precautions Incorrect: A = airborne C = airborne D = contact
A nurse is assessing a client who has a urine output of 250 mL in a 24-hour period. What term should the nurse place in the client's heath record? A.Enuresis B.Anuria C.Nocturia D.Oliguria
Correct: D Incorrect: A. Enuresis is involuntary urination B. Anuria is less than 100ml in 24 hours C. Nocturia is frequency of urination during the night
A nurse employed in a mental health clinic is greeted by a neighbor who says, "My best friend Michelle is seen at your clinic every week. How is she doing?" The best response is: A."I know you are really concerned so I will share with your that she is doing much better than before." B."I'm not supposed to discuss this, but because you are her best friend, I can tell you that she really has problems!" C."If you want to know about Michelle's progress, I suggest you ask her yourself. I'm not allowed to discuss this with you." D."I'm sorry and I'm sure you will understand, but as a nurse, I'm obligated to protect the privacy of all the clinic's clients"
D
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? A.Exposed bone B.Blood filled blisters C.Partial-thickness skin loss D.Necrotic subcutaneous tissue
D
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following? A.Serous B.Purulent C.Sanguineous D.Serosanguineous
D
A nurse is collecting a urine specimen to test a client's specific gravity. What does this test measure? A. leukocytes in the urine. B. uric acid crystals in the urine. C. proteins in the urine. D. solutes in the urine.
D
A nurse is instructing a female client on obtaining a midstream urine specimen. What statement by the client indicates understanding of the teaching? A.I will wipe from back to front using a cleansing cloth." B."I should not collect a urine sample when I am menstruating." C."I should let the urine cool to room temperature before sending it to the lab." D."I need to urinate a small amount in the toilet before collecting the sample."
D
A nurse is preparing a community health program for adults at risk for cardiovascular disease. What should the nurse include as a modifiable risk? A.Diagnosis of diabetes mellitus B.Family history of cardiac disease C.Increasing age D. Cigarette smoking
D
An unlicensed assistive personnel tells the nurse, "I am unable to find a large blood pressure cuff for an obese client. Can I use the regular cuff if I can get it to stay on?" The nurse replies that using a regular cuff on an obese client can result in a reading that is: A.inaudible. B.low. C.accurate. D.high.
D
The nurse is preparing a client To ambulate. What action should the nurse take to determine a client's level of strength? A.Ask the client how strong he/she feels today B.Ask the client to touch his/her finger to the nose C.Palpate client's pedal pulses Ask the client to push his/her feet against the nurse's palm
D
The nurse is teaching a mother how to administer eardrops to an infant. The nurse demonstrates the procedure by pulling the ear: A.Up and back, directing the solution onto the eardrum. B.Down and back, directing the solution onto the eardrum. C.Up and back, directing the solution toward the wall of the canal. D.Down and back, directing the solution toward the wall of the canal.
D
The nursing instructor is observing a nursing student transfer a client from the bed to a chair. The instructor intervenes if the student is observed performing which action? A.Keeping the back, neck, pelvis, and feet aligned B.Flexing the knees and keeping the feet wide apart C.Encouraging the client to assist as much as possible D.Positioning self as far away from the client as possible
D
For which of the following diseases should the nurse institute contact precautions A.Measles B.Varicella zoster (shingles) C.Pulmonary tuberculosis D.Respiratory syncytial virus (RSV)
D (all others require airborne precautions) B (chicken pox) actually requires both airborne and contact What PPE is included in standard precautions?
A nurse is providing education about prostate health to a group of clients. What is an appropriate statement for the nurse to make regarding a PSA test? A."You should fast for 8 hours prior to having the PSA collected." B."Yearly PSA screening should begin at age 40 in all men." C."Normal PSA values decrease as you get older." D."The PSA test should not be obtained for 48 hours following a DRE."
D - screening begins at 50
An emergency department nurse is assessing an older adult client with community-acquired pneumonia. What finding should the nurse anticipate? A.Unequal pupils B.Hypertension C.Tympany upon chest percussion D.Confusion
D: confusion due to hypoxemia Would have dull lung percussion sounds and possible hypotension
pallor
Extreme or unnatural paleness
GI Assessment - Inspection
First, observe the contour of the abdomen, noting any masses, scars, or areas of distention. Significant findings may include the presence of distention (inflation) or protrusion (projection).
stage 4 pressure injury
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
Bladder incontinence treatments
Initially, treatment focuses on approaches that don't involve medication or surgery. These include: •lifestyle changes - e.g. reducing caffeine intake (including green tea), smoking cessation, and losing weight •pelvic floor muscle training - this technique strengthens the pelvic floor muscles and is an effective treatment for stress incontinence, especially if the muscle has been damaged. (example: Kegel exercises) bladder training - bladder training involves learning techniques to increase the length of time between feeling the need to urinate and passing urine. The course usually lasts for at least six weeks and can be combined with the Kegel exercises. Some individuals may find timed toileting to be helpful, particularly people with a learning disability or cognitive impairment
urine sample procedure
Keeping the labia spread open, urinate a small amount into the toilet bowl, then stop the flow of urine. Hold the urine cup a few inches (or a few centimeters) from the urethra and urinate until the cup is about half full, then finish urinating into the toilet bowl.
GI Assessment - Percussion
Place your non-dominant hand firmly against the abdominal wall such that only your middle finger is resting on the skin. Using the middle finger of your dominant hand, tap on the middle finger of the non-dominant hand in the center of the finger 2 or 3 times listening for the sound it makes. Abdominal percussion is useful for delineating the outlines of solid tissue, for example, the liver or the spleen, or of intra-abdominal masses such as tumors or fecal masses. The percussion tones that you are likely to hear when percussing the abdomen include dullness, tympany, and resonance. Dullness is heard over solid organs such as the liver and spleen. Tympany is commonly heard over areas that contain gas, such as the stomach and intestines. Resonance is heard over healthy lung tissue.
A male adult client comes into an urgent care clinic accompanied by his wife. He is tachypneic and states he is having difficulty breathing. The pulse ox is 89% on RA. What should the nurse do?
RA= room air The nurse needs to intervene to relieve the respiratory distress; health history and complete assessment can be completed later;his wife can be a source of information as well
Where should the nurse check for dependent edema in this client?
Sacrum
GI Assessment - Palpation
Watch the patient's face for nonverbal signs of pain during palpation. Palpate each quadrant in a systematic manner, noting muscular resistance, tenderness, enlargement of the organs, or masses. If the patient complains of abdominal pain, palpate the area of pain last. If the patient's abdomen is distended, note the presence of firmness or tautness. Abnormal findings include involuntary rigidity, spasm, and pain (which may indicate trauma, peritonitis, infection, tumors, or enlarged or diseased abdominal organs).
Post Residual Void (PVR)
What is it: amount of urine left in your bladder after using the restroom. measure? 1. The amount of leftover (residual) urine can be measured by draining the bladder with a thin flexible tube (catheter) 2. by using ultrasound. The catheter method has a slight risk of causing infection or injury to the tube leading from the bladder (urethra).This test is performed to measure the amount of urine that is left in your bladder after you have made attempt to empty it completely. The test is done with ultrasound.
fecal impaction
a mass of dry, hard stool that remains packed in the rectum and cannot be expelled
obstructive sleep apnea (OSA)
a temporary lack of breathing that occurs during sleep when the posterior pharynx relaxes and covers the trachea
Injectable bulking agents
agents, such as collagen and silicone, can be injected into the muscles of the sphincter and rectum to strengthen them.
Transient UI
appears suddenly and lasts 6 months or less - can be result of confusion, infection, diuretics, intravenous fluid
Overflow UI
associated with overdistention and overflow of the bladder Functional: Inability to reach the toilet in time (e.g. rings bell and no one comes)
cyanosis
bluish discoloration of the skin from hypoxia
biofeedback training
bowel retraining exercise that involves placing a small electric probe into the anus. The sensor relays detailed information about the movement and pressure of the muscles in the rectum to an attached computer. The individual is asked to perform a series of exercises designed to improve bowel function. The sensor checks that the exercises are being performed in the right way.
Mixed UI
combination of one or more types of incontinence
Total UI
continuous (dribbling) and unpredictable loss of urine - surgery, trauma, physical malformation
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm at the point of pressure. What is the severity of this client's edema? A.4+ B.3+ C.2+ D. 1+
correct: B -3+ =6 mm 1234 = 2,4,6,8 mm Incorrect: D. 1+ = 2 mm C. 2+ =4 mm A. 4+ =8 mm
Tibial nerve stimulation
fairly new treatment for bowel incontinence. A fine needle is inserted into the tibial nerve just above the ankle and an electrode is placed on the foot. A mild electric current is passed through the needle to stimulate the tibial nerve. It's not known exactly how this treatment works, but it is thought to work in a similar way to sacral nerve stimulation.
Influenza
flu virus
Artificial sphincter
may be implanted if bowel incontinence has been caused by damage to the sphincter muscles. The operation involves placing a circular cuff under the skin around the anus. The cuff is filled with fluid and sits tightly around the anus, keeping it closed. A tube is placed under the skin from the cuff to a control pump. In men, the pump is placed near the testicles, in women it's placed near the vagina. A special balloon is placed into the abdomen, and this is connected to the control pump by tubing that runs under the skin. The pump is activated by pressing a button located under the skin. This drains the fluid from the cuff into the balloon, so the anus opens and stools can be passed. When the stool is passed, the fluid slowly refills the cuff and the anus closes.
Urge UI
occurs when there is an urge to void
Sphincteroplasty
operation to repair damaged sphincter muscles. The surgeon removes some of the muscle tissue and the muscle edges are overlapped and sewn back together. This provides extra support to the muscles, which makes them stronger.
stage 2 pressure injury
partial thickness skin loss involving epidermis, dermis, or both -> blister/shallow crater
purulent
producing or containing pus odorous
argyria
rare skin condition that can happen if silver builds up in your body over a long time. It can turn your skin, eyes, internal organs, nails, and gums a blue-gray color, especially in areas of your body exposed to sunlight. That change in your skin color is permanent
Serosanguineous
red and watery
erythema
redness of the skin
Endoscopic heat therapy
relatively new treatment for bowel incontinence. Heat energy is applied to the sphincter muscles through a thin probe, to encourage scarring of the tissue. This tightens the muscles and helps to control bowel movements.
respiration character
rhythm, depth, ease of breathing, and sound
sacral nerve stimulation
treatment used for people with weakened sphincter muscles. Electrodes are inserted under the skin in the lower back and connected to a pulse generator. The generator releases pulses of electricity that stimulate the sacral nerves, which causes the sphincter and pelvic floor muscles to work more effectively.
Laxatives
used to treat constipation. They loosen stools and increase bowel movement. Bulk-forming laxatives are usually recommended as they help the stools to retain fluid. This means they're less likely to dry out, which can lead to faecal impaction
Bowel retraining
used to treat people with reduced sensation in their rectum as a result of nerve damage, or for those who have recurring episodes of constipation. There are three goals in bowel retraining: •to improve stool consistency •to establish a regular time to empty the bowels •to find ways of stimulating the bowels to empty themselves
rectal irrigation
used when bowel incontinence is caused by faecal impaction and other treatments have failed to remove the impacted stool from the rectum. The procedure involves placing a small tube in the anus and injecting a medicine in fluid form to wash out the rectum.
Suppositories/Enemas
used when other treatments are deemed ineffective. Suppositories are small and bullet-shaped and are used to deliver medication to soften hard faeces blocking the rectum. Enemas work in a similar way but the medication is delivered through a small tube inserted into the rectum.
Colostomy
usually only recommended if other surgical treatments are unsuccessful. A colostomy is a surgical procedure in which the colon (lower bowel) is cut and brought through the wall of the stomach to create an artificial opening. Stools can then be collected in a bag, known as a colostomy bag, which is attached to the opening.
Single-use silicone inserts
which form a seal around the rectum until the next bowel movement, are also being investigated as a treatment option for moderate to severe bowel incontinence.
jaundice
yellowing of the skin from liver damage
A client with a new diagnosis of OSTEOPOROSIS asks, "How is this disease cured, and why couldn't I tell that I had it?" How should the nurse respond?
•"Silent disease" •No cure but can be managed/prevent worsening. •Treat with Calcium/Vitamin D •Limit alcohol •Weight-bearing exercise •Bisphosphonates: Fosamax, Actonel, Boniva, zoledronic acid •The drugs must be taken first thing in the morning -- on an empty stomach. •You cannot sit or lie down for 30 minutes after taking it. •You cannot eat or drink anything. •You must wait for 30 to 60 minutes for the body to absorb the medicine. •When that time period is over, you can take other medications.
normal weight BMI
•Underweight: BMI is less than 18.5. •Normal weight: BMI is 18.5 to 24.9. •Overweight: BMI is 25 to 29.9. •Obese: BMI is 30 or more.
