Nursing Exam 1

stridor

Harsh, louid, high pitched, insp only. Caused by narrowing of larynx or trachea or foreign body in airway.

Native American Problems

Heart disease, cirrhosis of the liver, diabetes mellitus, fetal alcohol syndrome.

normal adult respiratory rate

12-20

Wheezing

A musical whistling sound caused by turbulent movement of air through constricted airways. Insp and exp.

Def integrity

Acting according to code of ethics.

ADPIE

Assessment Diagnosis Planning Implementation Evaluation

4 bioethical principles

Autonomy Beneficence Nonmaleficence Justice

crackles

Bubbling, crackling, popping Low- to high-pitched, discontinuous sounds Auscultated during inspiration and expiration Opening of deflated small airways and alveoli; air passing through fluid in the airways

What allows for voluntary control of breathing?

Cerebral Cortex

friction rub

Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration Inflamed pleura rubbing against chest wall

SBAR

Situation Background Assessment Recommendation

Normal Vital Sign Ranges

Temperature: 96.4 to 99.5 F Pulse: 60-100 bpm Respirations: 12-20 /min Blood Pressure: >120/80 SpO2: <90%

Which components must be included in an outcome? Select all that apply. The action the client will perform Modifiers describing the end result A description in subjective terms of the expected client behavior The particular circumstances in which the outcome is to be achieved The client or some part of the client A target time by which the client is expected to be able to achieve the outcome

The action the client will perform The particular circumstances in which the outcome is to be achieved The client or some part of the client A target time by which the client is expected to be able to achieve the outcome

What is ethical/moral distress?

When you know the right thing to do, but personal or institutional factors make it difficult to follow.

White health problems

breast cancer, heart disease, hypertension, diabetes mellitus, obesity

Jew health problem

cystic fibrosis, gauchers disease, spinal muscular atrophy, tay-sachs disease.

Hispanic health problems

diabetes mellitus, lactose intolerance.

What is pulse pressure?

difference between systolic and diastolic pressure

What is febrile?

fever

What is Cheyne-Stokes respiration?

it is an abnormal rhythm of breathing with alternation periods of hyperventilation and apnea (crescendo-decrescendo pattern)

Hypoxia symptoms

judgement, memory, alertness, coordination, calculations, headache, drowsiness, dizziness, uncoordinated, euphoria, belligerence.

sites for measuring body temperature

oral rectal axillary tympanic membrane skin/temporal artery

What are Maslow's hierarchy of needs?

physiological safety love/belonging esteem self-actualization

adventitious breath sounds

wheezing stridor rhonchi crackles Friction rub

Asian

Hypertension, cancer of liver, lactose intolerance, thalassemia

African American Problems

Hypertension, stroke, sickle cell anemia, lactose, intolerance, keloids.

Types of Assessment

1.Initial Assessment 2.Focus Assessment 3.Time-Lapsed Reassessment 4.Emergency Assessment

Rhonchi

snoring quality, low pitched continuous, insp and exp, coughing may clear. Cause by air passing through or around secretions.

What are nurse standards of practice?

1. Practice with compasion 2. Primary commitment to patient. 3. Advocate for patient. 4. Nurse has authority, accountability and responsibility. 5. Owes same duties to self. 6. Improves ethics in work area. 7. Advance profession via research. 8. Collab with other health pro's to protect human rights. 9. Articulate nurse values.

What percentage of weight change in 6 months is considered abnormal?

10%

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? Ask the gastroenterologist to explain the treatment plan to the client and family again. Ask the client to verbalize the medication regimen and diet modifications required. Ask the nutritionist to give the client strict meal plans to follow. Refer the client to available community resources and support groups.

Ask the client to verbalize the medication regimen and diet modifications required. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? Registered nurse Nursing assistant who is a nursing student A senior nursing student present for clinical Licensed practical nurse

Nursing assistant who is a nursing student The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? Process Structure Outcome Cost-effectiveness

Outcome An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

During a health assessment, the nurse uses deep palpation to assess a client's

liver.

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: physiological. behavioral. safety. family.

physiological The NIC is a comprehensive, evidence-based, standardized system for classifying nursing interventions. NIC groups interventions within seven domains, which, in order from the simplest to the most complex, are: Physiological: Basic; Physiological: Complex; Behavioral; Safety; Family; Health System; and Community.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family member.

Discontinue the education and attempt at another time. The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? Go to the client and assess the client's pain. Determine the frequency of pain medication. Medicate the client with the ordered pain medication. Instruct the client in nonpharmacologic pain management.

Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

Types of Value transmission

Modeling - watching Moralizing - value system is taught, church, school. Laissez-Faire - Free range parenting Responsible Choice - Children encouraged to explore competing values.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Secure the client's jewelry before surgery. Reassess the client's sacrum for redness when doing a bed bath. Provide the client with assistance in transferring to the bedside commode. Retrieve a unit of blood from the blood bank.

Provide the client with assistance in transferring to the bedside commode. Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

When creating a care plan, which is the purpose of identifying the client outcome? To design a plan of care to address the health problem To evaluate the plan of care developed To provide a basis for the scientific rationale To coordinate the nursing intervention

To design a plan of care to address the health problem The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

Which is an example of a psychomotor outcome? Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. The client will verbalize understanding of the need to continue to take medications as prescribed. The client's skin will remain smooth, moist, and without breakdown or ulceration.

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing. Cognitive outcomes describe an increase in the client's knowledge, such as understanding the need to continue to take medications as prescribed. Affective outcomes describe changes in client values, beliefs, and standards, such as decreasing the number of cigarettes one smokes due to adopting a belief that smoking is harmful. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved, such as a client's skin not developing breakdown or ulceration.

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? "I must conduct research to validate the usefulness of my nursing interventions." "I can learn about evidence-based practice by reading professional nursing journals." "Nursing interventions should be supported by a sound scientific rationale." "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

"I must conduct research to validate the usefulness of my nursing interventions." Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? Nursing diagnosis Rationale Outcome Nursing intervention

Rationale The nursing rationale is "why" a nursing intervention is to be performed. In this case, the reason for assisting with position changes is to prevent pressure injuries. The nursing dignosis is the client's health problem that the client outcome and the nursing intervention must address. In this case, the likely nursing diagnosis would be Risk for Impaired Skin Integrity. The client outcome is the goal that the nursing interventions are attempting to achieve. In this case, the client outcome would be something like, "The client will not develop any pressure injuries before discharge." The nursing intervention is an action the nurse takes to address the client's health problem and achieve the client's outcomes. In this case, the nursing intervention is providing assistance with position change every 2 hours.

For which client would a standardized plan of care most likely be appropriate? A client who was admitted for shortness of breath and who has been diagnosed with pneumonia A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? Remind the client that the client is responsible for the client's own health care decisions. Ask the client whether the client is afraid that the spouse will be angry. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form.

Ask the surgeon to wait until the client has had a chance to talk to the spouse. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply. Allow the client to order favorite foods from the hospital menu. Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods. Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of having nothing by mouth is likely to result in gastrointestinal distress. It is appropriate for the nurse to monitor bowel sounds and to consult with the dietician.

A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome? Choosing actions that do not solve the problem Failing to update the written plan of care Beginning the plan without family to help Stating outcomes too broadly

Choosing actions that do not solve the problem Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. In this case, ALS is a progressive degenerative neuromuscular disorder. It is unrealistic to expect the client to regain abilities that are lost.

Which is an appropriate expected outcome for a client? By the next clinic visit, client will report taking antidepressant medication. After attending diabetes education classes, client will understand diet modifications. Client will independently follow transplant medication schedule 1 week after surgery. Client will perform complete PICC line care within 24 hours of insertion.

Client will independently follow transplant medication schedule 1 week after surgery Outcomes should be specific, measurable, attainable, realistic, and timebound. Expecting a transplant recipient to follow the medication schedule after surgery is reasonable and meets all the characteristics of an outcome. The other options are not complete. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable, such as "know" and "understand."

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use? Cllinical pathway Computer database Nursing diagnosis Concept map

Cllinical pathway Clinical pathways are standardized, multidisciplinary care plans. Clinical pathways specify client outcomes within a specific time. For clients undergoing orthopedic surgery, the care plan would involve nurses, physical therapists, occupational therapists, and case managers. Concept maps assist with identifying relationships among concepts but are not used for a standardized care delivery system. Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. A computer database is a collection of information organized to provide efficient retrieval. In the health care setting, the computer database is the client electronic health record.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? Discuss the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the physician. Discuss the client's options with other church members. Discuss the client's refusal with hospital risk managers.

Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

Which is an independent (nurse-initiated) action? Executing physician orders for a catheter Meeting with other health care professionals to discuss a client Helping to allay a client's fears about surgery Administering medication to a client

Helping to allay a client's fears about surgery An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from a physician or any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a physician's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? Individualize the plan to the client. Expect to modify the plan significantly. Identify the appropriate nursing diagnoses. Include the rationale for the interventions.

Individualize the plan to the client Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? Narcotic analgesic to treat pain Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness Acetaminophen to treat pain and fever

Narcotic analgesic to treat pain A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized narcotic plan that will help them to receive narcotics in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.

Which phase of the nursing process most involves establishing priorities? Assessment Diagnosis Outcome identification and planning Implementation

Outcome identification and planning During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

What are specific measurable and realistic statements of goal attainment? Nursing diagnoses Nursing interventions Evaluations Outcomes

Outcomes Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? Perform vital signs and blood glucose level. DIscuss the need to change positions slowly, especially when moving from sitting to standing. Perform a full review of systems. Initiate an intravenous line and administer 500mL of normal saline.

Perform vital signs and blood glucose level. A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.

Before implementing any planned intervention, which action should the nurse take first? Have the required equipment ready for use. Reassess the client to determine whether the action is needed. Ask the client whether this is a good time to do the intervention. Record the planned intervention in the client's medical record.

Reassess the client to determine whether the action is needed. Although being prepared with the necessary equipment and checking with the client to make sure that the client is physically and psychologically ready for the intervention are important, it is crucial to reassess the client to determine whether the action is still needed before implementing any nursing intervention. Recording the intervention occurs after the nurse has completed the intervention.

Which accurately identify the characteristics of effective client goals represented in the acronym SMART? Select all that apply. S = supportive S = specific M = measurable A = accurate R = realistic T = timebound

S = specific M = measurable R = realistic T = timebound

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Start from client's knowledge, teach about diet modifications, and check for learning. Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style. Answer the client's questions about diet alterations, and then evaluate understanding.

Start from client's knowledge, teach about diet modifications, and check for learning. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.